Internal and emergency medicine
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Several widely used scoring systems for septic patients have been validated in an ICU setting, and may not be appropriate for other settings like Emergency Departments (ED) or High-Dependency Units (HDU), where a relevant number of these patients are managed. The purpose of this study is to find reliable tools for prognostic assessment of septic patients managed in an ED-HDU. In 742 patients diagnosed with sepsis/severe sepsis/septic shock, not-intubated, admitted in ED between June 2008 and April 2016, SOFA, qSOFA, PIRO, MEWS, Charlson Comorbidity Index, MEDS, and APACHE II were calculated at ED admission (T0); SOFA and MEWS were also calculated after 24 h of ED-High-Dependency Unit stay (T1). ⋯ The different scores show a modest-to-moderate discrimination (T0 SOFA 0.695; T1 SOFA 0.741; qSOFA 0.625; T0 MEWS 0.662; T1 MEWS 0.729; PIRO: 0.646; APACHE II 0.756; Charlson Comorbidity Index 0.596; MEDS 0.674, all p < 0.001). At a multivariate stepwise Cox analysis, including age, Charlson Comorbidity Index, MEWS, and lactates, SOFA shows an incremental prognostic ability both at T0 (RR 1.165, IC 95% 1.009-1.224, p < 0.0001) and T1 (RR 1.168, IC 95% 1.104-1.234, p < 0.0001). SOFA score shows a moderate prognostic stratification ability, and demonstrates an incremental prognostic value over the previous medical conditions and clinical parameters in septic patients.
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Auto-titrating noninvasive ventilation (NIV) has been developed as a new mode applying variable expiratory-positive airway pressure (EPAP) in addition to variable inspiratory pressures (IPAP), both to deliver targeted tidal volume (VT) and to eliminate upper airway resistance. The purpose of this study is to evaluate whether NIV with auto-titrating mode will decrease more PaCO2 within a shorter time compared to volume-assured mode in hypercapnic intensive care unit (ICU) patients. The hypercapnic respiratory failure patients treated with average volume assured pressure support- automated EPAP mode (group1) were compared with those treated with average volume-assured pressure support mode (group2). ⋯ This response was more pronounced within the first 6 h (mean reduction in PaCO2 was 7 ± 7 mmHg in group 1 and 2 ± 5 mmHg in group 2, p = 0.025), and significantly greater reductions in PaCO2 (18 ± 11 mmHg in group 1 and 9 ± 8 mmHg in group 2, p = 0.008) and plasma HCO3 levels (from 32 to 30 mEq and from 35 to 35 mEq, p = 0.007) took place within first 4 days. While mean IPAP was similar in both groups, maximum EPAP, mean VT and leak were significantly higher in group 1 than in group 2 (p < 0.05). Results of this preliminary study suggest that, this new auto-titrating NIV mode may provide additional benefit on volume-assured mode in decreasing PaCO2 more efficiently and rapidly in hypercapnic ICU patients.
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Current guidelines recommend that patients with non-ST elevation myocardial infarction (NSTEMI) are treated with medical management alone, or in combination with coronary angiography within 24 h. Recent research suggests that NSTEMIs show angiographic evidence of complete occlusion at rates comparable to STEMIs, suggesting a subgroup of NSTEMI patients who require urgent angiography. Novel ECG changes, termed 'STEMI-equivalents', have been described as a way of identifying this subgroup. ⋯ These patients demonstrated equivalent initial troponin readings. Recognition of STEMI-equivalents represent a chance for earlier intervention with prompt coronary angiography, as these findings are often associated with complete occlusion of the culprit vessel. These findings provide further evidence supporting the potential inclusion of STEMI-equivalents in future ACS guidelines.
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Carbon monoxide (CO) is a colorless, odorless gas that is found in the environment, in the home, and in the human body as a normal part of mammalian metabolism. Poisoning from CO, a common exposure, is associated with significant morbidity and mortality if not recognized and treated in a timely manner. This review evaluates the signs and symptoms of CO poisoning, conditions that present similar to CO poisoning, and an approach to the recognition and management for CO poisoning. ⋯ Once diagnosed, treatment options range from observation to the use of hyperbaric oxygen. CO poisoning is an elusive diagnosis. This review evaluates the signs and symptoms CO poisoning, common chameleons or mimics, and an approach to management of CO poisoning.