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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

An Unnoticed Case; Hypermagnesemia at the Emergency Department


Introduction. Hypermagnesemia generally develops in people with renal function disorders or due to exogen Mg intake for constipation. Hospitalized cases of fatal hypermagnesemia are rare in the literature. The aim of this case report was to see if fatal progression could be due to delayed diagnose.

Case Presentation. A 61 year old woman presented at the emergency department (ED) for the evaluation of her symptoms which were leg pain, weakness, nausea, constipation and general debility. In her prior history, she had used magnesia calcine for laxative until two weeks before. Electrocardiography showed atrial fibrillation with high ventricular respond (HVRAF). Initial serum magnesium (Mg) concentration was 6.80 mEq/l. 10% calcium gluconate with 20 ml used to antagonize symptoms for treatment. Intravenous (IV) metoprolol was used for HVRAF but the patient was unresponsive. On the second day Mg rose to 7.06 mEq/l. The patient’s consciousness was altered, she developed lethargy, and hemodynamic instability was revealed. In addition, respiratory distress was present and patient was intubated. Therefore, she was diagnosed with a suspected Mg intoxication due to laxative use. Continuous hemodiafiltration (CHDF) was urgently used to decrease Mg. On the third day the patient was unresponsive to the treatment and died in intensive care unit (ICU).

Conclusion. Patients with nonspecific symptoms due to a prolonged laxative use can be admitted to the ED. Hypotension, altering consciousness and cardiac dysthymias can be revealed quickly and therefore the progress is fatal. Mg intoxication must be noticed early in the ED. IV calcium directly antagonises the effects of magnesium. It can reverse effects such as cardiac arrhythmias. IV normal saline must be used for supportive treatment and if those not responding to intravenous calcium and other supportive measures, CHDF must be used urgently for all patients with features of life threatening hypermagnesemia.

Keywords: Emergency Department, Laxative, Hypermagnesemia

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Serum cortisol level as a useful predictor of surgical disease in patients with acute abdominal pain


Introduction. The immediate aim should be to identify potentially resuscitative acute abdominal pain that requires prompt investigation or early surgical intervention. We aimed to evaluate whether serum cortisol levels differentiate surgical and non-surgical disease in patients with acute abdominal pain.

Materials and methods. In this prospective cross-sectional study, the primary end-point was defined as differences in serum cortisol levels between surgically and non-surgically treated patients with non-traumatic acute abdominal pain. The secondary end-point was to compare the cortisol levels with defined complete blood count (CBC) parameters in those groups.

Results. One hundred eleven patients with acute abdominal pain were included in the study. Three most frequent diagnoses were nonspecific abdominal pain, acute appendicitis and dyspeptic complaints. Thirty patients were hospitalized and 22 of them were operated. The median cortisol level was 23.13 µg/dl in surgically treated patients and 13.94 µg/dl in non-surgically treated patients (p<0.001). The area under the ROC curve using cortisol to detect surgical disease was 0.750 (95% CI, 0.659-0.827) and the accuracy of cortisol to detect surgical disease was not inferior to defined CBC parameters. A cortisol value of 17.98 µg/dl had a sensitivity of 67.4% and a specificity of 77.3% for surgical disease.

Conclusion. Operated patients had higher serum cortisol levels. High serum cortisol levels may indicate surgical disease at the early stage on admission in ED patients with acute abdominal pain and may be used as a marker in the prediction of acute surgical abdomen.

Key words: abdominal pain, cortisol, emergency department, surgery

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Prognostic value of lactate in prehospital care as a predictor of mortality and high-risk patients with trauma


Objectives. Major injury is a time-dependent illness in which the quantification of the life prognosis is fundamental for professionals. The objective of this study is to evaluate the capacity of prehospital lactic acid to predict mortality (2, 7 and 30 days) and the admission to the Intensive Care Unit (ICU) from the index event.

Methods. This is a longitudinal, prospective observational study, which included patients who were treated by an Advanced Life Support Unit and transferred to the Emergency Department between April 1 and September 30, 2018. We calculated sensitivity, specificity, and likelihood ratios. The main outcome variable was mortality from any cause (2, 7 and 30 days) and admission to ICU.

Results. 109 patients were included in our study. Eleven patients (10%) experienced early mortality before the first 48 hours after the index event, with an ICU admission rate of 28%. The sensitivity and specificity of the test to determine mortality in less than two days was 63.6% (95% CI, 35.4-84.8%) and 87.8% (95% CI, 79.8-92.9%).

Conclusions. Prehospital lactic acid has an excellent capacity to predict the mortality and the admission of patients with major injury to the ICU, and it is a cheap, easy-to-obtain and reliable diagnostic tool that can help in clinical decision-making.

Key words: Critical care, emergency department, outcome, survival, intensive care

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Influence of the adequacy of data collection, during two years, in the management of community-acquired pneumonia in emergency departments


Objective. The aim of this study was to analyze whether structured data collection of patients with community-acquired pneumonia (CAP) in the Emergency Department (ED) improves compliance with clinical guidelines regarding inpatient and outpatient treatment and prescription of antibiotics at discharge.
Material and methods. We performed a quasi experimental, multicenter, pre/post-intervention study. The intervention consisted of basic training for the participating physicians and the incorporation of a data collection sheet in the clinical history chart, including the information necessary for adequate decision making regarding patient admission and treatment, in the case of discharge. We analyzed the adequacy of the final destination of patients classified as Fine I-II and antibiotic treatment in patients receiving outpatient treatment, with each participating physician including 8 consecutive patients (4 pre-intervention and 4 post-intervention).
Results. A total of 738 patients were included: 378 pre-intervention and 360 post-intervention. In the pre-intervention group, Fine V was more frequent and patients were older, had more ischemic heart disease, active neoplasms and fewer risk factors for atypical pneumonia. Of the patients with Fine I-II, 23.7% were inadequately admitted and 19.6% of those discharged received treatment not recommended by guidelines. No differences were observed in the target variables between the two groups.
Conclusion. The adequacy of the decision to admit patients with Fine I-II CAP and outpatient antibiotic treatment can be improved in the ED. Structured data collection does not improve patient outcome.

Key words: community-acquired pneumonia, emergency department, antibiotic treatment, adequacy of admission

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Ed overcrowding – matematic models for integrated solutions and decisions

Dear Editor In Chief,

We are writing to You in line with an very interesting point of view regarding the Emergency Department (ED) development. The paper titled Improving  Emergency  Department Capacity Efficiency, published in your Journal 2016; 12(1): 52-57, as an original articles, spotlight solution for ED crowding.

So we are proposing a mathematics models for reciprocal accommodation of patients flows to the response capacity of the ED.

ED overcrowding is not just a reality but a huge problem, not only on satisfaction of staff and patients, but also in terms of ED performance. It is already known that, prolonged stay in ED is associated with lower compliance of ACC rules for care of ACS/NSTEMI (1) and increased mortality for hospitalized patients.(2,3)

Theoretically, there are two possible approaches: modulating demand (categorization and stratification of entries, triage, types and volume of auxiliary resources patients, use bifocal FastTrack for reducing time of wait) or enhancing capacity.

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