Brief Report: Diabetic Keto-Acidosis (DKA) Induced Hypothermia may be Neuroprotective in Cardiac Arrest.

Despite the decreased survival associated with diabetes with out-of-hospital cardiac arrest and the overall low survival to hospital discharge, we would like to present two cases of OHCA in diabetics who despite prolonged resuscitation efforts had complete neurological recovery likely due to concomitant hypothermia. There is a steady decreasing rate of ROSC with longer durations of CPR so that outcomes are best when <20 minutes compared to prolonged resuscitation efforts (>30-40 minutes). It has been previously recognized that hypothermia prior to cardiac arrest can be neurologically protective even with up to 9 hours of cardiopulmonary resuscitation. Hypothermia has been associated with DKA and although often indicates sepsis with mortality rates of 30-60%, it may indeed be protective if occurring prior to cardiac arrest. The critical factor for neuroprotection may be a slow drop to a temperature <250C prior to OHCA as is achieved in deep hypothermic circulatory arrest for operative procedures of the aortic arch and great vessels. It may be worthwhile continuing aggressive resuscitation efforts even for prolonged periods before attaining ROSC for OHCA in patients found hypothermic from metabolic illnesses as compared to only from environmental exposures (avalanche victims, cold water submersions, etc.) as has been traditionally reported in the medical literature.

Gestalt clinical severity score (GCSS) as a predictor of patient severity of illness or injury.

OBJECTIVE: To determine if clinical judgement is accurate to predict the severity of injury or illness, and can be used at patient arrival when other formal scoring systems are not yet available. DESIGN: A multicenter pilot study using a prospective observational convenience sample of patients arriving by EMS to the emergency department (ED) or Trauma Center. SETTING: Two urban, Level 1 trauma centers at academic tertiary care hospitals. PATIENTS: Medical and trauma patients age 18 and older transported by EMS (N = 216). Exclusion criteria (prior to arrival): intubation, assisted ventilation (BVM or NPPV), CPR in progress, prisoners, or previously present motor or speech deficits. MEASUREMENTS: Completion of a novel 15-point scale of Verbal, Motor, and Facial Expression within 1-2 min of arrival by a clinician outside of the treatment team. Primary endpoint was the immediate disposition from the ED or Trauma Center: Home, Brief Observation (<24 h), Admission to Floor, ICU (OR and IR as surrogates since these patients ultimately go to the ICU), or Morgue. RESULTS: Univariate analysis revealed a strong, positive monotonic correlation between GCSS and disposition (Rho = 0.693, p < .0001). Multivariable logistic regression revealed the "best" model included GCSS and age (group 18-44 years old versus all the other age groups) (p < .0001). There was a 156% increase in the odds of being discharged home (versus being admitted) for a one-unit increase in GCSS (OR = 2.56, 95% CI 1.94, 3.37). CONCLUSIONS: Physicians can make accurate predictions of severity of injury and illness using a gestalt method and the scoring system we have developed as patient disposition correlates well with GCSS score. GCSS is most accurate with the 18-44 age group.

Nine years of pediatric gunshot wounds: A descriptive analysis.

Pediatric firearm violence carries significant morbidity and mortality. Studies targeting children ≤14 years are limited. Our goal was to study the distribution and determinants of GSWs in the pediatric population. We performed a retrospective review of children ≤14 years presenting with GSWs at this level 1 trauma center. This cohort was split into younger children, 0-12 years, and older children, 13-14 years. Summary and bivariate statistics were calculated using Stata v10. 142 patients (68.3% black, 76.7% male) were identified. Injuries more often occurred at home (39.6%) by family or friends (60.7%). Older children often suffered handgun injuries (85.5%) and more often were sent immediately to the OR on presentation (29.2%). Younger children more often suffered from air-gun (50%) and pistols (40%). Younger children more commonly had blood transfusions (9.4%) compared to exploratory laparotomy in older children (13.5%). The most common disposition from the ED was home (36.2%). Descriptive data entailing incident specifics such as time of injury and CPS involvement were frequently missing in the healthcare record. Older children were more likely to be injured by strangers, have longer lengths of stay especially associated with surgical operations, and have a disposition of immediate arrest compared to their younger cohort. Consequently, this group may benefit from interventions typically aimed at older patients such as violence intervention programs. When available, differences in demographics and outcomes were identified which could shape novel prevention strategies for firearm injury.

Hydropneumothorax Due to Esophageal Rupture.

BACKGROUND: A brief review of the historical aspects of esophageal rupture is presented along with a case and current recommendations for diagnostic evaluation and treatment. CASE REPORT: A 97-year-old woman complained of acute dyspnea without prior vomiting. Chest x-ray study showed a large right pneumothorax with associated effusion. A thoracostomy tube was placed with return of > 1 L turbid fluid with polymicrobial culture and elevated pleural fluid amylase level. Chest computed tomography (CT) scan demonstrated overt leakage of oral contrast into the right pleural space. She was treated with ongoing pleural evacuation, antibiotics, antifungals, and total parenteral nutrition. The patient and family declined surgical resection as well as endoscopic stent placement. In 1724, Boerhaave described spontaneous rupture of the esophagus postmortem; Boerhaave syndrome remains the name for complete disruption of the esophageal wall in the absence of pre-existing pathology typically occurring after vomiting. It most commonly occurs in the distal left posterolateral thoracic esophagus. Contrast esophagram is considered the "gold standard" for diagnosing esophageal rupture although CT esophagography also shows good diagnostic performance. Treatment includes nil per os status, broad-spectrum antibiotics, and drainage of the pleural space. Surgical repair of the esophageal perforation should be done early if the patient is deemed a good candidate, and esophageal stenting is also an option. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Esophageal perforation should be suspected in patients with new pleural effusion, often with overt pneumothorax, that is polymicrobial with elevated amylase.

Incomplete Lemierre syndrome.

An invasive Fusobacterium infection may originate from an apparent routine pharyngitis and lead to significant distant septic complications. Even without internal jugular thrombosis, the same mechanism of disease exists, and therefore, the same morbidity, prognosis, and treatments are applicable, hence the suitable term incomplete Lemierre syndrome. We present a case of invasive Fusobacterium infection that meets all criteria for Lemierre syndrome except lacking internal jugular thrombosis. A review of the literature that forms the diagnostic criteria for this syndrome and the rationale for our creating this novel term is presented.

Stroke registry: hemorrhagic vs ischemic strokes.

BACKGROUND: Epidemiologic studies of stroke in the 1970s and 1980s have reported the percentage of ischemic stroke as 73% to 86%, with hemorrhagic stroke as only 8% to 18%; the remainder was undetermined (due to not performing computed tomographic [CT] scanning or an autopsy). In our clinical work, it appeared anecdotally to the authors that we were seeing more hemorrhagic strokes than these previously quoted figures. METHODS: We conducted a retrospective review for 1 year of all patients discharged from the hospital, a regional stroke center, with a diagnosis of stroke; we compared ischemic to hemorrhagic stroke types. RESULTS: There were 757 patients included. Of the patients, 41.9% were hemorrhagic and 58.1% were ischemic. CONCLUSION: There were a much greater percentage of hemorrhagic strokes in this population than would have been predicted from previous studies. This finding may be due to improvement of CT scan availability and implementation unmasking a previous underestimation of the actual percentage or to an increase in therapeutic use of antiplatelet agents and warfarin causing an increase in the incidence of hemorrhage.