bluuebunny/crossref_metadata_2025 huggingface dataset:
Inpatient and Outpatient Management for Foreign Body Ingestion: A Retrospective Review in an Emergency Department of Hong Kong
Authors: Tse CT
Published: December 2017

Objectives

To evaluate the outcome of patients who presented to our accident and emergency department (AED) for foreign body (FB) ingestion, and were managed in inpatient or outpatient settings according to the departmental protocol.

Methods

It was a retrospective observational study of patients admitted to the AED of Kwong Wah Hospital for FB ingestion from 1st March to 30th June 2007. Patients without FB found by direct laryngoscopy were admitted for inpatient oesophagogastroduodenoscopy (OGD) if they were under 12 years old, had significant symptoms with haematemesis, vomiting more than twice, swallowed FB other than fish bone or had FB seen on cervical X-ray, according to the departmental protocol. Patients without the above criteria were discharged for outpatient OGD. Demographic data, clinical information, OGD findings and outcomes, including complication rate and re-attendance rate, were studied and compared.

Results

There were 152 patients in this study; 71 of them were admitted for inpatient OGD and 81 were discharged for outpatient OGD. The mean age of the inpatient group was 46.34 years and that of the outpatient group 51.08. The mean day of impaction was 1.39 days for the inpatient group and 1.25 days for the outpatient group respectively. OGD was done for 59 outpatients and 17 of them were found to have FB. OGD was done for 35 inpatients and 23 of them were found to have FB. Fish bones were the commonest FB detected. One patient of the inpatient group developed complication and one patient re-attended within one month. Re-attendance was not found in the outpatient group.

Conclusion

Foreign body ingestions were commonly encountered in the AED. No statistically significant difference in complication rate and re-attendance rate between inpatients and outpatients was demonstrated in this study.
Two Cases of Chickenpox Complicating Pregnancy and an Update on Management
Authors: Tang CL , Tsui SH , Tong HK
Published: December 2017

Susceptible pregnant women with chickenpox exposure are uncommon but are medical emergency conditions. Chickenpox infection in the first trimester is associated with the congenital varicella syndrome and in the third trimester is associated with fatal complications and the neonatal varicella syndrome. In this article, two cases and the management of chickenpox during pregnancy are discussed.
A Case of Malathion Poisoning with Prolonged Cholinergic Toxicity
Authors: Pang PKM , Lee FT
Published: December 2017

A case of severe organophosphate poisoning in a woman who ingested malathion is presented. Pralidoxime was given for more than two weeks but the lady had a poor response and developed recurrent episodes of cholinergic symptoms. Further studies are required to validate the World Health Organization regimen of pralidoxime in organophosphate poisoning.
Late‐Presenting Congenital Diaphragmatic Hernia: A Potentially Life Threatening Case
Authors: Chan HY , Wong CC , Ng F
Published: December 2017

Congenital diaphragmatic hernia (CDH) generally presents with respiratory distress in the neonatal period. Late onset CDH is less common and is associated with a wide range of clinical symptoms. We report a case of a 4‐year‐old child presenting with sudden onset of dizziness, abdominal pain and vomiting after swimming. Radiological investigations showed a left CDH with mediastinal shift. She gradually developed respiratory distress after admission. Urgent operation showed that the contents of the hernia included stomach, spleen, small and large bowels. This case highlights the importance of suspicion of CDH, proper clinical examination and investigation of children with acute non‐specific gastrointestinal complaints.
Should N‐Acetylcysteine be Administered Orally or Intravenously for the Treatment of Paracetamol Overdose?
Authors: Cattermole GN
Published: December 2017

Introduction

Paracetamol is the most commonly used drug in deliberate poisoning. N‐acetylcysteine is the standard antidote for significant acute paracetamol overdose, but the route of administration varies between countries. This review aimed to find and appraise those comparative studies which would help answer the following question: in patients who have taken an overdose of paracetamol requiring antidote, is there any difference between intravenous and oral N‐acetylcysteine in mortality, hepatotoxicity, adverse drug reactions or cost?

Methods

A literature search was conducted using Medline and other databases. Relevant papers were identified and appraised.

Results

One animal study and seven comparative clinical studies were identified and appraised. The quality of the evidence was generally poor, and there was no clear difference in outcomes between the two routes of administration.

Conclusions

Without evidence of advantage for one route over the other, routine practice should not be changed. However, after 30 years experience, both routes appear to be effective and safe, and in countries where intravenous administration is the standard, it would be reasonable to consider the oral route as an alternative when intravenous access is problematic. There is a need for prospective, randomised trials to determine the relative effectiveness, safety and cost of intravenous and oral formulations of N‐acetylcysteine.
Acute Urinary Retention: How Useful is an Ambulatory Care Protocol?
Authors: Li YK , Leung CS , Hui TL , Chiu LH
Published: December 2017

Introduction

Acute urinary retention (AUR) is a common urological presentation to emergency departments (ED). An ambulatory care protocol had been developed allowing trial without catheterization (TWOC) instead of admission to hospital after catheterization in the ED. This study aimed to evaluate the efficacy of the ambulatory care protocol for patients with AUR. The secondary aim was to identify any independent predictor(s) for successful weaning of urinary catheter in a short duration.

Methods

This was a prospective cohort study. A total of 143 male patients presenting with an episode of AUR underwent urinary catheterization once. Those who were unable to pass urine afterwards were catheterized again and discharged home with a urinary catheter in‐situ (Day 0). On Day 3, ability of spontaneous urination was assessed. If failed, spontaneous urination was assessed again on Day 6.

Results

Successful TWOC was recorded in 50.3% of the 143 patients after first catheterization. The cumulative successful rates for first (Day 3) and second (Day 6) follow‐ups were 76.9% and 79.0%, respectively. Among the associated predictors, only the urine retention volume on first catheterization was found to be independently associated with successful TWOC, using binary logistic regression (p=0.001).

Conclusion

The ambulatory care protocol was successful in weaning off urinary catheter for 50.3% of patients with AUR after first catheterization and a further 26.6% on Day 3, making a cumulative success rate of 76.9%. Those who failed TWOC on Day 3 would get little benefit on further trials. The first catheterization volume was independently associated with the chance of successful TWOC.
An Elderly with Purple Urine
Authors: Lau CL , Ong KL
Published: December 2017

Purple discolouration of urine is not commonly encountered in accident and emergency departments. We report a case of an elderly gentleman on long‐term urinary catheter who presented with purple discolouration of urine. He was found to have urinary tract infection caused by the bacteria Proteus mirabilis. The urine became clear after urinary catheter change and antibiotic treatment. This is called the purple urine bag syndrome and emergency physicians should be aware of this uncommon condition and the associated potentially dangerous conditions in order to initiate appropriate management.
The Efficacy of Emergency Medicine Ward for the Management of Patients with Mental Disorders
Authors: Chan CM , Wong MY , Chan SL , Wan MY , Mo YF
Published: December 2017

Objective

Patients with mental disorders are one of the target groups selected for management in the Emergency Medicine Ward (EMW) with the enrolment of psychiatric advanced practice nurses. This study aimed to determine whether the EMW can be efficiently used for the management of patients with mental disorders in terms of length of stay (LOS), admission rate, and re‐attendance rate when compared with the medical ward.

Methods

This was a retrospective descriptive study. Patients with mental disorders were defined and recruited from the Princess Margaret Hospital during two selected study periods: pre‐opening (pre‐EMW) and post‐opening (post‐EMW) of the EMW. All emergency department records of patients with mental disorders within these two periods were reviewed and data of the selected samples were retrieved from different computer databases.

Results

The total number of patients with mental disorders was 565 in the pre‐EMW period and 404 in the post‐EMW period; 214 (37.9%) cases were admitted into the medical ward in the pre‐EMW period while only 62 (15.3%) were admitted into the medical ward in the post‐EMW period. The mean LOS in the pre‐EMW period was 67.7 hours. For the post‐EMW period, the mean LOS was 32.3 hours. The reduction in mean LOS was 35.4 hours, and 82% of the study patients treated in the EMW were discharged within 48 hours. Notably, 23.3% of the cases re‐attended the emergency department after discharge from the medical ward, whereas only 8.8% of cases re‐attended after discharge from the EMW.

Conclusion

Patients with mental disorders or related problems can be efficaciously managed in the EMW, as evidenced by a decrease in the length of stay, admission rate, and re‐attendance rate.
Differences in Injury Pattern and Mortality between Hong Kong Elderly and Younger Patients
Authors: Cheng CH , Yim WT , Cheung NK , Yeung JHH , Man CY , Graham CA , Rainer TH
Published: December 2017

Background

The rapidly aging population in Hong Kong is causing an impact on our health care system. In Hong Kong, 16.5% of emergency department trauma patients are aged ≥65 years.

Objective

We aim to compare factors associated with trauma and differences in trauma mortality between elderly (≥65 years) and younger adult patients (15 to 64 years) in Hong Kong.

Methods

A retrospective observational study was performed using trauma registry data from the Prince of Wales Hospital, a 1200–bed acute hospital which is a regional trauma centre.

Results

A total of 2172 patients (331 [15.2%] elderly and 1841 [84.8%] younger) were included. Male patients predominated in the younger adult group but not in the elderly group. Compared with younger patients, elderly patients had more low falls and pedestrian‐vehicle crashes and sustained injuries to the head, neck and extremities more frequently. The odds ratio (OR) for death following trauma was 5.5 in the elderly group (95% confidence interval [CI] 3.4–8.9, p>0.0001). Mortality rates increased progressively with age (p>0.0001) and were higher in the elderly at all levels of Injury Severity Score (ISS). Age ≥65 years independently predicted mortality (OR=5.7, 95% CI 3.5–9.3, p>0.0001). The elderly had a higher co‐morbidity rate (58.6% vs. 14.1%; p>0.01). There was a lower proportion of trauma call activations for the elderly group (38.6% vs. 53.3%; p>0.01).

Conclusion

Elderly trauma patients differ from younger adult trauma patients in injury patterns, modes of presentation of significant injuries and mortality rates. In particular, the high mortality of elderly trauma requires renewed prevention efforts and aggressive trauma care to maximise the chance of survival.
An Uncommon Cause of Deep Vein Thrombosis: Mycotic Aneurysm Secondary to Salmonella Arteritis
Authors: Wong OF , Lam TSK , Wong TT , Fung HT
Published: December 2017

Mycotic aneurysm is an uncommon surgical emergency with high mortality. Endovascular infection due to salmonella is the commonest cause of intra‐abdominal mycotic aneurysm. We report a rare presentation of mycotic aneurysm in a 78‐year‐old man who presented to the accident and emergency department with deep vein thrombosis due to compression of the iliac vein by a mycotic aneurysm arising from the internal iliac artery and an adjacent abscess. A comprehensive review of the aetiology, clinical presentation and management of mycotic aneurysm secondary to salmonella arteritis is presented.
Association between Drink Driving and Severity of Crash Injuries to Road Users
Authors: Tsui KL , Sze NN , So FL , Wong SC
Published: December 2017

Objective

To determine the association between alcohol impairment in drivers and risk of severe injury in other road users in Hong Kong.

Method

The Road Casualty Injury Information System (RoCIS) was set up by linking a regional hospital injury registry to the police traffic injury database. Based on the year 2004 linked dataset, a specific model namely the External Casualty Model (ECM) was designed to measure the association between severe injury outcome of other (non‐driver) road user casualties (as stratified by ISS groups [ISS <9 or ISS ≥9]) and the level of alcohol impairment (as measured by breath alcohol concentration [BAC <22 µg/100 ml or BAC ≥22 µg/100 ml]) in drivers involving in the crash, controlling for the driver's demographics (age and sex) and behaviour (as measured by driving‐offence points [DOP]) and another attribute (day of week of crash). Binary logistic regression was used in the analysis.

Results

Out of 1818 matched RoCIS cases in the year 2004, 439 ECM records were available for analysis. Alcohol impaired drivers led to a significantly higher risk of severe injury to other road users (OR=4.2, 95%CI=1.21, 14.36, p=0.02). Crashes on weekdays seemingly led to a lower severe injury risk (OR=0.57, p=0.08) than crashes on weekends. DOP of drivers did not predict a higher severe injury risk to other road users.

Conclusions

Alcohol impairment on driver increases the risk of severe injury to other road users by four times. Road safety education campaign should stress on this adverse impact of drink driving on innocent people.
Cost Benefits of the Drug and Poison Information Centre in Preventing Unnecessary Hospitalisation: The Singapore Experience
Authors: Ponampalam R , Loh CS
Published: December 2017

Background

The Drug and Poison Information Centre (DPIC) in Singapore was piloted as a new service in April 2004. This study evaluated the cost benefits of its interventions in the first two years of its operation.

Method

A two‐year retrospective review of DPIC call records was performed and the following outcome measures were noted: (A) proportion of patients who were managed onsite and hence did not need to attend the emergency department (ED); and (B) proportion of patients who were managed in the ED without the need for admission. Cost savings were calculated based on admission costs for patients with poisoning, including other out‐of‐hospital costs. This amounted to savings of S$1390 and S$1170 for patients who fulfilled outcome measures A and B respectively. Savings for the hospital was S$1477 per case. The cost of operating the DPIC over the same period was S$507,922.

Results

There were 831 calls on acute toxic exposures over the study period. Of these, 115 and 405 patients fulfilled outcome measure A and B respectively with consequent cost savings of S$159,850 (115 x S$1390 per patient), and S$473,850 (405 x S$1170 per patient). The hospitals saved S$768,040 (520 x S$1477) from prevented admissions. Excluding operating cost, this gave net savings of S$893,818 over the two years from DPIC interventions.

Conclusion

The cost savings from DPIC services is evident from this study. This translates to more effective use of limited healthcare resources.
A Volunteer Study on the Blood Salicylate Level of Excessive Use of Topical Methylsalicylate
Authors: Yip WL , Ng HW , Chan YC , Tse ML , Lau FL
Published: December 2017

Objective

The purpose of this study was to evaluate the serum level of salicylate after topical application of methylsalicylate (analgesic balm), and to determine the safety of its use in our population.

Methods

This was a human volunteer study involving six volunteers. Each of them applied 10 grams of analgesic balm (containing 5 grams of methylsalicylate) on the limbs, and serial serum salicylate levels were measured just before the trial, and 1, 2, 4 and 8 hours after application. The time required to reach the maximum blood level after application was recorded.

Results

The serum salicylate level ranged from non‐detectable level up to near therapeutic level in different subjects. The maximum salicylate level measured was 130 mg/L in one of the volunteers 8 hours after application. The calculated systemic bioavailability of dermal methylsalicylate in our study was 19‐45%, which was comparable to previous studies.

Conclusions

Dermal application of massive amount of analgesic balm may cause unpredictable absorption of methylsalicylate. Patients and physicians should be aware of its potential risk.
A Rare but Potentially Fatal Bacterial Infection in a Patient with Poorly Controlled Diabetes Mellitus: Emphysematous Pyelonephritis
Authors: Cheung RKH , Lam TSK , Wong OF , Fung HT
Published: December 2017

Emphysematous pyelonephritis, a necrotizing infection of the renal parenchyma caused by gas‐producing organism, is a rare but life‐threatening condition. The initial presentation could be non‐specific. We report a case of emphysematous pyelonephritis in a patient presenting with poorly controlled diabetes mellitus and severe sepsis. Its pathogenesis and management are briefly discussed.
Acute Coronary Syndrome Secondary to Methylphenidate Overdose
Authors: Wong OF , Tsui KL , Fung HT
Published: December 2017

A 28‐year‐old lady presented to the emergency department after an overdose of methylphenidate. She complained of chest pain and developed an acute coronary syndrome with marked ST segment depression in the electrocardiogram and elevated troponin I level. She was closely monitored in the cardiac care unit and was treated with the standard therapy for acute coronary syndrome. Echocardiogram showed global left ventricle impairment. The follow‐up echocardiogram showed that the left ventricular function normalised and the subsequent coronary angiogram was normal. The clinical use, abuse potential, toxicity and overdose treatment of methylphenidate are discussed.
Timolol Eye Drops Induced Bradycardia
Authors: Lau KK , Ng HW , Tse ML
Published: December 2017

We report a 25‐year‐old man with bradycardia after administration of ophthalmic timolol. The patient was asymptomatic, and his bradycardia resolved after stopping the eye drop. He was discharged after a four‐hour observation. This case demonstrated that topical timolol eye drop may cause systemic adverse reaction. The use of timolol and its possible side‐effects are discussed.
Reliability and Validity of the “Extended ‐ Hurt, Insult, Threaten, Scream” (E‐Hits) Screening Tool in Detecting Intimate Partner Violence in Hospital Emergency Departments in Hong Kong
Authors: Chan CC , Chan YC , Au A , Cheung GOC
Published: December 2017

Objectives

To assess the reliability and validity of a brief screening instrument, “E‐HITS” (Extended ‐ Hurt, Insult, Threaten, Scream), for detecting female intimate partner violence (IPV) in Hong Kong emergency departments (EDs).

Method

Quantitative data were collected from a victim group (n=110) and a control group (n=116). Statistical properties of the instruments were analysed to ascertain its internal consistency, test/re‐test reliability, concurrent validity and discriminant validity.

Results

Cronbach's alpha was 0.90 for the E‐HITS. Two‐week test/re‐test reliability was 0.71 (p<0.001). Respondents' scores on the E‐HITS positively correlated with those on psychological aggression, physical assault, sexual coercion and injury scales, and negatively correlated with the negotiation scale of the revised Conflict Tactics Scale at a statistically significant level. Subsequent Receiver Operating Characteristic (ROC) curve analysis revealed that E‐HITS reached a sensitivity of 98.2% and a specificity of 94.8% at a cut‐off of 8.5. The overall accuracy of the E‐HITS indicated by the area under curve (AUC) in the ROC is 0.991.

Conclusion

These results show that the E‐HITS has good internal consistency, test/re‐test reliability, as well as concurrent and discriminant validity. The E‐HITS is a valid and reliable tool for screening intimate partner violence in Hong Kong EDs.
A Prospective Clinical Trial Comparing Self‐Administered Nitrous Oxide and Haematoma Block for Analgesia in Reducing Fracture of the Distal Radius in an Emergency Department
Authors: Man KH , Fan KP , Chan TN , Yue YM , Sin FP , Lam KW
Published: December 2017

Objective

To compare the effectiveness and efficacy of self‐administered nitrous oxide and haematoma block in pain relief during close reduction of fractured distal radius in adult patients.

Methods

This was a prospective clinical trial. All adult patients aged 18 years or above with fracture of the distal radius within 24 hours requiring close reduction in the Accident and Emergency Department of Kwong Wah Hospital were included. Patients with known contraindications were excluded. A consecutive series of patients were randomised into the two groups in alternating fashion. Pain perception (VAS score), procedure time, patient acceptance and complications were measured and monitored.

Results

A total of 67 patients (53 females and 14 males) with age ranging from 26 to 94 years were enrolled during the period from April 2008 to December 2008; 33 patients received Entonox and 34 received haematoma block. The average VAS score before reduction was 6.97 cm for the Entonox group and 6.76 cm for the haematoma block group (p=0.61). The average VAS score during reduction was 7.19 cm for the Entonox group and 2.80 cm for the haematoma block group (p<0.0001). For the difference of average VAS scores during and before reduction, there was 0.22 cm increase in the Entonox group and 3.95 cm decrease in the haematoma block group (p<0.0001). The relative change of mean VAS score was 3% increase in the Entonox group and 58% decrease in the haematoma block group (p<0.0001). The average procedure time was 6.29 min for the Entonox group and 6.44 min for the haematoma block group (p=1). In the Entonox group, 64% patients agreed to use the same analgesia method under similar circumstances whereas in the haematoma block group, it was 91% (p=0.009). There were no complications or failed reductions in both groups.

Conclusion

Haematoma block is a safe and effective analgesia in the reduction of fractured distal radius with less pain perception, more patient acceptance and similar procedure time compared with Entonox.
Predictive Factors for the Existence of Foreign Body following Fish Bone Ingestion: A Prospective Study
Authors: Poon KC , Lee HY , Yau WH
Published: December 2017

Objectives

To look at the factors that will affect the likelihood of a fish bone (FB) in throat and help to improve the use of oesophagogastroduodenoscopy (OGD).

Methods

It was a prospective cohort study of patients who attended the Accident and Emergency Department of Queen Elizabeth Hospital because of having foreign body sensation after eating fish in the period of 15th May 2008 to 15th February 2009. A pro forma was designed for the collection of information on various clinical parameters to be studied. Direct laryngoscopic examination (DL) and OGD findings were recorded. Tracing through the computerised Clinical Management System or telephone enquiry for the clinical outcome was employed for patients who refused or defaulted OGD. The primary outcome measured was the predictive power of the sharp pricking sensation symptom, radiographic finding and full visualisation by DL on the presence of FB. The data were analysed by logistic regression.

Results

The findings of 259 patients were analysed: 94 FBs were found; 83 (88.3%) FBs were lodged at a level above the hyoid bone; 73 FBs (77.7%) were removed by DL and 21 (22.3%) by OGD. Sharp pricking sensation was the only significant predictive factor for the presence of FB (OR=8.27; 95% CI=2.66, 25.76; p<0.01) in the group of patients requiring OGD whereas positive radiological finding (p=0.07) and full visualisation by DL (p=0.36) were not. Full visualisation by DL alone could not reliably rule out the presence of fish bone. Two FBs were missed.

Conclusion

The presence of definite sharp pricking sensation is a significant independent predictor for the presence of fish bone whilst full visualisation by DL and positive X‐ray findings are not significant predictors.
A Case of Tolterodine Poisoning
Authors: Lui CT , Fung HT
Published: December 2017

We present a case of acute tolterodine overdose with anticholinergic toxidrome including drowsiness, confusion and pyrexia. Tolterodine was commonly used in recent years for the treatment of overactive bladder syndrome. Experience with acute tolterodine poisoning was limited. The pharmacology, clinical use and side effects of tolterodine were reviewed. The clinical manifestations, toxicology and management of tolterodine poisoning are discussed.
Simultaneous Fractures of Capitate and Hamate in a Child
Authors: Celiktas M , Kose O , Sagiroglu S
Published: December 2017

Carpal fractures are rare injuries in children, with the scaphoid being fractured most frequently. We report a case with simultaneous fractures of the capitate and hamate in a 9‐year‐old boy that were successfully treated with conservative treatment.
Correlation between Physical Features of Elementary School Children and Chest Compression Depth
Authors: Uhm TH , Oh JK , Park JH , Yang SJ , Kim JH
Published: December 2017

Introduction

The height and body weight of 6th grade elementary school children may have influence on chest compression.

Materials & methods

In accordance with the 2005 American Heart Association guidelines and 2006 Korean Association of CardioPulmonary Resuscitation (CPR) guidelines, a 25‐minute audiovisual presentation and practical demonstration of CPR were presented by the researchers and assistants. The assistants supervised and corrected the practical performance of the students who performed 5 cycles of CPR (2 minutes each) with the aid of the Laerdal Resusci® Anne SkillReporter™. The students then carried out another 5 cycles of CPR (2 minutes each) using the skill reporter; and a short report was printed.

Results

The correlation coefficient between body weight and chest compression was 0.467 (p=0.000), and the correlation coefficient between height and chest compression was 0.309 (p=0.009). The intercept between body weight and chest compression was 21.763 (p=0.000), and the slope was 0.324 (p=0.000). Student height showed no linear correlation with chest compression depth.

Conclusions

The body weight of 6th grade elementary school children showed moderate correlation with chest compression depth. A minimal body weight of 50 kg is required to attain a standard chest compression depth of 38 mm. With improved training, some students with body weight less than 50 kg may also achieve satisfactory performance of CPR.
A Case of Cardiac Arrest Caused by Peripartum Cardiomyopathy
Authors: Yun SY , Cho KH , Lee HM , Lee DH , Choi YH
Published: December 2017

Many women experience dyspnoea, orthopnoea, and peripheral oedema during pregnancy, and diagnosing cardiac problem is confounded by these signs and symptoms of normal pregnancy. Peripartum cardiomyopathy (PPCM) is a rare life‐threatening cardiomyopathy of unknown aetiology that occurs between the last month of pregnancy and the first 5 months postpartum in previously healthy woman. Multiparity, twins, advanced maternal age, preeclampsia, gestational hypertension, and black race are known risk factors. The course of PPCM can range from readily treatable to acutely fatal. We present a lady with dyspnoea in the peripartum period admitted in cardiac arrest as a result of PPCM.
Case Report of Aspirin Overdose: Bezoar Formation and Controversies of Multiple‐Dose Activated Charcoal in Salicylate Poisoning
Authors: Wong OF , Fung HT , Lam TSK
Published: December 2017

Bezoar formation is cited to be the cause of delayed absorption of aspirin in overdose of enteric‐coated aspirin preparation. However, such phenomenon from oral overdose of regular aspirin preparation has not been clearly demonstrated in human. The use of multiple‐dose activated charcoal (MDAC) in salicylate poisoning remains controversial. We report a case of regular‐preparation salicylate poisoning with rebound of the serum salicylate level after discontinuation of MDAC administration. Bezoar formation as the underlying cause of the rebound and the effect of MDAC on serum salicylate level are discussed.
Succinylcholine‐Induced Masseter Muscle Rigidity in an Emergency Department: A Case Report
Authors: Suen KW , Lee HY , Ho HF
Published: December 2017

Succinylcholine is the most popular muscle relaxant employed in local accident and emergency departments because of its effectiveness and short‐acting half life. Significant adverse reaction is rare and it increases the success rate of intubation. We describe a case of masseter muscle rigidity after administration of succinylcholine alone in the emergency room. The patient subsequently required nasotracheal intubation for ventilation.
Chewing Gum as an Unusual Cause of Systemic Allergic Reaction
Authors: Cevik Y , Kavalci C
Published: December 2017

Chewing gum allergy is a rare condition in emergency settings. A 48‐year‐old man presented to the emergency department with generalised itchiness which was more prominent on the periorbital areas, nausea, vomiting, and dyspnoea after taking chewing gum. Vital signs showed hypotension with a blood pressure of 72/45 mmHg, and heart rate 95 beats per minute. Auscultation of the chest revealed diffuse rhonchi and coarse crackles. There was blanchable skin rash over the body especially on the abdomen. As the symptoms were compatible with systemic allergic reactions after chewing gum, the patient was given supplemental oxygen, subcutaneous adrenaline, intravenous methylprednisolone and nebulised salbutamol. The patient responded dramatically. He was discharged with oral hydroxyzine (Atarax® tablet) prescription. Although there are lots of well‐known allergic substances including foods and drugs, we may encounter allergic reactions associated with rare allergens like chewing gum.
Comparison of the Karl Storz Video Laryngoscope with the Macintosh Laryngoscope for Intubating Difficult Airway: A Manikin Study
Authors: Lee IYC , Tung WK , Lo CM
Published: December 2017

Objective

To compare the Karl Storz video laryngoscope (KSVL) with the conventional Macintosh laryngoscope in simulated difficult airway scenarios, using a Laerdal resuscitation manikin.

Methods

This was a prospective comparative study. The scenarios were normal airway, reduced mouth opening, tongue oedema and cervical spine immobilisation. Thirty-five doctors performed endotracheal intubation with both devices in each of the scenarios. The outcome measures were the successful rate of intubation, time taken for intubation, vocal cord visualisation, and ease of intubation. We also surveyed the doctors' preference for the intubation devices.

Results

The use of the KSVL resulted in significantly better laryngoscopic grading than the Macintosh laryngoscope in all four scenarios. The mean time of intubation in the cervical spine immobilisation scenario was significantly shorter with the KSVL than the Macintosh laryngoscope (12.56 sec and 14.00 sec, respectively; P=0.049). The mean time of intubation in the tongue oedema scenario was shorter with the KSVL than the Macintosh laryngoscope (19.37 sec and 22.04 sec, respectively), although this was not statistically significant (P=0.546). There was no difference in the mean time required for intubation in the normal and reduced mouth opening scenarios. There was no significant difference in the success rate in all four scenarios. The ease of intubation score of the KSVL was significantly better than that of the Macintosh laryngoscope in all three difficult airway scenarios

Conclusions

Our study showed that the KSVL provided a better glottic view in both normal and difficult airways than the conventional Macintosh laryngoscope. It also showed an advantage over the conventional Macintosh laryngoscope in the time required for intubation in patients under cervical immobilisation.
Hong Kong Poison Information Centre: Annual Report 2008
Authors: Chan YC , Tse ML , Lau FL
Published: December 2017

Objective

To report the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2008.

Methods

From 1st January 2008 to 31st December 2008, all poisoning cases received by HKPIC were retrieved from its database (DATOX & PIC-MS) for analysis.

Results

4,029 poisoned cases were analyzed. There were 1,755 male patients (43.6%) and 2,262 female patients (56.1%). Nearly two-thirds of them were between 20 and 59 years old. Common causes of exposure were suspected self harm/suicidal attempt, unintentional exposure and abusive use. Sedatives, household products, paracetamol, and ketamine were common poisons exposed and non-benzodiazepine sedative-hypnotics were involved in about one-seventh of the poisoning cases. The majority of the patients were managed conservatively, with 6.0% and 5.9% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; about 1% of the poison exposure resulted in death and about 5% of the exposure had major outcomes.

Conclusions

This annual report provides updated epidemiological information on poisoning in Hong Kong in 2008 and highlights some changes in comparison with our previous reports. The increase in abusive substance poisoning, in particular ketamine, requires further attention.
Sonographic Measurement of the Epiglottis in Normal Chinese Adults
Authors: Chau CW , Chan HH , Wong CP , Wong TW , Lau CC
Published: December 2017

Objectives

(1) To assess the normal range of thickness of the epiglottis by means of ultrasound measurement. (2) To evaluate inter-observer agreement in measuring the thickness of the epiglottis of normal individuals by ultrasound. (3) To assess the association between biological factors and the thickness of the epiglottis.

Methods

Fifty adult volunteers working at a local accident and emergency department were recruited. The thickness of the epiglottis was measured by means of ultrasound examination, which was performed twice by two emergency physicians at different time. The study subjects' age, sex, height and body weight were recorded.

Results

The mean thickness of the epiglottis was 0.236 cm and the standard deviation was 0.020. Male subjects had thicker epiglottis. Interobserver agreement of the two emergency physicians who performed the ultrasound scan was very good. Multiple regression models showed that sex and height were useful predictors of the thickness of the epiglottis.

Conclusions

Bedside ultrasound assessment of the epiglottis is an easy, rapid and reliable method to evaluate its thickness. Further studies are needed to evaluate the thickness of the epiglottis in patients with epiglottitis before it can be put into clinical use.
Successful Resuscitation of Out-Of-Hospital Ventricular Fibrillation Cardiac Arrest in an Adolescent
Authors: Kung SW , Yung TC , Chiu WK
Published: December 2017

Cardiac arrest in the paediatric age group is uncommon. Successful resuscitation of out-of-hospital cardiac arrest in children with subsequent hospital discharge and normal neurological outcome is even rarer. A 14-year-old girl who presented with recurrent convulsive syncope was misdiagnosed to be suffering from epilepsy. Subsequently she was witnessed to have cardiac arrest and was successfully resuscitated. Catecholaminergic polymorphic ventricular tachycardia was suspected to be the underlying cause of her symptoms. This case illustrated the important concept of the paediatric chain of survival in the prevention of death and improvement of survival in paediatric cardiac arrest.
Accidental Use of Sodium Hypochlorite Instead of Haemodialysis Solution: A Case Report
Authors: Katirci Y , Kandis H , Aslan S , Keles M , Cakir Z , Karcioglu O
Published: December 2017

Haemodialysis that involves diffusion of solutes across a semi-permeable membrane allows excretion of harmful solutes and excess fluids. All dialysis machines are disinfected by chemical agents (e.g. sodium hypochlorite, formaldehyde, glutaraldehyde, peroxyacetic acid). Sodium hypochlorite (NaOCl), which is known as household bleach, is a whitening agent and used in medical treatment and disinfection of tap water. Herein, we present a 66-year-old female patient who was inadvertently connected to NaOCl solution infusion in a routine haemodialysis session. By the time the accident was noticed, approximately 200 ml of undiluted NaOCl cleaning solution (concentration 1.21-1.23 g/ml) had been added to the dialysis bath, soaking the membrane fibres. The patient was admitted to the hospital about 30 minutes after the exposure, and her Glasgow Coma Scale score was recorded as 5/15 (E1, V1, M3). In conclusion, more stringent standards should be enforced in the sterilization of haemodialysis machines and related equipments. Accidental contacts with disinfectants should be prevented in dialysis units.
Retained Gauze Material in the Nasal Cavity after Functional Endoscopic Sinus Surgery for Ten Years: A Case Report
Authors: Dalgic A , Kandogan T , Gonullu H , Erkan N
Published: December 2017

We report a case of retained packing gauze material in the right nasal cavity for ten years. A 55-year-old woman presented to the emergency service with headache, nasal discharge, and epistaxis from the right nasal cavity. Her past surgical history included a functional endoscopic sinus surgery because of nasal polyposis 10 years ago. In the endoscopic nasal examination, foreign body similar to nasal packing material about 5 cm in length was detected in the right anterior ethmoid sinus. CT of the paranasal sinuses showed only loss of aeration in the right nasal cavity. The nasal packing material was removed under local anaesthesia on the same day. Foreign body left behind after operation is a serious medicolegal issue and is often under-reported.
Diagnosing Acute Pancreatitis: Amylase or Lipase?
Authors: Chang JWY , Chung CH
Published: December 2017

Introduction

Serum amylase has all along been used to aid the diagnosis of acute pancreatitis in hospitals in Hong Kong. Another serum marker lipase, on the other hand, has been claimed to have better accuracy in other countries. The aim of this study was to evaluate serum lipase as a diagnostic tool compared to the traditional serum amylase.

Methods

This was a retrospective study in a district hospital in Hong Kong. The two serum markers were taken from 3451 patients with acute abdominal pain who presented to our emergency department over an eight-month period. Receiver operating characteristic (ROC) curve was used to assess the diagnostic accuracy of both markers. Other diagnostic efficacy modalities, including sensitivity, specificity, positive and negative predictor values were also calculated.

Results

Both amylase and lipase had high accuracy index in the area under the ROC curve (0.992 and 0.996 respectively). The sensitivity and specificity of amylase at 3-fold above normal limit were 63.6% and 99.4% while those of lipase were 95.5% and 99.2% respectively.

Conclusion

Both serum enzymes had good diagnostic accuracy in our study but lipase was slightly better than amylase.
Monday Syndrome: Using Statistical and Mathematical Models to Fine-Tune Services in an Emergency Department
Authors: Tsoi LCH , Ip SY , Poon LK
Published: December 2017

Objective

To determine the accident and emergency department (A&E) attendance pattern.

Design

A retrospective study was carried out to examine the attendance pattern on a day-of-the-week basis. Attendance data were collected from 1st April to 30th June 2010 and arranged in the days of the week for analysis.

Setting

A&E of a regional hospital.

Main outcome measures

Mean attendance with 95% confidence interval for different days of the week.

Result

Monday was shown to have 12.2% higher attendance than non-Mondays (95% CI=8.4%, 16.0%).

Conclusion

Since Monday has the highest attendance, it is necessary to take measures to reduce the “predictable workload” on Monday to ease overcrowding and reduce waiting time to deal with the anticipated attendance.
Snakebites in Hong Kong: How to Face the Possible Changes?
Authors: Fung HT
Published: December 2017

Introduction

Over the past years, the environmental and scientific changes have shaped the snakebite scenarios and will continue to do so. Their effects ahead are discussed.

Incidence

Because of declining plant agricultural industry and rising urbanization, a falling incidence is reasonably expected in future. In order to maintain the knowledge and skills, training for clinicians will become more crucial.

Venom detection kits

Kits for Naja atra and Cryptelytrops albolabris have been available overseas. Local data should be gathered regarding their clinical application.

Antivenoms

The common local species covered by the haemotoxic and neurotoxic polyvalent antivenoms from Thailand is only Cryptelytrops albolabris. Introduction into Hong Kong is not recommended.

Enzyme inhibitors

With an aim to improve the control of local injury that is unsatisfactorily accomplished by antivenoms, therapy with venom enzyme inhibitors is under research.

Conclusion

A decreasing number of snakebite is anticipated. Venom detection kits should be explored for the use in appropriate cases. (Hong Kong j.emerg.med. 2011;18:217‐220)
An Extremely Rare Side Effect of Ranitidine: Junctional Rhythm
Authors: Dedeoglu E , Uzun A , Bayram B , Cevik E , Arslan D
Published: December 2017

Ranitidine is a H2 receptor blocker and rarely cause bradycardia. A 28 years old male patient attended the emergency department for urticaria. He was given 45 mg of phenyramine and 50 mg of ranitidine intravenously. He then complained of dizziness and developed bradycardia and hypotension. Electrocardiogram detected junctional bradycardia rhythm. He was given 0.5 mg atropine intravenously and his rhythm then returned to normal. His symptoms subsided and the blood pressure improved. Ranitidine is a frequently used medication and this case illustrated a rare but serious side‐effect of the medication.
Systemic Poisoning after Mucosa and Skin Contact of Paraquat
Authors: Wong OF , Fung HT , Lam SK , Leung KCH , Lee HM
Published: December 2017

Paraquat poisoning is associated with very high mortality and often results in severe complications including pulmonary fibrosis and multi‐organ failure. Majorities of the reported cases had paraquat exposure from oral route either due to accidental intake or suicidal attempt. Systemic complications from dermal exposure were infrequently reported. We reported a patient suffering from acute renal failure and liver function derangement due to systemic absorption of paraquat from accidentally dermal and mucosal contact. The case has illustrated the danger of improper use of this high toxic substance as a household product.
May a Penalty in Football Cause an Anaphylactic Shock? a Case of Hydatid Cyst
Authors: Golcuk Y , Oray D , Atilla OD , Acar K , Karadeniz M
Published: December 2017

Hydatid disease is a parasitic infection caused by Echinococcus granulosus characterised by cyst formation in various organs. The liver is the most commonly involved organ. Hydatid disease is endemic in many parts of the world and its prevalence is also high in the Mediterranean region including Turkey. Uncomplicated liver cysts may stay asymptomatic for a long time. Hydatid cysts can rupture either spontaneously or following trauma. Anaphylaxis is an acute, life-threatening medical emergency with many potential triggers. The rupture of hydatid cysts caused by sports trauma is very rare and can lead to anaphylactic reactions and fatal anaphylaxis. We described a patient who was previously unknown to have hydatid disease being treated in the emergency setting following a sports trauma.
An Unfamiliar “Common” Skin Disease: Poison Ivy Allergic Contact Dermatitis
Authors: Lee KH , Ho JKK , Lam KM , Wu WY
Published: December 2017

We present a case of phytodermatitis caused by a poisonous plant known as poison ivy. It is one of the leading causes of allergic contact dermatitis and it causes significant morbidity in the United States. Prevention of the disease is by identification and avoidance of the plant. Barrier protection minimises the chance of contact and prompt rinsing with soap water limits antigen exposure after skin contact. General approach to treatment of allergic contact dermatitis can be applied but special precaution should be taken on the duration of systemic steroid therapy. Too short a course of oral steroid may result in a more severe recurrent flare. High potency topical steroids may limit the development of skin lesions. (Hong Kong j.emerg.med. 2011; 18:335-338)
A Prospective Investigation into the Epidemiology of In-Hospital Cardiopulmonary Resuscitation Using the International Utstein Reporting Style
Authors: Song W , Chen S , Liu YS , He NN , Mo DF , Lan BQ , Gao YS
Published: December 2017

Introduction

The Utstein template has been used to guide the assessment and study of cardiopulmonary resuscitation (CPR) in many countries. This article used the Utstein templates for cardiac arrest and resuscitation registries to evaluate outcomes of CPR at Hainan Provincial People's Hospital (HPPH), China.

Methods

A prospective observational study using Utstein CPR registry form to evaluate the epidemiological characteristics and outcomes of 511 resuscitation cases in the emergency department, HPPH.

Results

A total of 511 CPR patients registered were studied. Higher cardiac arrest rates were observed for the group of patients who were 40-70 years old. In preexisting chronic diseases, cardiovascular diseases (190, 37.2%) cerebrovascular diseases (48, 9.4%) and respiratory diseases (39, 7.6%) were common in the recruited patients. (173, 33.9%) of the cardiac arrest patients had underlying cardiac causes, of which 109 (21.3%) had acute myocardial infarct (AMI). Eighty (15.7%) patients had ventricular fibrillation as the first witnessed arrest rhythm. The return of spontaneous circulation (ROSC) and survival to discharge rates were 47.0% and 13.5% in the in-hospital cardiac arrest (IHCA) group but 16.7% and 4.7% in out-of-hospital cardiac arrest (OHCA) group (p<0.01) respectively.

Conclusions

This study indicated that the cardiovascular diseases, cerebrovascular diseases, and respiratory diseases were the most common preexisting chronic diseases. Myocardial infarct, stroke and trauma were the most common precipitation cause of cardiac arrest in the recruited patients. The rate of ROSC and survival to discharge for the patients with IHCA were higher than the ones with OHCA, but figures were still low. (Hong Kong j.emerg.med. 2011;18:391-396)
Three Cases of Exercise-Induced Rhabdomyolysis: A Potential Hazard in University Students Participating in Orientation Programs
Authors: Au-Yeung KL , Lam CC , Tsui SH
Published: December 2017

Most students entering universities will participate in the orientation programs organised by the universities, residential halls and departments. Many of these programs involve strenuous exercises and yet not being closely supervised by recognised physical trainers. Some students are not accustomed to heavy exercises. Still they may have to complete such tasks under peer pressure and sometimes in adverse environmental conditions. This makes them prone to develop exercise-induced/exertional rhabdomyolysis (ER). The hallmark symptoms of rhabdomyolysis are non-specific. As a result, it is often under-diagnosed. We described three cases of exercise-induced rhabdomyolysis in college students diagnosed in the accident and emergency department. All cases were managed successfully with supportive care in emergency medicine ward though the initial creatine kinase levels were alarming. (Hong Kong j.emerg.med. 2011;18:437-440)