Rare Life-threatening Emergency Research Articles

Neglected Biliary Stent with Hepatico-lithiasis Causing Left Lobe Pyogenic Liver Abscess with Rupture into Left Pleural Cavity: A rare Life-threatening Emergency

Abstract Biliary tract disease is currently the leading cause of pyogenic liver abscess (PLA) and complications of rupture are associated with high mortality and morbidity even with current medical knowledge advancement. We report a 35-year-old female who presented in emergency setting with complaints of jaundice, abdominal pain, fever, and respiratory distress. Patient had prior history of endoscopic management of biliary stones about 6 years back followed by asymptomatic period. Patient was managed by percutaneous drainage of left lobe liver abscess and left pleural empyema after initial resuscitation with further investigations revealing biliary stent with left hepatic abscess with transdiaphragmatic extension into left hemithorax. Neglected biliary stent has been reported to cause severe cholangitis with PLAs and these patients require immediate timely attention to the management of abscess and its complications.

Critically ill severe hypothyroidism: a retrospective multicenter cohort study

BackgroundSevere hypothyroidism (SH) is a rare but life-threatening endocrine emergency. Only a few data are available on its management and outcomes of the most severe forms requiring ICU admission. We aimed to describe the clinical manifestations, management, and in-ICU and 6-month survival rates of these patients.MethodsWe conducted a retrospective, multicenter study over 18 years in 32 French ICUs. The local medical records of patients from each participating ICU were screened using the International Classification of Disease 10th revision. Inclusion criteria were the presence of biological hypothyroidism associated with at least one cardinal sign among alteration of consciousness, hypothermia and circulatory failure, and at least one SH-related organ failure.ResultsEighty-two patients were included in the study. Thyroiditis and thyroidectomy represented the main SH etiologies (29% and 19%, respectively), while hypothyroidism was unknown in 44 patients (54%) before ICU admission. The most frequent SH triggers were levothyroxine discontinuation (28%), sepsis (15%), and amiodarone-related hypothyroidism (11%). Clinical presentations included hypothermia (66%), hemodynamic failure (57%), and coma (52%). In-ICU and 6-month mortality rates were 26% and 39%, respectively. Multivariable analyses retained age > 70 years [odds ratio OR 6.01 (1.75–24.1)] Sequential Organ-Failure Assessment score cardiovascular component ≥ 2 [OR 11.1 (2.47–84.2)] and ventilation component ≥ 2 [OR 4.52 (1.27–18.6)] as being independently associated with in-ICU mortality.ConclusionsSH is a rare life-threatening emergency with various clinical presentations. Hemodynamic and respiratory failures are strongly associated with worse outcomes. The very high mortality prompts early diagnosis and rapid levothyroxine administration with close cardiac and hemodynamic monitoring.

Selective sensory nerve blocks for effective pain management in the emergency department for a term pregnant cobra snake envenomation patient.

Sir, Snake bites with envenomation are a rare life-threatening emergency during pregnancy.[1] We report a case of a young full-term parturient who reported intense localized pain at the cobra (Naza Naza) bite site which was managed successfully by selective sensory nerve blocks. She subsequently underwent a caesarean section under spinal anaesthesia and had an uneventful post-partum course. A 26-year-old eight month pregnant patient presented to the emergency department (ED) post-cobra bite. The patient was taken to a local hospital within 30 min of the event. The bite mark was present on the right foot near the 4th toe [Figure 1]. There was minimal localized swelling but intense pain in the bite area. She had an episode of vomiting 45 min post-snake bite (suggesting the onset of systemic symptoms) and was administered 10 vials of anti-snake venom and referred to our tertiary care set-up.Figure 1: Distribution of superficial peroneal nerve (a); Probe placement for USG-guided block (b); USG image showing the superficial peroneal nerve (c); Snake bite mark on foot of the patient (d)When she presented to our ED 3h post-bite, the swelling had increased considerably and 10 more vials of anti-snake venom were infused. The investigations revealed leucocytosis with mild thrombocytopenia and anaemia. Local site pain was unbearable even after intravenous paracetamol and diclofenac. A superficial peroneal nerve and sural nerve blocks to cover the dorsolateral aspect of the foot was planned. The nerves were localized using a linear transducer (8–13 MHz) and a 3.5 ml of 0.75% ropivacaine was deposited. [Figures 1 and 2] Within 5 mins, the numeric rating scale (NRS) fall to 2 from the initial score of 10. At 10h, the patient reported an NRS score of 6, and the same blocks were repeated and effective pain relief was reported. The patient underwent a caesarean section under spinal anaesthesia at 18h post-admission given foetal distress. The baby was kept on nasal continuous positive airway pressure for 18h in view of respiratory distress and both of them were discharged in stable condition on the 3rd day of admission.Figure 2: Distribution of sural nerve (a); Probe placement for USG-guided block (b); USG image showing the sural nerve (c)Snake bites are rare in pregnancy but maternal mortality and foetal loss remain high.[1] An early presentation and rapidity of treatment with anti-snake venom probably led to a good outcome in this case. Acute localized moderate-to-severe pain is often documented as the first sign of a venomous snake bite (VSB).[2,3] The presynaptic and postsynaptic neurotoxins may directly interact with the nerve endings or indirectly cause severe pain secondary to ischemia due to local oedema.[1] Antivenom treatment fails to alleviate the local pain which may last for 48–72 h.[3] Weak opioids such as tramadol or paracetamol often provide inadequate analgesia.[4] Systemic opioids and non-steroidal anti-inflammatory drugs may be harmful to the foetus in term pregnancy. Furthermore, opioids can increase the risk of respiratory depression in neurotoxic envenomation cases as seen in cobra bite.[4] Untreated pain can have adverse consequences on foeto-maternal circulation.[5] In our case, the patient had intense pain with an NRS of 10 despite analgesics and responded well to nerve blocks. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

SIMULTANEOUS BILATERAL SPONTANEOUS PNEUMOTHORAX (SBSP) AS THE FIRST PRESENTATION OF COPD

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: A secondary spontaneous pneumothorax is defined as pneumothorax secondary to underlying lung disease that occurs without a trauma or iatrogenic cause [1,2]. Simultaneous bilateral spontaneous pneumothorax (SBSP) forms a total of 1.3% of all spontaneous pneumothorax cases [3]. CASE PRESENTATION: A 66-year-old male with significant smoking history who presented to the Emergency Department (ED) for exertional shortness of breath of 3 weeks duration associated with mild chest pain and persistent dry cough. The patient initially went to a secondary hospital where he was diagnosed with bilateral pneumothoraces and was treated with bilateral pigtail chest tubes and oxygen therapy. However, he was in moderate respiratory distress; hence he was referred to a tertiary hospital. In ED, his vital signs were normal except for low oxygen saturation. Physical examination was remarkable for moderate distress, decreased breath sounds bilaterally and bilateral pigtail chest tubes attached. Laboratory studies including metabolic panel and complete blood counts were normal except for leukocytosis of 19.7 K/CMM. Computed tomography scan showed 60-70% bilateral pneumothoraxes, 2 chest tubes, and bilateral patchy consolidation (Figure 1). Patient was followed by repeated physical examinations and CXRs. His right pneumothorax improved and the chest tube was removed. However, the left chest tube showed persistent air leak necessitating pleurodesis with Doxycycline initially and Talc later as the patient wanted to be treated conservatively. Later, he became hemodynamically unstable, CXR showed right tension pneumothorax and an urgent right chest tube was inserted which normalized his vital signs. However, shortly after, he became unstable again, repeated CXR showed recurrent right tension pneumothorax, another chest tube was inserted complicated by right hemothorax; hence he was taken emergently for Video-Assisted Thoracoscopic Surgery (VATS) for hemothorax evacuation. Biopsy from VATS showed dense fibrosis and honeycombing emphysematous changes. Right-sided talc pleurodesis was done, and both chest tubes were removed. Repeated CXR demonstrated small left pneumothorax. Patient was discharged home, pulmonary rehabilitation and smoking cessation were strongly recommended. DISCUSSION: SBSP is a rare life-threatening emergency that requires immediate recognition and treatment. The presentation may vary from mild respiratory distress to cardiopulmonary failure. Diagnosis is confirmed on radiological findings and bilateral chest tubes are the initial appropriate treatment which in 82% of cases can stop air leak in 48 hours. However, the persistent air leak is an indication for surgery with VATS being most common. CONCLUSIONS: Presentation of SBSP can vary from mild respiratory symptoms to respiratory failure, diagnosis can be confirmed on chest radiography and the treatment is emergent chest tube placement. Reference #1: [1]Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000 Mar 23;342(12):868-74. Review. PubMed PMID: 10727592. [2] Noppen M, De Keukeleire T. Pneumothorax. Respiration. 2008;76(2):121-7. https://doi.org/10.1159/000135932. Epub 2008 Jun 26. Review. PubMed PMID: 18708734 [3] Esther Graf-Deuel, Andreas Knoblauch: Simultaneous bilateral spontaneous pneumothorax. Chest. 1994;105:1142–6. DISCLOSURES: No relevant relationships by Noor Hajjaj, source=Web Response no disclosure on file for Chandler Patton; no disclosure on file for Julio Pernia; No relevant relationships by Ahmad Sharayah, source=Web Response

The effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital.

Preparing healthcare providers to manage relatively rare life-threatening emergency situations effectively is a challenge. Training sessions enable staff to rehearse for these events and are recommended by several reports and guidelines. In this review we have focused on interactive training, this includes any element where the training is not solely didactic but provides opportunity for discussions, rehearsals, or interaction with faculty or technology. It is important to understand the effective methods and essential elements for successful emergency training so that resources can be appropriately targeted to improve outcomes. To assess the effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital on patient outcomes, clinical care practices, or organisational practices, and to identify essential components of effective interactive emergency training programmes. We searched CENTRAL, MEDLINE, Embase, CINAHL and ERIC and two trials registers up to 11 March 2019. We searched references of included studies, conference proceedings, and contacted study authors. We included randomised trials and cluster-randomised trials comparing interactive training for emergency situations with standard/no training. We defined emergency situations as those in which immediate lifesaving action is required, for example cardiac arrests and major haemorrhage. We included all studies where healthcare workers involved in providing direct clinical care were participants. We excluded studies outside of a hospital setting or where the intervention was not targeted at practicing healthcare workers. We included trials irrespective of publication status, date, and language. We used standard methodological procedures expected by Cochrane and Cochrane Effective Practice and Organisation of Care (EPOC) Group. Two review authors independently extracted data and assessed the risk of bias of each included trial. Due to the small number of studies and the heterogeneity in outcome measures, we were unable to perform the planned meta-analysis. We provide a structured synthesis for the following outcomes: survival to hospital discharge, morbidity rate, protocol or guideline adherence, patient outcomes, clinical practice outcomes, and organisation-of-care outcomes. We used the GRADE approach to rate the certainty of the evidence and the strength of recommendations for each outcome. We included 11 studies that reported on 2000 healthcare providers and over 300,000 patients; one study did not report the number of participants. Seven were cluster randomised trials and four were single centre studies. Four studies focused on obstetric training, three on obstetric and neonatal care, two on neonatal training, one on trauma and one on general resuscitations. The studies were spread across high-, middle- and low-income settings.Interactive training may make little or no difference in survival to hospital discharge for patients requiring resuscitation (1 study; 30 participants; 98 events; low-certainty evidence). We are uncertain if emergency training changes morbidity rate, as the certainty of the evidence is very low (3 studies; 1778 participants; 57,193 patients, when reported). We are uncertain if training alters healthcare providers' adherence to clinical protocols or guidelines, as the certainty of the evidence is very low (3 studies; 156 participants; 558 patients). We are uncertain if there were improvements in patient outcomes following interactive training for emergency situations, as we assessed the evidence as very low-certainty (5 studies, 951 participants; 314,055 patients). We are uncertain if training for emergency situations improves clinical practice outcomes as the certainty of the evidence is very low (4 studies; 1417 participants; 28,676 patients, when reported). Two studies reported organisation-of-care outcomes, we are uncertain if interactive emergency training has any effect on this outcome as the certainty of the evidence is very low (634 participants; 179,400 patient population).We examined prespecified subgroups and found no clear commonalities in effect of multidisciplinary training, location of training, duration of the course, or duration of follow-up. We also examined areas arising from the studies including focus of training, proportion of staff trained, leadership of intervention, and incentive/trigger to participate, and again identified no clear mediating factors. The sources of funding for the studies were governmental, local organisations, or philanthropic donors. We are uncertain if there are any benefits of interactive training of healthcare providers on the management of life-threatening emergencies in hospital as the certainty of the evidence is very low. We were unable to identify any factors that may have allowed us to identify an essential element of these interactive training courses.We found a lack of consistent reporting, which contributed to the inability to meta-analyse across specialities. More trials are required to build the evidence base for the optimum way to prepare healthcare providers for rare life-threatening emergency events. These trials need to be conducted with attention to outcomes important to patients, healthcare providers, and policymakers. It is vitally important to develop high-quality studies adequately powered and with attention to minimising the risk of bias.

Management of Laryngotracheal Trauma: A Five-Year Single Institution Experience

Laryngotracheal trauma is a rare life-threatening emergency that requires early identification and immediate intervention. Here, we present 26 patients with laryngotracheal trauma from a tertiary hospital in India. The aim was to describe the clinical presentation and management of laryngotracheal trauma patients. This was a retrospective study of laryngotracheal trauma patients treated between January 2011 and March 2016. Patients who presented with a breach in the laryngotracheal framework were included, while those who had penetrating neck injuries superficial to strap muscles/platysma, burn injuries, caustic ingestion, or endotracheal injuries were excluded from the study. Of 253 patients with neck injury, 26 (23 adults, three children; 21 males, five females; age range, 5-60 years) presented with a breach in the laryngotracheal framework (15 blunt neck-trauma patients and 11 penetrating neck-trauma patients). The most common cause of neck injury was road traffic accidents, seen in 12 patients (46.2%). Computed tomography (CT) was performed in all blunt trauma cases and in four patients with penetrating trauma. All penetrating trauma patients underwent neck exploration. Twelve blunt trauma patients (46.1%) were managed conservatively, while three (11.5%) required surgical intervention. The most common neck exploration finding noted in patients with a penetrating injury was fracture of the thyroid cartilage, which was seen in eight patients (30.8%). Twenty patients (76.9%) had a normal voice, five patients (19.2%) had a hoarse voice, and one patient (3.8%) had a breathy voice post treatment. Early intervention of laryngotracheal trauma is crucial. The role of a CT scan is essential in decision making in blunt trauma cases.

Normothermic thyroid storm: an unusual presentation.

Thyroid storm is a rare life-threatening emergency due to thyrotoxicosis. A 30-year-old female presented with restlessness, tachycardia and vomiting but with normothermia which is an unusual presentation. There is the need for clinicians to be aware of atypical clinical features that can make the diagnosis of thyroid storm difficult.

Spontaneous splenic rupture during induction chemotherapy for acute myeloid leukemia

Spontaneous splenic rupture (SSR) is a rare life-threatening emergency that can be uniformly fatal if not promptly recognized and adequately managed. SSR in patients with acute myeloid leukemia (AML), especially after initiation of chemotherapy, is a very rare event [1-4]. Here we report a case of SSR with hemorrhagic shock in a patient with AML who was successfully managed, and review relevant literature.

Beware of the Migrating Chest Pain and Widened Mediastinum: Case Series on Aortic Dissection

Objective Aortic dissection is not a rare life-threatening emergency. Undiagnosed and untreated aortic dissection is associated with a high mortality. A review of cases in the hospital may provide a baseline picture to guide clinical decisions. Design Retrospective case review for a period of 3 years and 4 months. Setting District general hospital near the Hong Kong – Shenzhen ‘border’ with 24-hour Accident & Emergency service but without cardiothoracic surgical capability. Population All cases coded as ‘aortic dissection’ in the computerized ‘Clinical Management System’ of the hospital. Main outcome measures Date, sex, age, history of hypertension, presenting symptoms, pulse deficit, chest X-ray findings, pericardial effusion, A&E diagnosis, type of dissection and patient outcome. Results From August 1998 to November 2001, 26 cases of aortic dissection were identified. There were 19 males and 7 females. Age range was 26 to 90 years (mean 65.04 ± SD 15.04, median 66.50, mode 65). In the plain chest X-rays, widened superior mediastinum (>8 cm) was present in 19 patients (73.1%) and pleural effusion in three (11.5%). Pericardial effusion was found in six patients (23.1%). As regard to outcome, 11 were discharged home (42.3%), 14 were transferred to cardiothoracic surgical unit (where two subsequently died) and one died in the hospital. Conclusion The prevalence of aortic dissection may be more common than is generally appreciated by emergency physicians. Owing to its variable clinical presentations mimicking other diseases, the diagnosis of aortic dissection is easily missed. Higher clinical vigilance should be exercised for this potentially deadly condition.