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Background: Sodium bicarbonate administration is mostly restricted to in-hospital use in Taiwan. This study was conducted to investigate the effect of sodium bicarbonate on outcomes among patients with out-of-hospital cardiac arrest (OHCA)., Methods: This population-based study used a 16-year database to analyze the association between sodium bicarbonate administration for resuscitation in the emergency department (ED) and outcomes. All adult patients with OHCA were identified through diagnostic and procedure codes. The primary outcome was survival to hospital admission and secondary outcome was the rate of death within the first 30days of incidence of cardiac arrest. Cox proportional-hazards regression, logistic regression, and propensity analyses were conducted., Results: Among 5589 total OHCA patients, 15.1% (844) had survival to hospital admission. For all patients, a positive association was noted between sodium bicarbonate administration during resuscitation in the ED and survival to hospital admission (adjusted odds ratio [OR]: 4.47; 95% confidence interval [CI]: 3.82-5.22, p<0.001). In propensity-matched patients, a positive association was also noted (adjusted OR, 4.61; 95% CI: 3.90-5.46, p<0.001)., Conclusions: Among patients with OHCA in Taiwan, administration of sodium bicarbonate during ED resuscitation was significantly associated with an increased rate of survival to hospital admission., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Dehydration is associated with acute ischemic stroke. However, the relationship between hydration therapy given during acute ischemic stroke and clinical outcomes remains unclear., Aims: We determined whether hydration therapy in patients with a blood urea nitrogen/creatinine (BUN/Cr) ratio of at least 15 improved clinical outcome., Methods: We conducted a nonblinded, phase II, single-arm, prospective study of patients with acute ischemic stroke and BUN/Cr ratio of at least 15 with historical controls. The hydration group received intravenous bolus (300-500 mL) saline followed by maintenance saline infusion (40-80 mL/h for the first 72 hours), whereas the control group received maintenance saline infusion (40-60 mL/h for the first 24 hours and 0-60 mL/h for 24-72 hours after stroke). The study end point was the percentage of patients with a favorable outcome defined as modified Rankin scale score of 2 or lower at 3 months after stroke., Results: A total of 237 patients were enrolled (hydration, n = 134; control, n = 103). The mean volume of saline infused within the first 72 hours was significantly larger (P < .001), and the rate of favorable outcome at 3 months after stroke was significantly higher (P = .016) in the hydration group than in the controls. Further analysis revealed that the difference was significant in the lacunar stroke subtype (P = .020) but not in the nonlacunar subtype., Conclusions: Blood urea nitrogen/Cr ratio-based saline hydration therapy in patients with acute ischemic stroke significantly increased the rate of favorable clinical outcome with functional independence at 3 months after stroke., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The measurements for predicting early deterioration of stroke patients is controversial. We studied laboratory measurements and previously identified risk factors to identify factors or predictors of early deterioration after stroke. A prospective observational study of 196 patients with first-time acute ischemic stroke was performed. Demographic data, patient histories, laboratory measurements, and initial stroke severity assessments were recorded. Patients with early deterioration in National Institutes of Health Stroke Scale scores (increase ≥3 points within 3 days) were defined as having stroke-in-evolution (SIE). Thirty patients were diagnosed with SIE. An initial National Institutes of Health Stroke Scale score of 12 or higher, a Glasgow Coma Scale score of 12 or lower, d-dimers more than 1000, or blood urea nitrogen/creatinine (BUN/Cr) ratio higher than 15 were more frequent in SIE patients. After multivariate analysis, only a BUN/Cr higher than 15 was independent predictor of SIE. These patients were 3.41-fold more likely to have SIE (P = .008). These findings suggest that BUN/Cr may be a novel predictor of SIE, potentially useful in emergency departments., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: Overcrowding in hospitals, especially in EDs, is a serious problem in the United States, Europe, and Taiwan. However, the association between prolonged ED boarding stay and mortality in patients with necrotizing fasciitis remains underinvestigated., Methods: This was a retrospective study. A total of 195 patients were enrolled and analyzed. The sample was divided into 2 groups: nonmortality and mortality. A stepwise logistic regression model was developed to investigate 3 factors of clinical relevance predicting patient mortality., Result: The results of the stepwise logistic regression analysis revealed that hypotension (odds ratio [OR], 32.9; 95% confidence interval [CI], 6.9-156.0) and prolonged ED boarding stay (OR, 3.4; 95% CI 1.3-8.6) were both associated with higher mortality. Early operation (OR: 0.16; 95% CI: 0.06-0.45) was associated with lower mortality., Conclusion: Prolonged ED boarding stay was associated with increased mortality in patients with necrotizing fasciitis. Early operation (within 24 hours of ED arrival) was associated with decreased mortality.

Acquired hemophilia A is defined as the development of factor VIII inhibitors in a nonhemophilic patient. The inhibitors can develop in association with autoimmune disease, allergic drug reactions [1,2], malignancies [2], and pregnancy [3]. It is rare, but frequently complicated by severe bleeding and compartment syndrome [1,4]. Therapeutic cupping is a traditional remedy done by applying heated cup over the back and limbs to cause congestion. This procedure is mostly used by South Asian and Middle Eastern countries. We report a 58-year-old woman who presented with extensive and compressive bruising which led to pending compartment syndrome of her left thigh in 2 days after cupping. The coagulopathy was first considered owing to new-onset severe deep tissue bleeding. Acquired hemophilia A was diagnosed with prolonged activated partial thromboplastin time (83 seconds) and incorrectable mixing plasma test. Quantitative assays revealed reduced level of factor VIII (b0.1%) and the presence of factor VIII inhibitors (20 BU) in the serum. Fresh frozen plasma transfusion, coagulation factor supply, and immunosuppressive therapy with steroid began immediately after diagnosis was made. Her activated partial thromboplastin time was gradually normalized. She was discharged home with improving symptoms and minimized bruises 1 week later. To our knowledge, acquired hemophilia A associated with therapeutic cupping has never been mentioned before in the literature.

Transient ischemic attack is one of the most common causes of transient neurologic deficit. Anemic hypoxia results from reduced hemoglobin content with normal arterial oxygen tension and saturation. Anemic hypoxia caused by blood loss or hemolysis has not been considered as an independent factor leading to significant neurologic problems because cerebral homeostasis adjusted by the physiologic regulation in cerebral hemodynamics and oxygenation would meet the brain oxygen requirement in most circumstances even with profound anemia. We report a case of severe anemia associated with transient ischemic attack involving vertebrobasilar circulation.

Glyphosate-surfactant is used extensively as a nonselective herbicide. Suicidal attempts with glyphosate-surfactant herbicide (GlySH) has been encountered with increasing frequency. The effect of GlySH intoxication often involves multiple systems. We report a case of a severely intoxicated man who developed chemical pneumonitis and respiratory failure after suicidal ingestion of GlySH. Acute pancreatitis, which was never covered by any previous case reports, developed in the first day, and the symptom persisted for 10 days during hospitalization.

Background: Dermatologic complaints are common presentations in the ED. Hemorrhagic bullae are an example of dermatologic manifestation caused by variable etiologies. The life-threatening skin lesion usually is an external sign of a systemic or immune response stimulated by an infection, toxin, medication, or disease process. Although most patient with life-threatening skin lesion, such as hemorrhagic bullae, may appear ill, patients who present in the early course of illness may appear well but deteriorate rapidly. For greater comprehension of hemorrhagic bullae, we prospectively followed 42 patients who presented with hemorrhagic bullae at the ED and analyzed their clinical characteristics and their confirmative diagnoses., Methods: This is a prospective, observational cohort study conducted at a university-affiliated community hospital. Data were collected from January 2002 to January 2007. Patients presenting to the ED with hemorrhagic bullae were enrolled prospectively., Results: All of our patients with hemorrhagic bullae had evidence of a serious disease: necrotizing fasciitis (42 case, 100%). The most common comorbidity was diabetes mellitus (18 cases; 42.9%). Vibrio species was the most common organism from blood culture (8/16 cases) and wound culture (17/27 cases). Streptococcal species was found in only 1 patient via blood culture and 4 patients via wound culture. The yield of positive wound culture with Vibrio species was significantly greater than with streptococcal species (P < .05). Fourteen (33.3%) patients came to the ED for help 48 hours later after the onset of hemorrhagic bullae. None of these 14 patients died. In our total of 42 patients, 8 (19%) died., Conclusion: In our study, the most common causative disease of hemorrhagic bullae was necrotizing fasciitis. Hemorrhagic bullae are a more common clinical feature in Vibrio infection than in streptococcal infection. Hemorrhagic bullae may occur in the early stage of necrotizing fasciitis. Necrotizing fasciitis may be the first sign that emergency physicians come across in patients with hemorrhagic bullae that are not in the oral, genital, anal, ocular area, and high index of suspicion of Vibrio infection should be considered. More aggressive treatment may be needed as hemorrhagic bullae may occur in the early stage of a serious disease. Further multi-institution study may be required to support these findings.

Background: Necrotizing fasciitis is an uncommon and life-threatening soft tissue infection with high mortality. Though early aggressive surgical intervention is important for improving survival, the impact of mortality from different microorganisms remains uncertain. Our study aims to identify the association of mortality and different microorganisms, and the positive and negative predictors of mortality in patients with necrotizing fasciitis., Methods: This retrospective cohort study enrolled patients admitted via the emergency department (ED) with discharged diagnosis of necrotizing fasciitis (International Classification of Diseases, Ninth Revision, code 72886). Multivariate logistic regression analysis was used to identify microbiological, clinical, and biochemical variables independently associated with the mortality of necrotizing fasciitis., Results: Multivariate logistic regression analysis showed that Vibrio infection, Aeromonas infection, hypotension, malignancy, and band form 10% or greater were significantly associated with increase of mortality (P < .05). They were considered as positive predictors of mortality. The presence of hemorrhagic bullae, however, was significantly associated with decrease of mortality (P < .05). It was considered as negative predictor of mortality., Conclusion: Aeromonas infection, Vibrio infection, cancer, hypotension, and band form white blood cell count greater than 10% are independent positive predictors of mortality in patients with necrotizing fasciitis. Streptococcal and staphylococcal infections, in contrast, are not predictors of mortality. The presence of hemorrhagic bullae is an independent negative predictor of mortality. Further study should focus on the accuracy of these factors.

Background: Several risk score systems are designed for triage patients with acute nonvariceal upper gastrointestinal bleeding (UGIB). Blatchford score, which relies on only clinical and laboratory data, is used to identify patients with acute UGIB who need clinical intervention (before endoscopy). Clinical Rockall score, which relies on only clinical variables, is used to identify patients with acute UGIB who have adverse outcome, such as death or recurrent bleeding. Complete Rockall score, which relies on clinical and endoscopic variables, is also used to identify patients with acute UGIB who died or have recurrent bleeding. In our study, we define patients who need clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control) as high-risk patients. Our study aims to compare Blatchford score with clinical Rockall score and complete Rockall score in their utilities in identifying high-risk cases in patients with acute nonvariceal UGIB., Methods: International Classification of Diseases, Ninth Revision, Clinical Modification codes for admission diagnosis were used to recognize a cohort of patients (N = 354) with acute UGIB admitted to a tertiary care, university-affiliated hospital. Medical record data were abstracted by 1 research assistant blinded to the study purpose. Blatchford and Rockall scores were calculated for each enrolled patient. High risk was defined as a Blatchford score of greater than 0, a clinical Rockall score of greater than 0, and a complete Rockall score of greater than 2. Patients were defined as needing clinical intervention if they had a blood transfusion or any operative or endoscopic intervention to control their bleeding. Such patients were defined as high-risk patients., Results: The Blatchford score identified 326 (92.1%) of the 354 patients as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control). The clinical Rockall score identified 289 (81.6%) of the 354 patients as high-risk, and the complete Rockall score identified 248 (70.1%) of the 354 patients as high-risk. The yield of identifying high-risk cases with the Blatchford score was significantly greater than with the clinical Rockall score (P < .0001) or with the complete Rockall score (P < .0001). In our total 354 patients, 246 (69.5%) patients were categorized as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control, as aforementioned) in our study. The Blatchford score identified 245 (99.6%) of 246 patients as high-risk. Only 1 patient who met the study definition of needing clinical intervention was not identified via Blatchford score. This patient did not have recurrent bleeding nor die and did not receive blood transfusion. The clinical Rockall score identified 222 (90.2%) of 246 patients as high-risk. Twenty-four patients who met the study definition of needing clinical intervention were not recognized via clinical Rockall score. Of these patients, 0 died, 7 developed recurrent bleeding, and 6 needed blood transfusion. The complete Rockall score identified 224 (91.1%) of 246 patients as high-risk. Twenty-two patients who met the study definition of needing clinical intervention were not recognized via complete Rockall score. Of these patients, 2 died, 3 developed recurrent bleeding, and 20 needed blood transfusion., Conclusions: The Blatchford score, which is based on clinical and laboratory variables, may be a useful risk stratification tool in detecting which patients need clinical intervention in patients with acute nonvariceal UGIB. It does not need urgent endoscopy for scoring and has higher sensitivity than the clinical Rockall score and the complete Rockall score in identifying high-risk patients.