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Table of Content

    01 September 2021, Volume 12 Issue 4
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    Orginal Articles
    Fatal and non-fatal injuries due to suspension trauma syndrome: A systematic review of definition, pathophysiology, and management controversies
    Patrizio Petrone, Sofía Espinoza-Villalobos, Gerard A. Baltazar, Kjetil Søreide, Adam Stright, Collin E.M. Brathwaite, D’Andrea K. Joseph
    2021, 12(4):  253-260.  doi:10.5847/wjem.j.1920-8642.2021.04.001
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    BACKGROUND: Suspension trauma syndrome is a life-threatening event that occurs when a person is “trapped” in a prolonged passive suspension. It is most commonly seen in people who engage in occupational or sport activities that require harness suspension. The aim of this study is to identify the predisposing factors, pathophysiology, and management of suspension trauma.
    METHODS: A review and analysis of the literature published in English and Spanish from 1972 to 2020 on suspension trauma were performed. Search sources were PubMed, Medline, Cochrane Library, MeSH, UpToDate, and Google Scholar. Articles referring to suspension trauma associated with other injury mechanisms (traumatic impact injuries, drowning, asphyxiation, or bleeding), case reports, and pediatric population were excluded.
    RESULTS: Forty-one articles were identified. Of these, 29 articles related to mechanism, pathophysiology, and management of individuals who suffered prolonged suspension trauma without associated traumatic injuries were included in the study. We encountered several controversies describing the putative pathophysiology, ranging from blood sequestration in the lower extremities versus accumulation of metabolic waste and hyperkalemia to dorsal hook-type harness as a trigger cause of positional asphyxia; to vascular compression of femoral vessels exerted by the harness causing decreased venous return. Pstients suspended in a full-body harness with dorsal hook showed more hemodynamic alterations in response to the compressive effect on the rib cage, causing a reduction in perfusion by presenting a decrease in pulse pressure. Management strategies varied across studies.
    CONCLUSIONS: Progress has been made in individualizing the population at risk and in the management of suspension trauma. We recommend the formation of consensus definitions, larger cohort or registry studies to be conducted, and experimental animal models to better understand the mechanisms in order to develop management and life support guidelines from a trauma and emergency medicine perspective.

    Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study
    Dong Jia, Chao Ji, Min Zhao
    2021, 12(4):  261-267.  doi:10.5847/wjem.j.1920-8642.2021.04.002
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    BACKGROUND: There is controversy regarding whether saddle main pulmonary artery (MPA) embolism represents a high risk of deterioration in non-high-risk acute pulmonary embolism (PE) patients. This study aims to address this issue by conducting a propensity score matching (PSM) study.
    METHODS: A total of 727 non-high-risk acute PE patients were retrospectively evaluated. We evaluated the Bova score and risk stratification to examine the risk of deterioration. Deterioration defined as any adverse event within 30 days after admission. Computed tomographic pulmonary angiography was used to identify the embolism type. All patients were matched into four subgroups by PSM according to age, sex, Bova score, and risk stratification: (1) MPA and non-MPA embolism; (2) non-saddle MPA and non-MPA embolism; (3) saddle MPA and non-saddle MPA embolism; (4) saddle MPA and non-MPA embolism. Correlations were analyzed using Cox regression analysis, and deterioration risk was compared between subgroups using Kaplan-Meier analysis.
    RESULTS: Cox regression analysis revealed that MPA embolism was correlated with deterioration, regardless of whether saddle MPA embolism was included or excluded. Saddle MPA embolism was not correlated with deterioration, regardless of comparison with non-saddle MPA embolism or non-MPA embolism. Patients with MPA and non-saddle MPA embolism presented a high risk for deterioration (log-rank test=5.23 and 4.70, P=0.022 and 0.030, respetively), while patients with saddle MPA embolism were not at a high risk of deterioration (log-rank test=1.20 and 3.17, P=0.729 and 0.077, respetively).
    CONCLUSIONS: Saddle MPA embolism is not indicative of a high risk of deterioration in non-high-risk acute PE patients.

    Two-point compression ultrasonography: Enough to rule out lower extremity deep venous thrombosis?
    Ralphe Bou Chebl, Nader El Souki, Mirabelle Geha, Imad Majzoub, Rima Kaddoura, Hady Zgheib
    2021, 12(4):  268-273.  doi:10.5847/wjem.j.1920-8642.2021.04.003
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    BACKGROUND: Deep venous thrombosis (DVT) is a major cause of morbidity and is a common presenting complaint to the emergency department (ED). Point-of-care two-point compression ultrasonography has evolved as a quick and effective way of diagnosing DVT. The purpose of this study is to validate the prevalence and distribution of venous thrombi isolated to proximal lower extremity veins, other than common femoral and popliteal veins in patients with DVT.
    METHODS: This is a single-center retrospective study that looked at patients presenting to the ED of a tertiary care hospital between January 2014 and August 2018. The clinical presentation and laboratory and imaging results were obtained using the hospital’s electronic medical record.
    RESULTS: A total of 2,507 patients underwent a lower extremity duplex ultrasound during the study period. Among them, 379 (15%) were included in the study. The percentages of isolated thrombi to the femoral vein and deep femoral vein were 7.92% and 0.53%, respectively. When the patients were stratified into the two groups of isolated DVT and two-point compression DVT, there were no statistically significant differences in the laboratory results between both groups. However, immobilized patients and patients with recent surgeries were more likely to have an isolated DVT.
    CONCLUSIONS: Thrombi isolated to proximal lower extremity veins other than the common femoral and popliteal veins make up 8.45% of DVTs. Given this significant number of missed DVTs, the authors recommend the addition of the femoral and deep femoral veins to the two-point compression exam.

    High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study
    Shan-xiang Xu, Chun-shuang Wu, Shao-yun Liu, Xiao Lu
    2021, 12(4):  274-280.  doi:10.5847/wjem.j.1920-8642.2021.04.004
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    BACKGROUND: We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen (HFNCO2) therapy and noninvasive ventilation (NIV) using lung ultrasound score (LUS) in comparison with standard care among patients in the intensive care unit (ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days.
    METHODS: During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points (at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO2. Patients with an LUS score ≥14 points (at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress; patients received HFNCO2 therapy combined with sessions of preventive NIV (4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation.
    RESULTS: In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference (P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure (P=0.61). The length of ICU stay (9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate (at 48 hours: 18.4% vs. 10.2%; seven days: 22.4% vs. 12.2%) significantly varied between the two groups (P<0.05). There was no significant difference in the 28-day mortality rate (6.1% vs. 8.2%) between the control and treatment groups.
    CONCLUSIONS: Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO2 protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.

    Clinical characteristics and risk factors of Talaromyces marneffei infection in human immunodeficiency virus-negative patients: A retrospective observational study
    Hong-yan Wei, Wen-jie Liang, Bin Li, Ling-yu Wei, An-qi Jiang, Wei-dong Chen, Peng-hao Guo, Jia Xu
    2021, 12(4):  281-286.  doi:10.5847/wjem.j.1920-8642.2021.04.005
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    BACKGROUND: To investigate the clinical characteristics and risk factors of human immunodeficiency virus (HIV)-negative patients with Talaromyces marneffei (T. marneffei) infection.
    METHODS: We retrospectively collected the clinical information of HIV-negative patients with T. marneffei infection from January 1, 2010 to June 30, 2019, and analyzed the related risk factors of poor prognosis.
    RESULTS: Twenty-five cases aging 22 to 79 years were included. Manifestations of T. marneffei infection included fever, cough, dyspnea, chest pain or distress, lymphadenopathy, ear, nose, and throat (ENT) and/or skin lesions, bone or joint pain, edema and pain in the lower extremities, digestive symptoms, icterus, malaise, and hoarseness. Two cases had no comorbidity, while 23 cases suffered from autoimmune disease, pulmonary disease, cancer, and other chronic diseases. Sixteen cases had a medication history of glucocorticoids, chemotherapy or immunosuppressors. Pulmonary lesions included interstitial infiltration, nodules, atelectasis, cavitary lesions, pleural effusion or hydropneumothorax, bronchiectasis, pulmonary fibrosis, pulmonary edema, and consolidation. The incidence of osteolytic lesions was 20%. Eight patients received antifungal monotherapy, and 11 patients received combined antifungal agents. Fifteen patients survived and ten patients were dead. The Cox regression analysis showed that reduced eosinophil counts, higher levels of blood urea nitrogen (BUN), alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactic dehydrogenase (LDH), myoglobin (Mb), procalcitonin (PCT), and galactomannan were related to poor prognosis (hazard ratio [HR]>1, P<0.05).
    CONCLUSIONS: Bone destruction is common in HIV-negative patients with T. marneffei infection. Defective cell-mediated immunity, active infection, multiple system, and organ damage can be the risk factors of poor prognosis.

    Comparison of clinical characteristics in patients with coronavirus disease and influenza A in Guangzhou, China
    Wen-qiang Jiang, Xu-sheng Li, Wen-hong Zhong, Lin-qiang Huang, Xiao-jun Lin, Miao-yun Wen, Yu-jun Deng, Xin Li, Hong-ke Zeng
    2021, 12(4):  287-292.  doi:10.5847/wjem.j.1920-8642.2021.04.006
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    BACKGROUND: This study aims to compare the epidemiological, clinical and laboratory characteristics between patients with coronavirus disease (COVID-19) and influenza A (H1N1), and to develop a differentiating model and a simple scoring system.
    METHODS: We retrospectively analyzed the data from patients with COVID-19 and H1N1. The logistic regression model based on clinical and laboratory characteristics was constructed to distinguish COVID-19 from H1N1. Scores were assigned to each of independent discrimination factors based on their odds ratios. The performance of the prediction model and scoring system was assessed.
    RESULTS: A total of 236 patients were recruited, including 20 COVID-19 patients and 216 H1N1 patients. Logistic regression revealed that age >34 years, temperature ≤37.5 °C, no sputum or myalgia, lymphocyte ratio ≥20% and creatine kinase-myocardial band isoenzyme (CK-MB) >9.7 U/L were independent differentiating factors for COVID-19. The area under curves (AUCs) of the prediction model and scoring system in differentiating COVID-19 from H1N1 were 0.988 and 0.962, respectively.
    CONCLUSIONS: There are certain differences in clinical and laboratory features between patients with COVID-19 and H1N1. The simple scoring system may be a useful tool for the early identification of COVID-19 patients from H1N1 patients.

    Development of septic shock and prognostic assessment in critically ill patients with coronavirus disease outside Wuhan, China
    Ren-qi Yao, Chao Ren, Di Ren, Jin-xiu Li, Ying Li, Xue-yan Liu, Lei Huang, Yong Liu, Mian Peng, Yong-wen Feng, Yong-ming Yao
    2021, 12(4):  293-298.  doi:10.5847/wjem.j.1920-8642.2021.04.007
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    BACKGROUND: The study aims to illustrate the clinical characteristics and development of septic shock in intensive care unit (ICU) patients confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and to perform a comprehensive analysis of the association between septic shock and clinical outcomes in critically ill patients with coronavirus disease (COVID-19).
    METHODS: Patients confirmed with SARS-CoV-2 infection, who were admitted to the ICU of the Third People’s Hospital of Shenzhen from January 1 to February 7, 2020, were enrolled. Clinical characteristics and outcomes were compared between patients with and without septic shock.
    RESULTS: In this study, 35 critically ill patients with COVID-19 were included. Among them, the median age was 64 years (interquartile range [IQR] 59-67 years), and 10 (28.4%) patients were female. The median ICU length of stay was 16 days (IQR 8-23 days). Three (8.6%) patients died during hospitalization. Nine (25.7%) patients developed septic shock in the ICU, and these patients had a significantly higher incidence of organ dysfunction and a worse prognosis than patients without septic shock.
    CONCLUSIONS: Septic shock is associated with a poor outcome in critically ill COVID-19 patients and is one of the hallmarks of the severity of patients receiving ICU care. A dysregulated immune response, uncontrolled inflammation, and coagulation disorders are strongly associated with the development and progression of COVID-19-related septic shock.

    Drug-induced erythroderma in patients with acquired immunodeficiency syndrome
    Wei-fang Zhu, De-ren Fang, Hong Fang
    2021, 12(4):  299-302.  doi:10.5847/wjem.j.1920-8642.2021.04.008
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    BACKGROUND: To explore the clinical manifestations, diagnosis, and treatment of patients with acquired immunodeficiency syndrome (AIDS) complicated with drug-induced erythroderma.
    METHODS: The clinical data of 12 AIDS patients with drug-induced erythroderma in our hospital were retrospectively analyzed. The general information, offending medications, complications, modified severity-of-illness score for toxic epidermal necrolysis (SCORTEN) scores, and disease outcome spectrums were analyzed.
    RESULTS: Drug-induced erythroderma was mostly caused by antiviral drugs, antituberculosis drugs, antibiotics, traditional Chinese medicine, and immune checkpoint inhibitors. The spectrum of sensitizing drugs was broad, the clinical situation was complex, and infections were common. The affected areas were greater than 40% body surface area in all patients. The modified SCOTERN score averaged 3.01±0.99. All patients were treated with glucocorticoids, and nine patients were treated with intravenous immunoglobulin (IVIG) pulse therapy at the same time. The average time to effectiveness was 7.08±2.23 days, and the average hospital stay was 17.92±8.46 days. Eleven patients were cured, and one patient died of secondary multiple infections, who had a modified SCORTEN score of 5 points. The mortality rate in this study was 8.3%.
    CONCLUSIONS: The clinical situation of AIDS patients with drug-induced erythroderma in hospitalized patients is complex and the co-infection rate is high. The use of modified SCORTEN score may objectively and accurately assess the conditions, and the use of glucocorticoid combined with IVIG therapy may improve the prognosis.

    Protective effect of extracorporeal membrane pulmonary oxygenation combined with cardiopulmonary resuscitation on post-resuscitation lung injury
    Ji-yang Ling, Chun-sheng Li, Yun Zhang, Xiao-li Yuan, Bo Liu, Yong Liang, Qiang Zhang
    2021, 12(4):  303-308.  doi:10.5847/wjem.j.1920-8642.2021.04.009
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    BACKGROUND: Cardiac arrest (CA) is a critical condition that is a concern to healthcare workers. Comparative studies on extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) technologies have shown that ECPR is superior to CCPR. However, there is a lack of studies that compare the protective effects of these two resuscitative methods on organs. Therefore, we aim to perform experiments in swine models of ventricular fibrillation-induced CA to study whether the early application of ECPR has advantages over CCPR in the lung injury and to explore the protective mechanism of ECPR on the post-resuscitation pulmonary injury.
    METHODS: Sixteen male swine were randomized to CCPR (CCPR; n=8; CCPR alone) and ECPR (ECPR; n=8; extracorporeal membrane oxygenation with CCPR) groups, with the restoration of spontaneous circulation at 6 hours as an endpoint.
    RESULTS: For the two groups, the survival rates between the two groups were not statistically significant (P>0.05), the blood and lung biomarkers were statistically significant (P<0.05), and the extravascular lung water and pulmonary vascular permeability index were statistically significant (P<0.01). Compared with the ECPR group, electron microscopy revealed mostly vacuolated intracellular alveolar type II lamellar bodies and a fuzzy lamellar structure with widening and blurring of the blood-gas barrier in the CCPR group.
    CONCLUSIONS: ECPR may have pulmonary protective effects, possibly related to the regulation of alveolar surface-active proteins and mitigated oxidative stress response post-resuscitation.

    Left-sided vagus nerve stimulation improves cardiopulmonary resuscitation outcomes in rats as effectively as right-sided vagus nerve stimulation 
    Wei-jing Shao, Ting-ting Shu, Shuang Xu, Li-cai Liang, Jehane Michael Le Grange, Yu-ran Zhou, He Huang, Yu Cai, Qing Zhang, Peng Sun
    2021, 12(4):  309-316.  doi:10.5847/wjem.j.1920-8642.2021.04.010
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    BACKGROUND: Our group previously reported that right-sided vagus nerve stimulation (RVNS) significantly improved outcomes after cardiopulmonary resuscitation (CPR) in a rat model of cardiac arrest (CA). However, whether left-sided vagus nerve stimulation (LVNS) could achieve the same effect as RVNS in CPR outcomes remains unknown.
    METHODS: A rat model of CA was established using modified percutaneous epicardial electrical stimulation to induce ventricular fibrillation (VF). Rats were treated with LVNS or RVNS for 30 minutes before the induction of VF. All animals were observed closely within 72 hours after return of spontaneous circulation (ROSC), and their health and behavior were evaluated every 24 hours.
    RESULTS: Compared with those in the RVNS group, the hemodynamic measurements in the LVNS group decreased more notably. Vagus nerve stimulation (VNS) decreased the serum levels of tumor necrosis factor-alpha (TNF-α) and the arrhythmia score, and attenuated inflammatory infiltration in myocardial tissue after ROSC, regardless of the side of stimulation, compared with findings in the CPR group. Both LVNS and RVNS ameliorated myocardial function and increased the expression of α-7 nicotinic acetylcholine receptor in the myocardium after ROSC. Moreover, a clear improvement in 72-hour survival was shown with VNS pre-treatment, with no significant difference in efficacy when comparing the laterality of stimulation.
    CONCLUSIONS: LVNS may have similar effects as RVNS on improving outcomes after CPR.

    Research Letter
    Case Letters
    Immediate oral amiodarone re-challenge following the development of parenteral-induced acute liver toxicity
    Joseph Offenbacher, Farnam Kazi, Niel Chen, Mohamed Mohamed, Jasmine Chacko, Nils Guttenplan, Vincent Nguyen
    2021, 12(4):  321-323.  doi:10.5847/wjem.j.1920-8642.2021.04.012
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    Extracorporeal membrane oxygenation treatment for high-risk pulmonary embolism with cardiac arrest in a young adult male
    Zhi-rong Zhang, Xia-qing Zhou, Zhao-kun Fan, Yin Shi, Ying-ying Shen, Chen Zhu, Wen Feng, Ling-cong Wang
    2021, 12(4):  324-326.  doi:10.5847/wjem.j.1920-8642.2021.04.013
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    Thoracic aortic rupture due to airbag deployment
    Michal Plodr, Miroslav Safr, Ivo Novak
    2021, 12(4):  327-329.  doi:10.5847/wjem.j.1920-8642.2021.04.014
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    Rare autonomic nervous system dysfunction: Alternating bilateral mydriasis
    Peng Xu, Jing Wu, Li-da Su, Fang Qian, Hu-qiang Wan, Yue Yu, Min Li, Ying-hong Hu, Man Huang
    2021, 12(4):  330-331.  doi:10.5847/wjem.j.1920-8642.2021.04.015
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    Filter implantation for double inferior vena cava: A case report and literature review
    Lei Jiang, Chuan-feng Yang, Jie Lin
    2021, 12(4):  332-334.  doi:10.5847/wjem.j.1920-8642.2021.04.016
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    The cell phone in the twenty-first century: Risk for addiction or ingestion? Case report and review of the literature
    Sanja Dragasevic, Milica Stojkovic Lalosevic, Ljubisa Toncev, Tamara Milovanovic, Aleksandra Pavlovic Markovic, Srdjan Djuranovic, Dragan Popovic
    2021, 12(4):  335-336.  doi:10.5847/wjem.j.1920-8642.2021.04.017
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