J Emerg Med
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Review
Emergency Department Management of Severe Hypoxemic Respiratory Failure in Adults With COVID-19.
While emergency physicians are familiar with the management of hypoxemic respiratory failure, management of mechanical ventilation and advanced therapies for oxygenation in the emergency department have become essential during the coronavirus disease 2019 (COVID-19) pandemic. ⋯ High flow nasal cannula and noninvasive positive pressure ventilation have a more limited role in COVID-19 because of the risk of aerosolization and minimal benefit in severe cases, but can be considered. Stable patients who can tolerate repositioning should be placed in a prone position while awake. Once intubated, patients should be managed with ventilation strategies appropriate for ARDS, including targeting lung-protective volumes and low pressures. Increasing positive end-expiratory pressure can be beneficial. Inhaled pulmonary vasodilators do not decrease mortality but may be given to improve refractory hypoxemia. Prone positioning of intubated patients is associated with a mortality reduction in ARDS and can be considered for patients with persistent hypoxemia. Neuromuscular blockade should also be administered in patients who remain dyssynchronous with the ventilator despite adequate sedation. Finally, patients with refractory severe hypoxemic respiratory failure in COVID-19 should be considered for venovenous extracorporeal membrane oxygenation.
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Randomized Controlled Trial
Oral 5-Day Lefamulin for Outpatient Management of Community-Acquired Bacterial Pneumonia: Post-hoc Analysis of the Lefamulin Evaluation Against Pneumonia (LEAP) 2 Trial.
Safe and effective oral antibiotics are needed for outpatient management of moderate to severe community-acquired bacterial pneumonia (CABP). ⋯ These data suggest that 5 days of oral lefamulin can be given in lieu of fluoroquinolones for outpatient treatment of adults with CABP and PORT risk class III/IV or CURB-65 scores of 2‒3.
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Emphysematous cholecystitis (EC) is a form of cholecystitis with high mortality rates more commonly seen in patients with medical histories such as diabetes, hypertension, and peripheral vascular disease. The common features of these medical diseases are impaired pain perception, particularly abdominal pain, due to advanced age and peripheral neuropathies. Accurate evaluation of characteristics observed at ultrasonography, the method of first choice in the diagnosis of EC, is therefore highly important in these patients. ⋯ This study reports a case of the champagne sign, rarely seen in EC, together with other EC findings. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The champagne sign is a little-known sonographic finding that is evidence of the presence of gas in the gallbladder. The champagne sign that will be detected while evaluating the hepatobiliary system on bedside ultrasound is one of the valuable findings in the diagnosis of emphysematous cholecystitis with high mortality.
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Case Reports
An Outbreak of Botulinum Types A, B, and E Associated With Vacuum-Packaged Salted Fish and Ham.
Botulinum toxin is a neurotoxin generated during the growth of Clostridium botulinum and can lead to a rare but life-threatening disease with neurologic symptoms. Relatively little is known about the many types of botulinum toxins in China. The clinical symptoms of the different types of botulism toxin-induced illnesses appear after an incubation period and vary greatly by the serotype and degree of exposure to the toxin. ⋯ We describe 4 patients who consumed vacuum-packaged salted fish and ham and then presented with severe gastrointestinal symptoms, resulting in vomiting and one death. Blood serum and urine samples tested by the botulinum neurotoxin Endopep-MS assay were positive for botulinum toxin types A, B, and E. The patient who consumed the largest amount of fish and ham died after 36 h, and the other patients were treated with botulism antitoxin after being diagnosed with a botulinum toxin-induced illness and recovered after 1 month. These cases illustrate the importance of early diagnosis and early treatment of botulism type E, in particular, because of the risk of respiratory failure and treatment delays, which can result in increased mortality and poorer overall outcomes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our cases illustrate the importance of early diagnosis and especially the treatment of illnesses related to botulism type E because of the risk of respiratory failure and because treatment delays can result in increased mortality and worsened overall outcomes.