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2.
J Emerg Med ; 2021 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-34497012

RESUMO

BACKGROUND: Aortic dissection (AD) is a challenging diagnosis associated with severe mortality. However, acute AD is a rare clinical entity and can be overevaluated in the emergency department. D-dimer, both alone and in combination with the Aortic Dissection Detection Risk Score (ADD-RS), has been studied as a tool to evaluate for AD. CLINICAL QUESTION: Can a negative D-dimer in low-risk patients exclude AD in the emergency department? EVIDENCE REVIEW: Retrieved studies included three systematic review and meta-analyses and two prospective cohort studies. D-dimer was found to be highly sensitive for acute AD, with a sensitivity of 98.0%. The ADD-RS was also highly sensitive (95.7%) for AD. Two meta-analyses reported a combination of a negative D-dimer and ADD-RS < 1 to have a pooled sensitivity of 99.9% and 100% for acute aortic syndrome. CONCLUSIONS: Neither D-dimer nor the ADD-RS alone provides adequate sensitivity to exclude acute AD. However, a negative D-dimer combined with an ADD-RS < 1 is likely sufficient to rule out AD. Even with these findings, physicians must place clinical judgment above laboratory testing or scoring systems when deciding whether to pursue a diagnosis of acute AD.

3.
J Emerg Med ; 2021 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-34535304

RESUMO

BACKGROUND: Syncope is a common presentation to the emergency department (ED). A significant minority of these patients have potentially life-threatening pathology. Reliably identifying that patients require hospital admission for further workup and intervention is imperative. CLINICAL QUESTION: In patients who present with syncope, is there a reliable decision tool that clinicians can use to predict the risk of adverse outcome and determine who may be appropriate for discharge? EVIDENCE REVIEW: Four articles were reviewed. The first retrospective study found no difference in mortality or adverse events in patients admitted for further evaluation rather than discharged home with primary care follow-up. The next two articles examined the derivation and validation of the Canadian Syncope Risk Score (CSRS). After validation with an admission threshold score of -1, the sensitivity and specificity of the CSRS was 97.8% (95% confidence interval [CI] 93.8-99.6%) and 44.3% (95% CI 42.7-45.9%), respectively. The last article looked at the derivation of the FAINT score, a recently developed score to risk stratify syncope patients. A FAINT score of ≥ 1 (any score 1 or higher should be admitted) had a sensitivity of 96.7% (95% CI 92.9-98.8%) and specificity 22.2% (95% CI 20.7-23.8%). CONCLUSIONS: Syncope remains a difficult chief symptom to disposition from the ED. The CSRS is modestly effective at establishing a low probability of actionable disease or need for intervention. However, CSRS might not reduce unnecessary hospitalizations. The FAINT score has yet to undergo validation; however, the initial derivation study offers less diagnostic accuracy compared with the CSRS.

4.
Am J Emerg Med ; 50: 459-465, 2021 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-34500232

RESUMO

INTRODUCTION: Acute heart failure (HF) exacerbation is a serious and common condition seen in the Emergency Department (ED) that has significant morbidity and mortality. There are multiple clinical decision tools that Emergency Physicians (EPs) can use to reach an appropriate evidence-based disposition for these patients. OBJECTIVE: This narrative review is an evidence-based discussion of clinical decision-making tools aimed to assist EPs risk stratify patients with AHF and determine disposition. DISCUSSION: Risk stratification in patients with AHF exacerbation presenting to the ED is paramount in reaching an appropriate disposition decision. High risk features include hypotension, hypoxemia, elevated brain natriuretic peptide (BNP) and/or troponin, elevated creatinine, and hyponatremia. Patients who require continuous vasoactive infusions, respiratory support, or are initially treatment-resistant generally require intensive care unit admission. In most instances, new-onset AHF patients should be admitted for further evaluation. Other AHF patients in the ED can be risk stratified with the Ottawa HF Risk Score (OHFRS), the Multiple Estimation of Risk Based on Spanish Emergency Department Score (MEESSI), or the Emergency HF Mortality Risk Grade (EHFMRG). These tools take various factors into account such as mode of arrival to the ED, vital signs, laboratory values like troponin and pro-BNP, and clinical course. If used appropriately, these scores can predict patients at low risk for adverse outcomes. CONCLUSION: This article discusses evidence-based disposition of patients in acute decompensated HF presenting to the ED. Knowledge of these factors and risk tools can assist emergency clinicians in determining appropriate disposition of patients with HF.

6.
Ann Emerg Med ; 78(3): 461-462, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34420565
8.
J Emerg Med ; 61(4): 365-375, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34256953

RESUMO

BACKGROUND: Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus. Therefore, it is important for emergency physicians to be aware of this unique diagnosis and treatment considerations. OBJECTIVE: This manuscript reviews the emergency department evaluation and management of the adult patient with hyperglycemic hyperosmolar state. DISCUSSION: Hyperglycemic hyperosmolar state is diagnosed by an elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status. Treatment involves fluid resuscitation and correction of electrolyte abnormalities. It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes. These patients are critically ill and generally require admission to an intensive care unit. CONCLUSIONS: Hyperglycemic hyperosmolar state is associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

10.
Am J Emerg Med ; 47: 101-108, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33794472

RESUMO

Pulmonary arterial hypertension (PAH) is a chronic progressive incurable condition associated with a high degree of morbidity and mortality. With over five drug classes FDA approved in the last decade, the significant advancements in the pharmacologic management of PAH has improved long-term outcomes. Drug therapies have been developed to directly target the underlying pathogenesis of PAH including phosphodiesterase type-5 inhibitors (PDE-5i), endothelin-receptor antagonists (ERAs), guanylyl-cyclase inhibitors, prostacyclin analogues, and prostacyclin receptor agonists. Although these agents offer remarkable benefits, there are significant challenges with their use such as complexities in medication dosing, administration, and adverse effects. Given these consequences, PAH medications are classified as high-risk, and the transitions of care process to and from the hospital setting are a vulnerable area for medication errors in this population. Thus, it is crucial for the emergency department provider to appropriately identify, manage, and triage these patients through close collaboration with a multidisciplinary team to ensure safe and effective medication management for PAH patients in the acute care setting.


Assuntos
Anti-Hipertensivos/administração & dosagem , Ativadores de Enzimas/administração & dosagem , Prostaglandinas I/administração & dosagem , Hipertensão Arterial Pulmonar/tratamento farmacológico , Anti-Hipertensivos/efeitos adversos , Serviço Hospitalar de Emergência/organização & administração , Ativadores de Enzimas/efeitos adversos , Humanos , Prostaglandinas I/efeitos adversos , Hipertensão Arterial Pulmonar/etiologia
11.
J Emerg Med ; 61(1): 97-104, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33838968

RESUMO

BACKGROUND: Atraumatic subarachnoid hemorrhage (SAH) is a deadly condition that most commonly presents as acute, severe headache. Controversy exists concerning evaluation of SAH based on the time from onset of symptoms, specifically if the headache occurred > 6 h prior to patient presentation. CLINICAL QUESTION: Do patients undergoing evaluation for atraumatic SAH who have a negative computed tomography (CT) scan of the head obtained more than 6 h after symptom onset require a subsequent lumbar puncture to rule out the diagnosis? EVIDENCE REVIEW: Studies retrieved included a retrospective cohort study, two prospective cohort studies, and a case-control study. These studies provide estimates of the diagnostic accuracy of head CT imaging obtained > 6 h from symptom onset and diagnostic test characteristics of subsequent lumbar puncture. CONCLUSION: The probability of SAH above which emergency clinicians should perform a lumbar puncture is 1.0%. This threshold is essentially the same as the estimated probability of SAH in patients with a negative head CT obtained more than 6 h from symptom onset. Emergency physicians might reasonably decide to either perform or forego this procedure. Consequently, we contend that the decision whether to perform lumbar puncture in these instances is an excellent candidate for shared decision-making.


Assuntos
Punção Espinal , Hemorragia Subaracnóidea , Estudos de Casos e Controles , Serviço Hospitalar de Emergência , Cefaleia/etiologia , Humanos , Estudos Prospectivos , Estudos Retrospectivos , Hemorragia Subaracnóidea/diagnóstico por imagem , Tomografia Computadorizada por Raios X
13.
Am J Emerg Med ; 47: 24-29, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33765589

RESUMO

INTRODUCTION: Cerebral venous thrombosis (CVT) is an uncommon neurologic emergency associated with significant morbidity and mortality that can be difficult to differentiate from other conditions. It is important for the emergency clinician to be familiar with this disease as it requires a high index of suspicion, and early diagnosis and management can lead to improved outcomes. OBJECTIVE: This narrative review provides an evidence-based update concerning the presentation, evaluation, and management of CVT for the emergency clinician. DISCUSSION: CVT is due to thrombosis of the cerebral veins resulting in obstruction of venous outflow and increased intracranial pressure. Early recognition is important but difficult as the clinical presentation can mimic more common disease patterns. The most common patient population affected includes women under the age of 50. Risk factors for CVT include pregnancy, medications (oral contraceptives), inherited thrombophilia, prior venous thromboembolic event, malignancy, recent infection, and neurosurgery. CVT can present in a variety of ways, but the most common symptom is headache, followed by focal neurologic deficit, seizure, and altered mental status. Imaging studies such as computed tomography (CT) venography or magnetic resonance (MR) venography should be obtained in patients with concern for CVT, as non-contrast CT will be normal or have non-specific findings in most patients. Treatment includes anticoagulation, treating seizures and elevated ICP aggressively, and neurosurgical or interventional radiology consultation in select cases. CONCLUSIONS: CVT can be a challenging diagnosis. Knowledge of the risk factors, patient presentation, evaluation, and management can assist emergency clinicians.


Assuntos
Trombose Intracraniana/fisiopatologia , Diagnóstico Diferencial , Serviço Hospitalar de Emergência , Feminino , Humanos , Trombose Intracraniana/diagnóstico , Trombose Intracraniana/terapia , Masculino , Gravidez , Fatores de Risco , Distribuição por Sexo
14.
J Emerg Med ; 60(6): 743-751, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33745765

RESUMO

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hematologic disorder resulting from an ineffective and pathologic activation of the immune response system that may mimic common emergency department presentations, including sepsis, acute liver failure, disseminated intravascular coagulation, and flu-like illnesses such as coronavirus disease 2019 (COVID-19). OBJECTIVE: This narrative review provides a summary of the disease and recommendations for the recognition and diagnostic evaluation of HLH with a focus on the emergency clinician. DISCUSSION: Though the condition is rare, mortality rates are high, ranging from 20% to 80% and increasing with delays in treatment. Importantly, HLH has been recognized as a severe variation of the cytokine storm associated with COVID-19. Common features include a history of infection or malignancy, fever, splenomegaly or hepatomegaly, hyperferritinemia, cytopenias, coagulopathies, abnormal liver enzymes, and hypertriglyceridemia. Using specific features of the history, physical examination, laboratory studies, and tools such as the HScore, HLH-2004/2009, and hyperferritinemia thresholds, the emergency clinician can risk-stratify patients and admit for definitive testing. Once diagnosed, disease specific treatment can be initiated. CONCLUSION: This review describes the relevant pathophysiology, common presentation findings, and a framework for risk stratification in the emergency department.


Assuntos
Linfo-Histiocitose Hemofagocítica , COVID-19 , Serviço Hospitalar de Emergência , Humanos , Linfo-Histiocitose Hemofagocítica/diagnóstico , Esplenomegalia/etiologia
15.
Am J Emerg Med ; 44: 157-160, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33626481

RESUMO

INTRODUCTION: Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often misdiagnosed due to a serum glucose <250 mg/dL. OBJECTIVE: This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians. DISCUSSION: EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology. CONCLUSIONS: Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.


Assuntos
Cetoacidose Diabética/diagnóstico , Cetoacidose Diabética/etiologia , Cetoacidose Diabética/terapia , Serviço Hospitalar de Emergência , Diagnóstico Diferencial , Humanos
16.
Am J Emerg Med ; 41: 130-138, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33440325

RESUMO

BACKGROUND: Cardiac transplant is an effective long-term management option for several severe cardiac diseases. These cardiac transplant patients may present to the emergency department with a range of issues involving the cardiac transplantation, including complications due to their transplant as well as altered presentations of disease resulting from their transplant. OBJECTIVE: This narrative review provides a focused guide to the evaluation and management of patients with cardiac transplantation and its complications. DISCUSSION: Cardiac transplant is an effective therapy for end-stage heart failure. A transplanted heart varies both anatomically and physiologically from a native heart. Several significant complications may occur. Graft failure, rejection, and infection are common causes of morbidity and mortality within the first year of transplant. As these patients are on significant immunosuppressive medication regimens, they are at risk of infection, but inadequate immunosuppression increases the risk of acute rejection. A variety of dysrhythmias such as atrial fibrillation and ventricular dysrhythmias may occur. These patients are also at risk of acute coronary syndrome, cardiac allograft vasculopathy, and medication adverse events. Importantly, patients with acute coronary syndrome can have an altered presentation with the so-called "painless" myocardial infarction. Consultation with the transplant physician is recommended, if available, for these patients to assist in evaluation and management. CONCLUSIONS: An understanding of the presentations and various complications that may affect patients with cardiac transplant will assist emergency clinicians in the care of these patients.


Assuntos
Serviço Hospitalar de Emergência , Transplante de Coração , Complicações Pós-Operatórias , Humanos , Complicações Pós-Operatórias/terapia
17.
Intern Emerg Med ; 16(4): 1031-1042, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33420904

RESUMO

INTRODUCTION: Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization. OBJECTIVE: This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM. DISCUSSION: This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS). CONCLUSIONS: CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.


Assuntos
Serviço Hospitalar de Emergência , Meningite Criptocócica/diagnóstico , Meningite Criptocócica/terapia , Diagnóstico Diferencial , Medicina Baseada em Evidências , Humanos
18.
Am J Emerg Med ; 39: 207-212, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33039222

RESUMO

BACKGROUND: Decompensated hypothyroidism, formerly known as myxedema coma, is an endocrine emergency that commonly presents with altered mental status, as well as hypothermia and depressed vital signs. The condition is often caused by an inciting event, which may lead to significant delays in the diagnosis and management of this disease. Although the incidence is low, this disease is associated with significant morbidity and mortality. Therefore, it is important for emergency clinicians to be aware of this condition. OBJECTIVE: This narrative review evaluates the emergency medicine diagnosis and management of adult patients with decompensated hypothyroidism. DISCUSSION: Decompensated hypothyroidism is a severe hypothyroid state associated with multiple organ failure. The diagnosis can be challenging due to similarities with more common diseases and lack of consideration of the diagnosis. Many patients may present with altered sensorium or depressed vital signs. Clinicians should obtain a thyroid stimulating hormone and free thyroxine level when considering the diagnosis. Management involves resuscitation, early steroid supplementation, thyroid hormone replacement, and treatment of the inciting event. CONCLUSIONS: Decompensated hypothyroidism should be considered in the evaluation of patients with altered sensorium and depressed vital signs so as to not miss this critical diagnosis.


Assuntos
Coma/etiologia , Medicina de Emergência/métodos , Hipotireoidismo/diagnóstico , Hipotireoidismo/terapia , Insuficiência de Múltiplos Órgãos/etiologia , Coma/diagnóstico , Coma/terapia , Terapia Combinada , Diagnóstico Diferencial , Emergências , Humanos , Hipotireoidismo/fisiopatologia , Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/terapia , Índice de Gravidade de Doença
19.
J Emerg Med ; 60(2): 175-191, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33092975

RESUMO

BACKGROUND: Palliative care is an essential component of emergency medicine, as many patients with terminal illness will present to the emergency department (ED) for symptomatic management at the end of life (EOL). OBJECTIVE: This narrative review evaluates palliative care in the ED, with a focus on the literature behind management of EOL symptoms, especially dyspnea and cancer-related pain. DISCUSSION: As the population ages, increasing numbers of patients present to the ED with severe EOL symptoms. An understanding of the role of palliative care in the ED is crucial to effectively communicating with these patients to determine their goals and provide medical care in line with their wishes. Beneficence, nonmaleficence, and patient autonomy are essential components of palliative care. Patients without medical decision-making capacity may have an advance directive, do not resuscitate or do not intubate order, or Portable Medical Orders for Life-Sustaining Treatment available to assist clinicians. Effective and empathetic communication with patients and families is vital to EOL care discussions. Two of the most common and distressing symptoms at the EOL are dyspnea and pain. The most effective treatment of EOL dyspnea is opioids, with literature showing little efficacy for other therapies. The most effective treatment for cancer-related pain is opioids, with expeditious pain control achievable with a rapid fentanyl titration. It is also important to address nausea, vomiting, and secretions, as these are common at the EOL. CONCLUSIONS: Emergency clinicians play a vital role in EOL patient care. Clear, empathetic communication and treatment of EOL symptoms are essential.


Assuntos
Cuidados Paliativos na Terminalidade da Vida , Assistência Terminal , Emergências , Serviço Hospitalar de Emergência , Humanos , Cuidados Paliativos
20.
Am J Emerg Med ; 40: 193-198, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33162266

RESUMO

BACKGROUND: Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is a novel virus responsible for causing the novel coronavirus disease of 2019 (COVID-19). OBJECTIVE: This article discusses the clinical manifestations of COVID-19 in pregnant patients, the effects of pregnancy on the course of COVID-19 disease, and the impact of COVID-19 on pregnancy outcomes. DISCUSSION: The physiological and mechanical changes associated with pregnancy increase maternal susceptibility to infections and complicate intubation and mechanical ventilation. The most common symptoms of COVID-19 in pregnant patients are cough and fever, although many infected individuals are asymptomatic. The majority of pregnant women diagnosed with COVID-19 disease have a mild course of illness and will recover without needing to deliver, but the risks of critical illness and need for mechanical ventilation are increased compared to the general population. Risk factors for death and severe disease include obesity, diabetes, and maternal age > 40 years. Women in their third trimester have the highest risk for critical illness, intensive care unit admission, and need for mechanical ventilation. Adverse fetal outcomes of maternal COVID-19 infection include increased risk of miscarriage, prematurity, and fetal growth restriction. Vertical transmission of SARS-CoV-2 is possible but has not been conclusively proven. CONCLUSIONS: COVID-19 is a potentially deadly infection, but data are limited concerning the pregnant population. Pregnant patients appear to present similarly to the general population, with fever and cough being the most reported symptoms in studies. Knowledge of these presentations and outcomes can assist clinicians caring for these patients.


Assuntos
COVID-19/diagnóstico , COVID-19/terapia , Complicações Infecciosas na Gravidez/diagnóstico , Complicações Infecciosas na Gravidez/terapia , Resultado da Gravidez , Algoritmos , Medicina de Emergência , Feminino , Humanos , Período Pós-Parto , Gravidez
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