World Journal of Emergency Medicine

What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance?

Lori Stolz, Elaine Situ-LaCasse, Josie Acuña, Matthew Thompson, Nicolaus Hawbaker, Josephine Valenzuela, Uwe Stolz, Srikar Adhikari

2021, 12(3): 169-173. doi:10.5847/wjem.j.1920-8642.2021.03.001

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BACKGROUND: Traditionally performed using a subxiphoid approach, the increasing use of point-of-care ultrasound in the emergency department has made other approaches (parasternal and apical) for pericardiocentesis viable. The aim of this study is to identify the ideal approach for emergency-physician-performed ultrasound-guided pericardiocentesis as determined by ultrasound image quality, distance from surface to pericardial fluid, and likely obstructions or complications.

METHODS: A retrospective review of point-of-care cardiac ultrasound examinations was performed in two urban academic emergency departments for the presence of pericardial effusions. The images were reviewed for technical quality, distance of effusion from skin surface, and predicted complications.

RESULTS: A total of 166 pericardial effusions were identified during the study period. The mean skin-to-pericardial fluid distance was 5.6 cm (95% confidence interval [95% CI] 5.2-6.0 cm) for the subxiphoid views, which was significantly greater than that for the parasternal (2.7 cm [95% CI 2.5-2.8 cm], P<0.001) and apical (2.5 cm [95% CI 2.3-2.7 cm], P<0.001) views. The subxiphoid view had the highest predicted complication rate at 79.7% (95% CI 71.5%-86.4%), which was significantly greater than the apical (31.9%; 95% CI 21.4%-44.0%, P<0.001) and parasternal (20.2%; 95% CI 12.8%-29.5%, P<0.001) views.

CONCLUSIONS: Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach. The distance from skin to fluid collection is the least in both of these views.

Accuracy of training blood volume quantification using a visual estimation tool

Janett Kreutziger, Philip Puchner, Stefan Schmid, Wolfgang Mayer, Harald Prossliner, Wolfgang Lederer

2021, 12(3): 174-178. doi:10.5847/wjem.j.1920-8642.2021.03.002

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BACKGROUND: We investigated whether the use of a specially designed visual estimation tool may improve accuracy in quantifying blood volumes related to surface spreading.

METHODS: A prospective, paired-control, single-blinded experimental study was performed at a medical university. Anesthesiologists and emergency medical personnel estimated various blood volumes on surfaces with varying absorptivity (carpet, towel, polyvinyl chloride, wooden flooring) in an experimental setting. We assessed the sensitivity of training blood volume quantification using a self-designed visual estimation tool by comparing the accuracy of visual blood volume estimations before and after practical training with the tool.

RESULTS: A total of 352 estimations by 44 participants were evaluated. Accurate estimations improved significantly from pre-training to post-training (P<0.05). The sensitivity of blood volume quantification was 33.0% after training with the visual estimation tool. Estimations did not depend on age, profession, gender or years of the estimator’s professional experience.

CONCLUSIONS: Training with a visual estimation tool by professional rescuers can improve the estimation accuracy of blood volumes spread on surfaces with varying absorptivity.

Risk factors and predictive model of adrenocortical insufficiency in patients with traumatic brain injury

Gui-long Feng, Miao-miao Zheng, Shi-hong Yao, Yin-qi Li, Shao-jun Zhang, Wei-jing Wen, Kai Fan, Jia-li Zhang, Xiao Zhang

2021, 12(3): 179-184. doi:10.5847/wjem.j.1920-8642.2021.03.003

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BACKGROUND: Neuroendocrine dysfunction after traumatic brain injury (TBI) has received increased attention due to its impact on the recovery of neural function. The purpose of this study is to investigate the incidence and risk factors of adrenocortical insufficiency (AI) after TBI to reveal independent predictors and build a prediction model of AI after TBI.

METHODS: Enrolled patients were grouped into the AI and non-AI groups. Fourteen preset impact factors were recorded. Patients were regrouped according to each impact factor as a categorical variable. Univariate and multiple logistic regression analyses were performed to screen the related independent risk factors of AI after TBI and develop the predictive model.

RESULTS: A total of 108 patients were recruited, of whom 34 (31.5%) patients had AI. Nine factors (age, Glasgow Coma Scale [GCS] score on admission, mean arterial pressure [MAP], urinary volume, serum sodium level, cerebral hernia, frontal lobe contusion, diffuse axonal injury [DAI], and skull base fracture) were probably related to AI after TBI. Three factors (urinary volume [X₄], serum sodium level [X₅], and DAI [X₈]) were independent variables, based on which a prediction model was developed (logit P= -3.552+2.583X₄+2.235X₅+2.269X₈).

CONCLUSIONS: The incidence of AI after TBI is high. Factors such as age, GCS score, MAP, urinary volume, serum sodium level, cerebral hernia, frontal lobe contusion, DAI, and skull base fracture are probably related to AI after TBI. Urinary volume, serum sodium level, and DAI are the independent predictors of AI after TBI.

Jun Yin, Yao Chen, Jun-ling Huang, Lei Yan, Zhong-shu Kuang, Ming-ming Xue, Si Sun, Hao Xiang, Yan-yan Hu, Zhi-min Dong, Chao-yang Tong, Chun-xue Bai, Zhen-ju Song

2021, 12(3): 185-191. doi:10.5847/wjem.j.1920-8642.2021.03.004

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BACKGROUND: The dynamic monitoring of immune status is crucial to the precise and individualized treatment of sepsis. In this study, we aim to introduce a model to describe and monitor the immune status of sepsis and to explore its prognostic value.

METHODS: A prospective observational study was carried out in Zhongshan Hospital, Fudan University, enrolling septic patients admitted between July 2016 and December 2018. Blood samples were collected at days 1 and 3. Serum cytokine levels (e.g., tumor necrosis factor-α [TNF-α], interleukin-10 [IL-10]) and CD14⁺ monocyte human leukocyte antigen-D-related (HLA-DR) expression were measured to serve as immune markers. Classification of each immune status, namely systemic inflammatory response syndrome (SIRS), compensatory anti-inflammatory response syndrome (CARS), and mixed antagonistic response syndrome (MARS), was defined based on levels of immune markers. Changes of immune status were classified into four groups which were stabilization (SB), deterioration (DT), remission (RM), and non-remission (NR).

RESULTS: A total of 174 septic patients were enrolled including 50 non-survivors. Multivariate analysis discovered that IL-10 and HLA-DR expression levels at day 3 were independent prognostic factors. Patients with MARS had the highest mortality rate. Immune status of 46.1% patients changed from day 1 to day 3. Among four groups of immune status changes, DT had the highest mortality rate, followed by NR, RM, and SB with mortality rates of 64.7%, 42.9%, and 11.2%, respectively.

CONCLUSIONS: Severe immune disorder defined as MARS or deterioration of immune status defined as DT lead to the worst outcomes. The preliminary model of the classification and dynamic monitoring of immune status based on immune markers has prognostic values and is worthy of further investigation.

Analysis of risk factors for early stent thrombosis in the Chinese population: A multicenter restrospective study

Yu-peng Wang, Lei Ding, Rui-tao Zhang, Xiao-zeng Wang, Dan-qing Yu, Shou-yan Hao, Jin-wei Tian, Zhen-yu Liu, Xiang-qian Qi, Hu Tan, Hong-yi Wu, Feng-hua Ding, Li-jun Guo, Ya-ling Han

2021, 12(3): 192-197. doi:10.5847/wjem.j.1920-8642.2021.03.005

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BACKGROUND: The predictive scoring systems for early stent thrombosis (EST) remains blank in China. The study aims to evaluate the risk factors and conduct a prediction model of EST in the Chinese population.

METHODS: EST was defined as thrombosis that occurs within the first 30 days after primary percutaneous coronary intervention (PCI). Patients from ten Chinese hospitals diagnosed as stent thrombosis (ST) from January 2010 to December 2016 were retrospectively included as the study group. A control group (1 case:2 controls) was created by including patients without ST, major adverse cardiovascular events, or cerebrovascular events during follow-up. The present study evaluated 426 patients with single-vessel lesions and ultimately included 40 patients with EST and 80 control patients, who were included to identify factors that predicted EST and to develop a prediction scoring system. The other 171 patients without integrated 1:2 pair were used for external validation.

RESULTS: EST was independently associated with a low hemoglobin concentration (adjusted odds ratio [OR] 0.946, 95% confidence interval [95% CI] 0.901-0.993, P=0.026), a high pre-PCI Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score (OR 1.166, 95% CI 1.049-1.297, P=0.004), and a DAPT (DAPT) duration of <30 days (OR 28.033, 95% CI 5.302-272.834, P<0.001). The simple EST prediction score provided an area under the curve (AUC) of 0.854 (95% CI 0.777-0.932, P<0.001) with 70.0% sensitivity and 90.0% specificity, and 0.742 (95% CI 0.649-0.835, P<0.001) with 54.5% sensitivity and 81.0% specificity for external validation dataset.

CONCLUSIONS: EST may be independently associated with DAPT discontinuation within 30 days, a low hemoglobin concentration, and a high SYNTAX score. The scoring system also has a good ability to predict the risk of EST and may be useful in the clinical setting.

Optimized strategy of rotational atherectomy of underexpanded coronary stents in patients with acute coronary syndrome

Kun Cui, You-quan Shi, Yuan-zheng Zhang, Zheng-gong Li, Chang-ling Li

2021, 12(3): 198-201. doi:10.5847/wjem.j.1920-8642.2021.03.006

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BACKGROUND: Stent under-expansion is a main cause of acute coronary syndrome (ACS), which can lead to serious clinical outcomes. The rotational atherectomy of underexpanded coronary stents (academically called stent ablation, SA) by intravascular ultrasound (IVUS) may provide more visual reference in the intervention. We aim to analyze the procedural and long-term outcomes of the optimized strategy of SA in patients with ACS and to provide real-world data on this technique.

METHODS: A total of 11 patients with ACS who underwent SA between April 2017 and January 2019 were analyzed. Clinical follow-ups were obtained either by telephone call or by scheduled visit. Clinical end-points included periprocedural and postprocedural myocardial infarction, stent thrombosis, target lesion revascularization, and major adverse cardiac events.

RESULTS: The mean age of patients was 69.6±6.5 years, and five (45.5%) patients were males. All cases presented with unstable angina and were admitted with ACS. All patients required at least two burrs during the intervention and the size of the burr was selected based on the data of minimum lumen diameter (MLD), and the first and the second burr/stent MLD ratios were 0.93 (0.88-0.99) and 1.09 (1.02-1.14), respectively. Nine patients were treated with drug-eluting stents and two were treated with drug-coated balloons. There were no complications including no flow, perforation, or burr entrapment during the intervention. No in-hospital deaths or major adverse cardiac events were documented during the follow-up period. In our study, less contrast agent and a lower dose of radiation were used during the intervention.

CONCLUSIONS: SA guided by IVUS can reduce the risk of complications, assess the results of surgery, inform the selection of stent size, and decrease the required dose of radiation and contrast.

Intensivists’ response to hyperoxemia in mechanical ventilation patients: The status quo and related factors

Zi-wei Ke, Yue Jiang, Ya-ping Bao, Ye-qin Yang, Xiao-mei Zong, Min Liu, Xiang-yun Guan, Zhong-qiu Lu

2021, 12(3): 202-206. doi:10.5847/wjem.j.1920-8642.2021.03.007

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BACKGROUND: Due to the still sparse literature in China, the investigation of hyperoxemia management is required. Thus, we aim to conduct a retrospective study to provide more information about hyperoxemia management in intensive care unit (ICU) patients.

METHODS: We retrospectively screened the medical records of adult patients (age ≥18 years) who required mechanical ventilation (MV) ≥24 hours from January 1, 2018, to December 31, 2018. All arterial blood gas (ABG) tested during MV was retrieved, and MV settings were recorded. The median arterial partial pressure of oxygen (PaO₂) >120 mmHg (1 mmHg=0.133 kPa) was defined as mild to moderate hyperoxemia, and PaO₂>300 mmHg as extreme hyperoxemia. Intensivists’ response to hyperoxemia was assessed based on the reduction of fraction of inspired oxygen (FiO₂) within one hour after hyperoxemia was recorded. Multivariable logistic regression analysis was performed to determine the independent factors associated with the intensivists’ response to hyperoxemia.

RESULTS: A total of 592 patients were finally analyzed. The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 21 (15-26). The PaO₂, arterial oxygen saturation (SaO₂), FiO₂, and positive end expiratory pressure (PEEP) were 96.4 (74.0-126.0) mmHg, 97.8% (95.2%-99.1%), 0.4 (0.4-0.5), and 5 (3-6) cmH₂O, respectively. Totally 174 (29.39%) patients had PaO₂ >120 mmHg, and 19 (3.21%) patients had extreme hyperoxemia at PaO₂ >300 mmHg. In cases of mild to moderate hyperoxemia with FiO₂ ≤0.4, only 13 (2.20%) patients had a decrease in FiO₂ within one hour. The multivariable logistic regression analysis showed that a positive response was independently associated with FiO₂ (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.06-1.12, P<0.001), PaO₂ (OR 1.01, 95% CI 1.00-1.01, P=0.002), and working shifts (OR 5.09, 95% CI 1.87-13.80, P=0.001).

CONCLUSIONS: Hyperoxemia occurs frequently and is neglected in most cases, particularly when mild to moderate hyperoxemia, hyperoxemia with lower FiO₂, hyperoxemia during night and middle-night shifts, or FiO₂ less likely to be decreased. Patients may be at a risk of oxygen toxicity because of the liberal oxygen strategy. Therefore, further research is needed to improve oxygen management for patients with MV in the ICUs.

Efficacy and safety of low-dose corticosteroids for acute respiratory distress syndrome: A systematic review and meta-analysis

Yu-qing Cui, Xian-fei Ding, Huo-yan Liang, Dong Wang, Xiao-juan Zhang, Li-feng Li, Quan-cheng Kan, Le-xin Wang, Tong-wen Sun

2021, 12(3): 207-213. doi:10.5847/wjem.j.1920-8642.2021.03.008

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BACKGROUND: There are conflicting results regarding whether corticosteroids have better efficacy than placebo in acute respiratory distress syndrome (ARDS) patients. Therefore, we aim to further evaluate the efficacy and safety of corticosteroids in adult ARDS patients.

METHODS: The databases, including Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, were searched from their inception to May 2, 2020. Randomized controlled trials (RCTs) and observational cohort studies were selected to assess the use of corticosteroids in adult ARDS patients. The quality of the results was judged by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The inverse-variance method with random or fixed effects modeling was used to compute pooled odds ratio (OR), standardized mean difference (SMD), and their 95% confidence interval (CI).

RESULTS: Eight eligible RCTs and six cohort studies were included. The use of corticosteroids was associated with reduced mortality (OR 0.57, 95% CI 0.43-0.76, I²=35.1%, P=0.148) in ARDS patients, and the result was confirmed in the included cohort studies (OR 0.51, 95% CI 0.27-0.95, I²=66.7%, P=0.010). The subgroup analysis stratified by the initiation time and duration of corticosteroid use showed that early ARDS and prolonged corticosteroid use had significant survival benefits in the RCTs. The low-dose corticosteroid use was also associated with significantly more ventilator-free days and a reduced rate of new infections in ARDS patients.

CONCLUSIONS: The low-dose corticosteroid therapy may be safe and reduce mortality, especially in patients with prolonged treatment and early ARDS.

Role of epithelial-to-mesenchymal transition in the pulmonary fibrosis induced by paraquat in rats

Jian-hua Yi, Zhao-cai Zhang, Mei-bian Zhang, Xin He, Hao-ran Lin, Hai-wen Huang, Hai-bin Dai, Yu-wen Huang

2021, 12(3): 214-220. doi:10.5847/wjem.j.1920-8642.2021.03.009

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BACKGROUND: This study aims to explore the characteristics of the epithelial-to-mesenchymal transition (EMT) process and its underlying molecular mechanisms in the period of paraquat (PQ)-induced pulmonary fibrosis (PF).

METHODS: Picrosirius red staining and collagen volume fraction were utilized to evaluate the pathological changes of PQ-induced PF in rats. Immunohistochemistry, Western blot, and real-time reverse transcriptase-polymerase chain reaction (RT-PCR) were used to measure the protein and gene expression of EMT markers, EMT-associated transcription factors, and regulators of EMT-related pathways, respectively.

RESULTS: The collagen deposition in the alveolar septum and increased PF markers were characteristics of pathological changes in PQ-induced PF, reached a peak on day 14 after PQ poisoning, and then decreased on day 21. The protein and gene expression of the fibrosis marker, EMT markers, transcription factors, and regulators of EMT-related signaling pathways significantly increased at different time points after PQ poisoning compared with corresponding controls (P<0.05), and most of them reached a peak on day 14, followed by a decrease on day 21. The gene expression of EMT markers was significantly correlated with PF markers, transcription factors, and regulators of EMT-related signaling pathways (P<0.05). The mRNA expression of transcription factors was significantly correlated with that of TGF-β1 and Smad2 (P<0.05 or P<0.01), instead of Wnt2 and β-catenin (P>0.05).

CONCLUSIONS: EMT process plays a role in the PQ-induced PF, in which most PF and EMT markers have a peak phenomenon, and its underlying molecular mechanisms might be determined by further studies.

Is routine measurement of international normalized ratio necessary as part of the investigation of patients with cardiac-type chest pain?

Samuel G. Campbell, Kirk Magee, Ismail Cajee, Simon Field, Michael B. Butler, Christine L. Campbell, Sarah E. Bryson

2021, 12(3): 221-224. doi:10.5847/wjem.j.1920-8642.2021.03.010

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Pediatric emergency preparedness in Canadian family physician offices: A national survey

Dayae Jeong, Subhrata Verma, Anushka Weeraratne, Marina Atalla, Mohammed Hassan-Ali, April J. Kam

2021, 12(3): 225-227. doi:10.5847/wjem.j.1920-8642.2021.03.011

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