Study Hypothesis Abnormal (both low and high) central venous saturation (ScvO2) is associated with increased mortality in Emergency Department (ED) patients with suspected sepsis. Methods Secondary analysis of four prospectively collected registries of ED patients treated with Early Goal Directed Therapy (EGDT) based sepsis resuscitation protocols from 4 urban tertiary care hospitals. Inclusion criteria: 1) sepsis; 2) hypoperfusion defined by SBP < 90 mmHg or lactate ≥ 4 mmol/L; and 3) EGDT therapy treatment. ScvO2 levels were stratified 3 groups: hypoxia (ScvO2 <70%); normoxia (71% - 89%); and hyperoxia (90 – 100%). The primary exposures were initial ScvO2 and maximum Scv02 achieved with the primary outcome as in-hospital mortality. Multivariate analysis was performed. Results There were 619 patients who met criteria and were included. For the maximum ScvO2, compared to the mortality rate in the normoxia of 96/465 (21%; 17 – 25%), both the hypoxia mortality rate 25/62 (40%; 29 – 53%) and hyperoxia mortality rate 31/92 (34%; 25 – 44%) were significantly higher, which remained significant in a multivariate modeling. When the initial ScvO2 measurement was analyzed in a multivariate model, only hyperoxia was significantly higher. Conclusions The maximum ScvO2 value achieved in the ED (both abnormally low and high) was associated with increased mortality. In multivariate analysis for initial ScvO2, the hyperoxia group was associated with increased mortality, but not the hypoxia group. This study suggests that future research aimed to target methods to normalize high ScvO2 values via therapies that improve microcirculatory flow or mitochondrial dysfunction may be warranted.
Thresholds were measured for the detection of vibratory stimuli of variable frequency and duration applied to the index fingertip and thenar eminence through contactors of different sizes. The effects of stimulus frequency could be accounted for by the frequency characteristics of the Pacinian (P), non-Pacinian (NP) I, and NP III channels previously determined for the thenar eminence (Bolanowski et al., J Acoust Soc Am 84: 1680-1694, 1988; Gescheider et al., Somatosens Mot Res 18: 191-201, 2001). The effect of changing stimulus duration was also essentially identical for both sites, demonstrating the same amount of temporal summation in the P channel. Although the effect of changing stimulus frequency and changing stimulus duration did not differ for the two sites, the effect of varying the size of the stimulus was significantly greater for the thenar eminence than for the fingertip. The attenuated amount of spatial summation on the fingertip was interpreted as an indication that the mechanism of spatial summation consists of the operations of both neural integration and probability summation.
In a previous study of the heat grill illusion, sensations of burning and stinging were sometimes reported when the skin was cooled by as little as 2 degrees C. Informal tests subsequently indicated that these nociceptive sensations were experienced if cooling occurred when the stimulating thermode rested on the skin, but not when the thermode was cooled and then touched to the skin. In experiment 1 subjects judged the intensity of thermal (cold/warm) and nociceptive (burning/stinging) sensations when the volar surface of the forearm was cooled to 25 degrees C (1) via a static thermode (Static condition), or (2) via a cold thermode touched to the skin (Dynamic condition). The total area of stimulation was varied from 2.6 to 10.4 cm(2) to determine if the occurrence of nociceptive sensations depended upon stimulus size. Burning/stinging was rated 10.3 times stronger in the Static condition than in the Dynamic condition, and this difference did not vary significantly with stimulus size. In experiment 2, thermal and nociceptive sensations were measured during cooling to just 31 degrees, 29 degrees or 27 degrees C, and data were obtained on the frequency at which different sensation qualities were experienced. Stinging was the most frequently reported nociceptive quality in the Static condition, and stinging and burning were both markedly reduced in the Dynamic condition. In experiment 3 we tested the possibility that dynamic contact might have inhibited burning and stinging not because of mechanical contact per se, but rather because dynamic contact caused higher rates of cooling. However, varying cooling rate over a tenfold range (-0.5 degrees to -5.0 degrees /s) had no appreciable effect on the frequency of stinging and burning. Overall, the data show that mild cooling can produce nociceptive sensations that are suppressed under conditions of dynamic mechanical contact. The latter observation suggests that cold is perceived differently during active contact with objects than during passive heat loss to the environment. Hypotheses about the physiological basis of the nociceptive sensations at mild temperatures and their possible role in the phenomena of paradoxical heat and synthetic heat are discussed.
Approximately 5% of patients presenting to emergency departments have neurological symptoms. The most common symptoms or diagnoses include headache, dizziness, back pain, weakness, and seizure disorder. Little is known about the actual misdiagnosis of these patients, which can have disastrous consequences for both the patients and the physicians. This paper reviews the existing literature about the misdiagnosis of neurological emergencies and analyzes the reason behind the misdiagnosis by specific presenting complaint. Our goal is to help emergency physicians and other providers reduce diagnostic error, understand how these errors are made, and improve patient care.
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