Repetitive hyperbaric oxygen therapy for paroxysmal sympathetic hyperactivity after acute carbon monoxide poisoning.

Delayed neuropsychological sequelae (DNS) are relatively common complications of acute carbon monoxide (CO) poisoning, and usually develop within several days to weeks after the initial clinical recovery from acute CO poisoning. DNS can consist of various symptoms such as memory loss, confusion, ataxia, seizures, urinary incontinence, fecal incontinence, emotional lability, disorientation, hallucinations, mutism, cortical blindness, psychosis, parkinsonism, gait disturbances, rigidity, bradykinesia, and other motor disturbances. Paroxysmal sympathetic hyperactivity (PSH) is a potentially life-threatening disease secondary to acute acquired brain injury. It is characterized by episodic and simultaneous paroxysmal increases in sympathetic and motor activities, not rare in patients with a severe traumatic brain injury. The term PSH is clinically more accurate than the previously used ones describing such conditions as non-stimulated tachycardia, hypertension, tachypnea, hyperthermia, external posturing, diaphoresis, and paroxysmal autonomic instability with dystonia. Development of PSH typically prolongs the length of hospital stay and potentially leads to a secondary brain injury or even death. To date, the occurrence of PSH in the DNS after acute CO poisoning has not been reported in the literature. Potential mechanisms underlying the development of DNS in the deep white matter of the brain are immune-related inflammation and vasodilatation. Repetitive hyperbaric oxygen therapy, combined with methylprednisolone administration, may inhibit DNS progression by inducing cerebral oxygenation, inhibiting inflammation, and reducing cerebral edema. Herein, we report three cases in which the patients recovered from the PSH as DNS after CO poisoning after receiving repetitive hyperbaric oxygen therapy.

Successful conservative management of a spontaneous intraperitoneal rupture of bladder diverticulum in a critical patient: A case report. A CARE-compliant article.

RATIONALE: A spontaneous rupture of the bladder diverticulum in an adult patient is extremely rare. The recommended treatment is surgery. However, some cases can be successfully treated with urinary catheterization, antibiotics, and/or percutaneous peritoneal drainage. In this case report, a spontaneous rupture of the bladder diverticulum was successfully treated non-surgically because it was deemed too risky for surgical intervention, such as non-ST segment elevation myocardial infarction (NSTEMI). PATIENT CONCERNS: A 76-year-old man presented with abdominal pain, distention, diarrhea, and oliguria for 3 days and hypotension for 1 day with no history of trauma. The patient showed direct and rebound tenderness in the lower abdomen. Computed tomography revealed an intraperitoneal bladder rupture associated with the bladder diverticula. Electrocardiography, echocardiography, and elevated cardiac enzyme suggested NSTEMI. DIAGNOSES: A spontaneous rupture of the bladder diverticulum, NSTEMI, and suspected sepsis due to gastroenteritis or urinary infection. INTERVENTIONS: The patient was treated conservatively with urinary catheterization and antibiotics for a bladder rupture and an infection. Percutaneous transluminal coronary angioplasty was performed for NSTEMI. OUTCOMES: The patient fully recovered without complications on hospitalization day 13. LESSONS: Conservative management might be an alternative for a spontaneous intraperitoneal bladder rupture in some cases. However, close observation is required, and surgical intervention is the first option for a spontaneous intraperitoneal rupture of the bladder diverticulum.

Evaluation of the diagnostic performance of a decision tree model in suspected acute appendicitis with equivocal preoperative computed tomography findings compared with Alvarado, Eskelinen, and adult appendicitis scores: A STARD compliant article.

This study evaluated the diagnostic performance of a new clinical approach based on decision tree (DT) analysis in adult patients with equivocal computed tomography (CT) findings of acute appendicitis (AA) compared with previous scoring systems.This retrospective study of 244 adult patients with equivocal CT findings included appendicitis (AG, n = 80) and non-appendicitis (NAG, n = 164) groups. The chi-squared automatic interaction detection algorithm was for AA prediction. A receiver operating characteristic curve analysis and area under the curve (AUC) were used to compare the DT analysis with Alvarado, Eskelinen score, and adult appendicitis scores (AAS).The following factors were selected for AA prediction: rebound tenderness severity, migration, urinalysis, symptom duration, leukocytosis, neutrophil count, and C-reactive protein levels. The DT comprised 11 final nodes with the following AA probabilities: node 1, 100% (16/16); node 2, 90% (9/10); node 3, 80% (8/10); node 4, 60.9% (14/23); node 5, 50% (3/6); node 6, 43.8% (7/16); node 7, 22.6% (12/53); node 8, 13% (10/77); node 9, 5.6% (1/18); node 10, 0% (0/12); and node 11, 0% (0/3). The AUC of the DT was higher (0.850 [95% confidence interval {CI}; 0.799-0.893]) than the Alvarado score (0.695 [95% CI; 0.633-0.752]), AAS (0.749 [95% CI; 0.690-0.802]), and the Eskelinen score (0.715 [95% CI; 0.654-0.770]). The results were statistically significant when compared with the AUCs of the Alvarado score, Eskelinen score, and AAS (P < .001, P < .001, P = .003, respectively).The DT-based approach facilitated AA diagnosis and determination of clinical status in patients with equivocal preoperative CT findings and ambiguous results.

Estimation of optimal pediatric chest compression depth by using computed tomography.

OBJECTIVE: This study aimed to compare the optimal chest compression depth for infants and children with that of adults when the simulated compression depth was delivered according to the current guidelines. METHODS: A total of 467 consecutive chest computed tomography scans (93 infants, 110 children, and 264 adults) were reviewed. The anteroposterior diameter and compressible diameter (CD) for infants and children were measured at the inter-nipple level and at the mid-lower half of the spine for adults. Compression ratio (CR) to CD was calculated at simulated 1/4, 1/3, and 1/2 antero-posterior compressions in infants and children, and simulated 5- and 6-cm compressions in adults. RESULTS: In adults, the CRs to CD at simulated 5- and 6-cm compression depth were 41.7±0.16%, 50.0±7.3% respectively. In children and infants, the CRs to CD at 1/3 chest compression were 55.1±2.4% and 51.8±2.4%, respectively, and at 1/2 chest compression, CRs were 82.7±3.7% and 77.7±3.6%, respectively. The CRs to CD of 4-cm compression depth in infants and 5-cm compression depth in children were 74.4±10.9%, 62.5±8.7%, respectively. The CRs to CD for children and infants were significantly higher than in adults (P<0.001). The CR to CD of 4-cm compression depth in children was almost similar to that of 6-cm compression depth in adults (50.0± 6.9% vs. 50.0±7.3%, P=0.985). CONCLUSION: Current pediatric guidelines for compression depth are too deep compared to those in adults. We suggest using 1/3 of the anteroposterior chest diameter or about 4 cm in children and less than 4 cm in infants.

Fever phobia in Korean caregivers and its clinical implications.

Fever is the most common complaint among children brought into the emergency department (ED). 'Fever phobia' is a descriptive term for an unrealistic concern about the consequences of fever. 'Fever phobia' is prevalent among parents and even healthcare providers, worldwide. The aim of this study was to determine the implications of fever-phobic ideas in Korean caregivers. A prospective, multi-center survey was conducted on Korean caregivers who visited the EDs with febrile children. In total, 746 caregivers were enrolled. The mean age of the subjects was 34.7 yr (SD±5.0). Three hundred sixty respondents (48.3%) believed that the body temperature of febrile children can reach higher than 42.0℃. Unrealistic concerns about the improbable complications of fever, such as brain damage, unconsciousness, and loss of hearing/vision were believed by 295 (39.5%), 66 (8.8%), and 58 (7.8%) caregivers, respectively. Four hundred ninety-four (66.2%) guardians woke children to give antipyretics. These findings suggest that fever phobia is a substantial burden for Korean caregivers.