Research Insights & Reviews: Emergency Medicine & Critical Care

Starvation ketoacidosis associated with tirzepatide use for weight loss in a nondiabetic East Asian woman: a case report

Mon, 31 Aug 2026 00:00:00 +0000

Background: Tirzepatide, a dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist, is increasingly used for obesity treatment, including in individuals without diabetes. Starvation ketoacidosis is a rare but serious complication associated with reduced caloric intake and enhanced ketogenesis. Reports of tirzepatide-associated starvation ketoacidosis in non-diabetic patients remain limited, and none have been reported in East Asian populations.

Case presentation: A 21-year-old Japanese woman with obesity initiated weekly subcutaneous tirzepatide (2.5 mg/week) for weight loss while practicing carbohydrate restriction. After the fifth injection, she developed persistent nausea and vomiting, leading to markedly reduced oral intake. She presented to the emergency department with hypoglycemia (68 mg/dL) and severe high–anion gap metabolic acidosis (pH 7.22, bicarbonate 10 mmol/L, anion gap 22.6 mmol/L). Urinalysis revealed ketonuria, and serum ketone levels were markedly elevated. She had lost 21 kg one month after the initiation of tirzepatide. No infection, toxin exposure, or alternative metabolic disorder was identified. Starvation ketoacidosis was diagnosed. Treatment with intravenous glucose-containing fluids resulted in rapid resolution of metabolic acidosis within 12 h without insulin therapy.

Conclusions: This case demonstrates that tirzepatide can precipitate starvation ketoacidosis in non-diabetic individuals, particularly when gastrointestinal adverse effects or dietary restriction lead to caloric deprivation. As the first reported case in an East Asian patient, it highlights the need for emergency physicians to consider starvation ketoacidosis in patients using tirzepatide for weight loss who present with vomiting, poor intake, or rapid weight loss. Early recognition and appropriate metabolic assessment are essential, and in patients with preserved endogenous insulin secretion, prompt glucose administration may allow rapid recovery without need for insulin therapy.

Clinical outcomes of cardiac arrest in pediatric patients presenting to the emergency department of a tertiary hospital in Kabul, Afghanistan: a retrospective cohort study

Mujeebullah Mahboob, Shafiqullah Shahim, Nijatullah Safi — Mon, 31 Aug 2026 00:00:00 +0000

Introduction: Outcomes of pediatric cardiac arrest in our country remain suboptimal. Understanding the factors that influence these outcomes is essential for improving survival rates. This study aimed to evaluate the clinical outcomes of pediatric cardiac arrest in the emergency department and to identify the factors associated with these outcomes.

Methods: A retrospective cohort study was conducted involving patients aged < 18 years who underwent cardiopulmonary resuscitation (CPR) in the emergency department of the French Medical Institute for Mothers and Children (FMIC) in Kabul, Afghanistan, between January 2021 and January 2025. Data were collected using the Utstein style of reporting. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with survival outcomes.

Results: Of the 200 patients who underwent CPR in the ED, sustained return of spontaneous circulation (ROSC) and survival to hospital discharge (STD) were achieved in 134 (67%) and 60 (30%) patients, respectively. Favorable neurological outcomes at hospital discharge were observed in 29 (14.5%) patients. Independent predictors of ROSC included IV/IO access established prior to arrest (AOR: 3.26, 95% CI: 1.68–6.3, p < 0.001), monitoring at the time of arrest (p = 0.003), administration of epinephrine during CPR (AOR: 18.3, 95% CI: 6.8–49.6, p < 0.001), endotracheal intubation during CPR (p < 0.001), and CPR duration ≤ 20 min (p < 0.001). Factors associated with survival to hospital discharge included response time ≤ 1 min (AOR: 7.2, 95% CI: 1.9–26.4, p = 0.003), time to first epinephrine dose ≤ 2 min (AOR: 5.3, 95% CI: 1.1–24.6, p = 0.03), administration of ≤ 2 doses of epinephrine during CPR (AOR: 5.3, 95% CI: 1.1–24.6, p = 0.03), CPR duration ≤ 15 min (p = 0.003), and post-resuscitation vasopressor/inotrope therapy (AOR: 5.79, 95% CI: 2.6–12.6, p < 0.001).

Conclusion: Factors associated with favorable post-cardiac arrest outcomes included monitoring at the time of arrest, response time ≤ 1 min, endotracheal intubation during CPR, administration of ≤ 2 doses of epinephrine during CPR, and CPR duration ≤ 15 min. Early recognition, immediate cardiac monitoring for at-risk patients, and timely high-quality CPR may significantly improve post-arrest outcomes.

Extensive thoracic spontaneous epidural hematoma presenting with position-induced transient paraplegia: successful conservative management in the resource limited settings

Kotaro Murakami, Noriaki Yamada, Nobuhiro Kodani, Yoshiaki Iwashita — Mon, 18 May 2026 00:00:00 +0000

Background: Spontaneous spinal epidural hematoma (SSEH) is a rare condition with an estimated incidence of 0.1 per 100,000 individuals. It is usually characterized by sudden spinal pain followed by rapidly progressive neurological deficits. Surgical treatment is generally indicated if a patient presents with neurological deficits. We report a case of SSEH presenting with neurological deficits relieved after position change, recovering without surgery.

Case presentation: The patient was a 73-year-old woman developed sudden, severe pain in the neck, back, lumbar region, and abdomen while sitting after meals. Upon arrival at the emergency department, her vital signs were stable except for hypertension. The patient was placed supine on a stretcher and became agitated because of back pain, but no motor or sensory symptoms were noted in the extremities. Pain initially improved with acetaminophen but recurred, requiring diclofenac. When attempting to sit again, complete motor and sensory deficits were noted in both lower limbs extending from the femur to the soles of the feet (the trunk was not assessed). Lower limbs muscle strength was 1/1 by Manual Muscle Test. Perineal sensory deficits and incontinence were present, leading to a diagnosis of bladder and bowel dysfunction (ASIA Grade A). Imaging revealed an extensive posterior epidural hematoma from C6 to Th12 with maximal cord compression at Th10–12. No coagulopathy or vascular malformations were observed. The hospital was unable to provide emergency surgical decompression because of limited medical resources, including the unavailability of an on-call spine surgeon and refusal of the transfer request. The patient was managed conservatively with analgesia, blood pressure control, and hemostatic agents. Motor function recovered fully, and she was discharged independently on day 13 with only mild residual sensory impairment.

Discussion: This case demonstrates a unique position-induced course; symptoms improved when supine and worsened while sitting. Treatment of SSEH is generally initiated once neurological symptoms appear. A case report described lumbar SSEH with position-induced symptoms; however, it was the opposite of the present case. This discrepancy reflects differences in position related spinal alignment. Lumbar lordosis decreases while sitting, expanding the canal, whereas thoracic kyphosis flattens when supine and increases while seated, narrowing the canal. In this patient, maximal compression at Th10–12 was relieved when supine but exacerbated when sitting. In this case, conservative treatment was selected due to resource limitations, including the lack of an on-call spine surgeon and refusal of the transfer request. This approach ultimately resulted in the most favorable therapeutic outcome. When rapid improvement in position-induced symptoms is observed, conservative treatment may be a
better option. These findings emphasize that SSEH presentation depends not only on hematoma size but also on lesion location and posture-related mechanics.

Determinants of out-of-hospital cardiac arrest (OHCA) and associated outcomes at a single center in Dubai

Mon, 31 Aug 2026 00:00:00 +0000

Background: Out-of-hospital cardiac arrest is a global health challenge with survival rates influenced by timely intervention and regional healthcare dynamics. Despite extensive research in Western contexts, data from rapidly urbanizing regions, such as Dubai, are scarce. This study aims to determine the survival and outcomes of Out-ofhospital cardiac arrest patients visiting emergency department.

Methods: This is a single-center, small observational study which used electronic health records and emergency logs to identify 48 Out-of-hospital cardiac arrest cases from a single healthcare center (January 2020–October 2024). Out-of-hospital cardiac arrest cases with resuscitation attempts and complete records were included only. Cox proportional hazard analysis was applied to determine the association between survival predictors and Out-of-hospital cardiac arrest outcomes.

Results: The majority were male (93.75%), belonging to low socioeconomic status (83.33%). Bystanders were present in 75% of cases, but only 22.92% performed cardiopulmonary resuscitation. Mean emergency medical services response time was 15.75 ± 8.55 min. Multivariable analysis identified the absence of bystanders (HR = 3.58, 95% CI1.53–5.51), no bystander cardiopulmonary resuscitation (HR = 2.12, 95% CI1.82–4.58), prior cardiac arrest (HR = 7.35, 95% CI1.81–9.76), and lack of ROSC (HR = 5.99, 95% CI2.16–8.38) as significant mortality predictors.

Conclusion: The survival rate in this study (20.83%) reflects intermediate outcomes, constrained by low bystander cardiopulmonary resuscitation rates and prolonged EMS response times. Outcomes could be improved via targeted public cardiopulmonary resuscitation training, automated external defibrillator, accessibility, and optimized emergency response systems.

Complete tracheal transection at the thoracic inlet: successful reconstruction with intraoperative Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) support – case report

Huade Luo, Lingling Jiang, Dongying Wang — Mon, 31 Aug 2026 00:00:00 +0000

Background: Tracheobronchial injuries from blunt chest trauma carry high mortality, with complete thoracic inlet tracheal transection being previously undocumented. While Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) has been increasingly recognized as a critical airway support modality in traumatic tracheal reconstruction, current evidence provides no consensus regarding optimal ECMO initiation timing in surgical decision-making.

Case presentation: A 58-year-old male driver sustained front and back chest impacts in a crash. CT scan revealed complete tracheal transection at the thoracic inlet (mimicking a “bitten-off” appearance). With a dedicated VV-ECMO team on standby, we expeditiously commenced tracheal repair surgery. Intraoperatively, refractory oxygenation deterioration prompted immediate initiation of VV-ECMO via pre-positioned cannulas. Despite this intervention, the patient experienced a 2-minute cardiac arrest, which was successfully reversed. The procedure was ultimately completed with sustained VV-ECMO support, and the patient achieved satisfactory postoperative recovery.

Conclusions: This case demonstrates a unique traumatic tracheal injury mechanism and highlights the critical role of preemptive VV-ECMO team activation in managing complex airway reconstruction.