bluuebunny/crossref_metadata_2025 huggingface dataset:
Focused Assessment with Sonography in Trauma (FAST): Experience of a Tertiary Hospital in Southeast Asia
Authors: Wong E , Ngo ASY , Wee JCP , Lee JMH
Published: December 2017

Objective

This study compares the positive predictive value (PPV) and negative predictive value (NPV) of focused assessment with sonography in trauma (FAST) versus abdominal-pelvic computed tomography scans (CTAP) after blunt abdominal injury as well as the need for abdominal surgery. We also sought to determine if any false negative ultrasound studies were associated with significant morbidity. The results were compared with other studies.

Design

Retrospective cross-sectional study.

Setting

A tertiary hospital.

Methods

Cases were retrieved from the trauma registry and electronic medical records in a tertiary hospital in Singapore over a two year period from 1 January 2009 to 31 December 2010. Exclusion criteria included penetrating trauma and burns. The sonographic finding, computed tomography finding, and the outcome of the patients were retrieved. Diagnostic characteristics including predictive values were calculated.

Results

A total of 476 patients were enrolled. Four hundred fifty-nine patients had FAST performed with fifty (10.9%) being positive. Forty-nine patients (21.7%) out of 226 patients had CTAP which showed abnormalities and nineteen (4.0%) patients underwent surgery. Comparing FAST to detect abnormalities on CTAP, the PPV and NPV were 0.590 and 0.863 respectively. Comparing FAST with the need for surgery, the PPV and NPV were 0.280 and 0.990 respectively. Four patients (0.98%) had negative FAST but required surgery. There were no significant adverse outcomes or surgical intervention in patients with normal vital signs, normal initial physical examination and negative FAST findings but who did not have a CTAP.

Conclusions

In patients with an initial normal physical examination and negative FAST, emergent CTAP may be avoided. (Hong Kong j.emerg.med. 2014;21:230-236)
Application of Bladder Scan in Ambulatory Management Protocol for Acute Urinary Retention with Presumed Diagnosis of Benign Prostatic Hypertrophy
Authors: Lai Ky , Chan Wk , Ho Wf , Leung Cs , Li Yk
Published: December 2017

Objective

Bladder scan was firstly used in the ambulatory management protocol for acute urinary retention (AUR) in Princess Margaret Hospital (PMH) emergency department (ED) since 2012. Bladder scan measurement was performed immediately after triage for early catheterisation in the new protocol for AUR. The primary objective of this study was to evaluate the accuracy of bladder scan in estimating the volume of urinary retention. The secondary objectives were to evaluate the change in unnecessary catheterisation rate and the change in door to catheterisation time (DTCT) after the implementation of new protocol.

Setting

Emergency department of a regional hospital.

Methods

Male patients over 40 years old presenting to the ED of PMH for difficulty to void within the study period were enrolled and managed according to the study protocol. Agreement analysis was carried out by the Bland and Altman method. The changes in DTCT were assessed by comparing data of current study and historical control.

Results

A total of 121 male patients were recruited. The bias between bladder scan readings and catheterised volume was 26.09 ml when the average bladder scan measurement and catheterised volume was 300ml. The 95% upper and lower limit were -95.82 ml and 151 ml, respectively. The relative risk reduction of unnecessary catheterisation was 90.9%. The absolute risk reduction was 8.26%. Number need to treat was 12 (95% CI 8-30). The DTCT of current study were shorter than that of historical control (DTCT: 22.85 minutes vs. 48.42 minutes; p<0.001).

Conclusions

Agreement between bladder scan readings and catheterised volume is satisfactory. Bladder scan can serve as a device to facilitate nurses to make decision on early catheterisation for AUR patients with presumed diagnosis of benign prostatic hypertrophy. (Hong Kong j.emerg.med. 2014;21:300-307)
A Rare Cause of Acute Urinary Retention and Faecal Incontinence in Women: Sacral Herpes Zoster
Authors: Bozkurt Ih , Arslan B , Yonguç T , Ors B , Kozacioglu Z , DeğIrmenci T
Published: December 2017

Shingles (herpes zoster) is a well-known disease presented with a cutaneous rash of fluid-filled blisters, similar to chickenpox. Rarely, inflammatory reaction could involve the spinal cord and anterior horn cells causing varied neurological disorders including urological alterations. We report a 57-year-old woman presenting with acute urinary retention and faecal incontinence attributable to unilateral sacral herpes zoster reactivation (S2-4). The patient was treated with valacyclovir. She recovered her urinary and bowel functions without complications 6 weeks later. (Hong Kong j.emerg.med. 2014;21:326-328)
A Study on the Medication Errors in the Administration of N-Acetylcysteine for Paracetamol Overdose Patients in Malaysia
Authors: Au V , Zakaria Mi
Published: December 2017

Introduction

N-Acetylcysteine (NAC) has been used to treat paracetamol overdose for four decades. But the administration of NAC regimens is complicated. Therefore, medication errors are an ongoing issue in the acute-care setting and directly impact the safety of patients.

Objective

To evaluate the rate of NAC-related medication errors during the management of paracetamol overdose at a teaching hospital in Malaysia.

Methods

This clinical audit study was performed retrospectively between June 2008 and June 2011. Patients who presented to the adult emergency department with paracetamol overdose and had received at least the loading dose of intravenous NAC were eligible. Children below the age of 12 years old were not included. Also, patients displaying chronic excessive paracetamol usage or recurrent paracetamol overdose were excluded. We determined the type and frequency of medication errors during intravenous NAC administration.

Results

The study population ranged from 13 to 87 years old (mean age: 25.06; median: 23) and was predominantly female. The overall prevalence of intravenous NAC-related medication errors was found to be 84.3%. Moreover, the following frequencies were observed based on error type: 5.9% wrong dose, 37.3% incorrect infusion rate, 8.5% interruption during treatment, and 66.5% unnecessary administration.

Conclusion

We observe a surprisingly high prevalence of medication errors related to the administration of intravenous NAC. Thus, this emerging issue needs be addressed in order to ensure patient safety as well as to prevent unnecessary hospital admissions and/or burdening treatment costs. (Hong Kong j.emerg.med. 2014;21: 361-367)
Pattern and Severity of Horse-Related Injuries Presenting to Emergency Room
Authors: Park Sm , Lim Sw , Ahn Hc , Lee Kj , Lee Yh , Ahn Jy , Sohn Yd
Published: December 2017

Introduction

Horseracing-related injuries have not been studied before in Korea in any detail, although horseracing takes place very regularly in the country. The injury rate is understandably high, owing to the weight of the horses and the speed they can achieve. The purpose of this study was to identify the incidence and the injury patterns of severe equestrian trauma, as well as the associated risk factors.

Methods

All patients with equestrian injuries who visited the emergency department (ED) between June 2007 and May 2011 were reviewed retrospectively.

Results

During the study period, 288 patients presented to ED with horse-related injury. Two hundred and eighty patients were enrolled in this study. The most common cause of the injury was a fall (168, 60.0%). The most common region of the injury was the face (123, 43.9%). The intermediate value of NISS was 3 (1-75). Thirty-two patients (11.4%) were diagnosed as having moderate to severe injury. Thoracic injuries occurred less often in cases of a fall. Facial and thoracic injuries occurred more often, however abdominal and pelvic injuries were not very common in cases of a clash. When thoracic injuries were accompanied by injuries to other parts of the body, the incidence of moderate to severe injury was very high.

Conclusions

Horseracing is a much rougher sport than general horse-riding. Therefore, one recommendation from this study is that jockeys who participate in horseracing should wear additional protective equipment other than a helmet and boots. (Hong Kong j.emerg.med. 2014;21:387-391)
Autonomic Dysfunction as an Unusual Initial Presentation of Generalised Tetanus
Authors: Chiang Tl , Deng Yw , Lu Tc , Lin Cs
Published: December 2017

In this paper, we report a rare case of a 65-year-old Chinese male farmer who was brought to an emergency department (ED) with a puncture wound on the left ankle. One week after being treated, the patient returned to the ED and exhibited signs of diaphoresis, hypertension, and slight rigidity and pain in the neck region. Eight hours after being admitted to the surgical ward, the patient developed typical signs of generalised tetanus, including abdominal muscle rigidity, trismus, and dysphagia. This case is unique because of the early manifestation of autonomic dysfunction, which is not common in people with tetanus. Therefore, to establish an early diagnosis of tetanus, physicians in EDs must obtain detailed patient histories and recognise acute changes in vital signs. (Hong Kong j.emerg.med. 2014;21:392-395)
Duodenal Perforation following Blunt Abdominal Trauma Presenting as Normal in Abdominal Computed Tomography
Authors: Tsai Pk , Yeh Yt , Yeh Cb
Published: December 2017

Most emergency department (ED) physicians implement the Advanced Trauma Life Support (ATLS) approach, including primary and secondary survey, for the assessment of blunt abdominal trauma (BAT) patients. This report emphasizes the need for repeat Focused Assessment with Sonography for Trauma (FAST) and abdominal computed tomography (CT) if a BAT patient's condition persists or worsens. After initial negative FAST and abdominal CT findings, it is recommended that BAT patients with suspected intraabdominal injury should receive repeat examination in an optimal time. We report a patient who sustained duodenal perforation following BAT diagnosed by repeat ultrasound examination and abdominal CT scan. (Hong Kong j.emerg.med. 2014;21:396-399)
Evaluation of the Effect of a Clinical Pathway on the Quality of Simulated Pre-Hospital Cardiopulmonary Resuscitation: Primary Experience from a Chinese Pre-Hospital Care Centre
Authors: Zhang Jg , Fu Wl , Qian Ln , Lu Ml , Zhang M
Published: December 2017

Objective

The aim of this study was to assess the quality of simulated cardiopulmonary resuscitation (CPR) in local pre-hospital care teams and the improvement achieved by using clinical pathways.

Methods

A prospective observation study. The 2010 American Heart Association Guidelines for CPR, the personnel characteristics of ambulance staff, China's legal system requirements, and the available medical resources were used to design a clinical pathway for pre-hospital care of cardiac arrest. Case simulations were used to evaluate the quality of CPR before and after implementation of the clinical pathway.

Results

The number of teams which successfully implemented electrocardiogram monitoring, endotracheal intubation and intravenous access before training were 8 (17.8%), 5 (11.1%) and 6 (13.3%) respectively. These increased to 45 (100%), 43 (95.6%) and 43 (95.6%), respectively, after training. The number of teams with successful implementation of artificial ventilation, airway management and insertion of oropharyngeal airway before training were 43 (95.6%), 38 (84.4%) and 12 (26.7%) respectively. These increased to 45 (100%), 42 (93.3%) and 43 (95.6%), respectively, after training. Nine (20%) teams decided CPR onsite before training and 35 (77.8%) after training. The average rate of chest compressions before and after training was 120.3 ± 17.9 and 123.2 ± 17.1 compressions per minute, respectively (p>0.05).

Conclusion

Training using established clinical pathway significantly improves the quality of CPR and increases the use of ALS techniques. CPR training requires ongoing validation and optimisation to maintain effectiveness. (Hong Kong j.emerg.med. 2015;22:14-22)
Ingestion of Multiple Magnets for Suicide
Authors: Tanrikulu Y , Tanrikulu C Sen , Karaman S , Sahin H
Published: December 2017

Foreign objects ingestion, either intentionally or accidentally, is a well-known problem in paediatric population. However, it is not uncommonly seen in adult especially in patients with psychiatric disorders and prisoners. We presented a case in which a seventeen year-old young man attended emergency department after attempting suicide by cutting his wrist. Incidentally, he was found to have ingested multiple magnets which stayed in the stomach. Removal by endoscopic method was failed. Surgical removal of a total of thirty-three magnets through a surgical gastrostomy was performed. (Hong Kong j.emerg.med. 2015;22: 50-52)
Holiday Fast-Track Reduced Medical Cost and Length of Emergency Department Stay: Preliminary Report from a Single Secondary Care Hospital
Authors: Lee Nk , Ahn Yr , Kim Yh , Lee Jh , Cho Kw , Hwang SY , Shin Ty , Ha Yr , Kim Ys , Hong Ck
Published: December 2017

Introduction

The aims of this study were to compare the effect of a Holiday Fast-Track (HFT) unit on medical costs and emergency department (ED) length of stay (LOS) associated with low acuity patients attended during the same timeframe in two consecutive years in a single secondary care hospital ED.

Methods

Two groups (non-HFT vs. HFT), before and after the fast-track unit was implemented, were compared. The HFT unit was operated to improve the flow of low acuity patients, which were defined as the patients classified as level 4 or 5 by the modified Canadian Triage and Acuity Scale. Data were collected from March 1 to April 30, 2011 for the non-HFT group and during the same period in 2012 for the HFT group.

Results

A total of 894 (431 for non-HFT period and 463 for HFT period) patients of acuity level 4 or 5 visited the ED during the study period. Compared to the non-HFT group, the ED LOS of the HFT group decreased by 27 min and 3.5 min in the patients with acuity levels 4 and 5, respectively (p=0.005 and p=0.003, respectively). Furthermore, total medical costs and laboratory fees were also reduced significantly in the HFT group (p<0.001, p=0.038). However, there was no difference in the other variables between those two groups.

Conclusions

The HFT system decreases the medical costs and LOS in low acuity patients visiting the ED of a secondary care hospital. (Hong Kong j.emerg.med. 2015;22:84-92)
Shearing Fracture of Volar Rim of Lunate Fossa of Distal Radius: From Case Report to Literature Review
Authors: Hung Jlp , Leung Yf
Published: December 2017

We report an extremely rare case of isolated fracture of the volar rim of lunate fossa which extends into the sigmoid notch, resulting in distal radioulnar joint (DRUJ) and radiocarpal joint instability. This fracture is easily missed with radiography alone in emergency setting, and should not be treated with casting due to DRUJ instability. (Hong Kong j.emerg.med. 2015;22:118-120)
Use of a Load Distributing Band Device (with Ventilation Prompts) during Cardiopulmonary Resuscitation
Authors: Annathurai A , Fook-Chong S , Lee Sh , Cheng Sy , Lee C , Shahidah N , Koh Zx , Ong Meh
Published: December 2017

Introduction

Over-ventilation can compromise coronary perfusion pressures during cardiopulmonary resuscitation (CPR) and should be minimised. We compared ventilations during manual and mechanical (load-distributing band - LDB) CPR, which gives ventilation prompts. Our primary objective was to compare the ventilation rate between manual CPR and LDB-CPR.

Method

This was a phased, non-randomised study at a tertiary hospital emergency department. All out-of-hospital, non-traumatic cardiac arrest adult patients during the study period from February 2007 till July 2008 were eligible. Pregnant females and patients aged less than 18 years of age were excluded. Ventilation rates in the first and second 5 minutes segments were recorded. Over-ventilation was defined as ventilation rate above 12 breaths per minute. All data analyses were performed with SPSS, version 17.0. Mean differences with 95% confidence interval (CI) were compared between the 2 treatment groups.

Results

From February 2007 till August 2007, there were 29 patients with manual CPR; and from September 2007 till July 2008, there were 62 with LDB-CPR. In the first 5 minutes of CPR, the proportion of patients that were over-ventilated, was 27.6% (manual) and 4.8% (LDB) (difference = 22.7%; 95% CI: 3.5-46.4%). In the next 5 minutes, the proportion of patients that were over-ventilated was 37.9% and 1.6% for manual and mechanical CPR respectively (difference = 36.3%; 95% CI: 16.5-58.9%).

Conclusion

Over-ventilation is reduced significantly in LDB-CPR compared to manual CPR during the first and second 5 minutes of resuscitation.
Massive Pulmonary Embolism after Overdose of Oral Benzodiazepine
Authors: Ho Sw , Yeh Yt , Wu Ch , Liu Yc , Yeh Cb
Published: December 2017

Overdose of benzodiazepines rarely causes morbidity or mortality. A 58-year-old woman presented to the emergency department in coma after ingestion of 30 tablets of 0.5 mg alprazolam. She recovered after flumazenil was administered. However, massive pulmonary embolism developed during observation in the emergency department. Endotracheal intubation and recombinant tissue plasminogen activator infusion were initiated. This case report highlights that benzodiazepine overdose can contribute to pulmonary embolism which is a life-threatening condition.
A Case Report of Traumatic Rupture of Splenic Pregnancy
Authors: Bao L , Ren XQ
Published: December 2017

Primary splenic pregnancy is a rare type of ectopic pregnancy, which could easily rupture in the early stage of pregnancy, causing life-threatening intraabdominal haemorrhage. Rupture of splenic pregnancy due to trauma is even rarer. We reported a case of splenic pregnancy occurring in a female patient of reproductive age. She was injured by the handlebar on the upper left abdomen while riding a bicycle, causing intraabdominal haemorrhage. Ultrasound showed splenic rupture. The patient underwent emergency surgery, and was diagnosed with a rupture of splenic pregnancy by postoperative pathology. It is an extremely rare case where the patient was diagnosed splenic pregnancy due to a traumatic rupture and haemorrhage. We hope this case can be helpful in the evaluation and diagnosis of acute abdomen in women of reproductive age. (Hong Kong j.emerg.med. 2015;22:312-315)
Blunt Traumatic Cardiac Rupture Presenting as Massive Haemothorax
Authors: Yen YT , Ho SW , Liu YC , Yen CB
Published: December 2017

Cardiac rupture following blunt thoracic trauma in motor vehicle crash generally causes death at scene, and is rarely diagnosed preoperatively. However, early emergency thoracotomy in the emergency department (ED) or operating room might reduce the mortality but the benefit is still controversial. A haemodynamically unstable 28-year-old woman following motor vehicle crash was detected to have right haemothorax on chest X-ray. Thoracic computed tomography (CT) revealed additional lung contusions and multiple bone fractures. She developed cardiac arrest during open thoracotomy and had restored spontaneous circulation after open-chest cardiopulmonary resuscitation (CPR). This report highlights that CT scan in haemodynamically unstable patients could delay surgical control of the injury. Open-chest CPR can be life-saving for blunt chest injury developing cardiac arrest. (Hong Kong j.emerg.med. 2015;22:320-323)
A 67-Year-Old Man with Epistaxis, Melena, Gross Haematuria and Haemarthrosis
Authors: Lee DH , Choi YH
Published: December 2017

Superwarfarins are widely used as rodenticides. They are similar to warfarin, but they are more potent and act longer. In case of poisoning, they cause severe bleeding, usually from multiple sites. Prolonged treatment with high doses of vitamin K and/or fresh frozen plasma (FFP) transfusions may be necessary. Awareness of the problem of superwarfarin intoxication among physicians remains low and cases may go undiagnosed for days or weeks, resulting in increased morbidity and even mortality. We presented a case of delayed diagnosis of superwarfarin ingestion. The patient presented to emergency department with epistaxis, melena, and gross haematuria. He was treated with vitamin K and the International Normalised Ratio (INR) dropped from >7.0 to 1.4. The patient was discharged. However, 3 weeks later, the patient presented with haemarthrosis. Blood investigation revealed INR value >7.0 again. The patient finally received treatment with FFP and vitamin K. This case illustrates the importance to consider superwarfarin ingestion when patients presented with poisoning with coagulopathy. (Hong Kong j.emerg.med. 2015;22:324-327)
A Manikin Study Comparing McGrath Mac®and Airtraq®with Macintosh Laryngoscope in Tracheal Intubation by Intensive Care Unit Doctors
Authors: Chan HKW , Wong OF , Kwan GWM
Published: December 2017

Objective

To compare the performance of the McGrath Mac®and the Airtraq®with the Macintosh laryngoscope for tracheal intubation.

Design

A manikin study with different simulated difficult airway scenarios.

Methods

Thirty intensive care unit (ICU) doctors (10 specialists and 20 non-specialists) performed intubation by using the 3 airway devices in the manikin with (i) normal airway, (ii) cervical rigidity, and (iii) tongue oedema. The intubation time, success rate, oesophageal intubation and number of episodes of dental injury were measured and compared.

Results

The mean intubation time was significantly less by using the Airtraq®comparing to the McGrath Mac®in the manikin with normal airway (12.77 sec vs. 24.23 sec; p<0.001). Similarly, the mean intubation time was less by using Airtraq®when comparing to the McGrath Mac®in the manikin with cervical rigidity (12.73 sec vs. 17.5 sec; p=0.013). In the scenario of simulated tongue oedema, the mean intubation time of Airtraq®was shorter than Macintosh laryngoscope (24.83 sec vs. 34.20 sec; p=0.011) while there was no difference between Airtraq®and the McGrath Mac®. Less dental injury was noted when using the Airtraq®compared to the Macintosh laryngoscope in simulated cervical rigidity (p=0.005) and tongue oedema (p<0.001). Less dental injury was also noted when using the McGrath Mac®compared to the Macintosh laryngoscope in simulated tongue oedema (p<0.001).

Conclusion

Even with prior limited experience in using the McGrath Mac®, the performance of tracheal intubation by using this new device is comparable with the Airtraq®. The McGrath Mac®can be a good alternative for tracheal intubation in difficult airway situations. (Hong Kong j.emerg.med. 2015;22:337-344)
Contributory Factors to critically wrong road-crossing judgements among older people: an integrated research study
Authors: Loo Bpy , Tsui Kl
Published: December 2017

Introduction

Older people are having higher risk of vehicle-pedestrian collisions. This study examines the relative importance of different environmental, physical and cognitive factors in contributing to critically wrong road-crossing judgements.

Methods

An integrated research design is adopted. Older pedestrians were recruited through Elderly Community Centres in Hong Kong. Data about their physical and cognitive ability were collected through setting up outreach laboratories within the participants' neighbourhood communities. In addition to obtaining two walking speeds, three clinical tests (the visual acuity test, Timed Up and Go test and Mini Mental State Examination [MMSE] test) were conducted. A questionnaire survey collected personal information and activity data. Eighteen different road-crossing scenarios showing the same dual-lane one-way local road with different traffic conditions (a vehicle approaching at different distances, at different speeds, and on different lanes) were captured in videos and presented to the participants. Their decision time and judgement for each scenario were recorded in a computer. Apart from descriptive statistics, a binary logistic generalised estimating equation model was estimated. The dependent variable is whether a road-crossing judgement was critically wrong or not.

Results and Conclusions

A total of 7,182 road-crossing judgements of 399 older people were collected. The most statistically significant factors contributing to critically wrong road-crossing judgements are the road environment variables of the speed and distance of the oncoming vehicle. On physical variables, walking speed is the most important factor. Lastly, the cognitive variable of MMSE score is significant. For the mild and moderate impairment groups, the chances of making a critically wrong judgement are 1.83 and 2.01 times that of the normal group respectively.
Case Series of Inflation Pressures of the Endotracheal Tube Cuffs among Intubated Patients at an Accident and Emergency Department in Hong Kong
Authors: Leung Sc , Chung Ahy , Chan Wk , Tsui Sh
Published: December 2017

Despite the frequent use of endotracheal tubes in daily practice of emergency medicine, not much emphasis has been put on the measurement of cuff pressure. We attempted to conduct a case series study of prospectively recruited patients to illustrate the risk of inappropriate cuff inflation without manometry. It was found that the pilot balloon palpation was an inaccurate method to estimate cuff under- or over-inflation, with large discrepancies when compared with an objective measure. Such discrepancies might be independent of doctors' and nurses' working experience in airway management. Use of an aneroid manometer remains an economical and cost-effective way to obtain an instantaneous yet reasonably reliable result and should become a routine in emergency departments.
A Case of Severe Varicella Pneumonia Requiring Extracorporeal Membrane Oxygenation
Authors: Tong Tmc , Wong Of , Kwan Gwm , Chan Kkc
Published: December 2017

A 35-year-old male Nigerian suffered from severe varicella pneumonia, which was complicated by severe acute respiratory distress syndrome, acute kidney injury and acute hepatitis. He developed persistent hypoxia despite maximum mechanical ventilation support requiring veno-venous extracorporeal membrane oxygenation. He recovered well with the treatment and the pulmonary infiltrates in the chest X-ray resolved within 5 days after the onset of respiratory failure. He was eventually discharged without major sequelae.
Comparison of the GlideScope® with the Macintosh Laryngoscope in Endotracheal Intubation during Uninterrupted Mechanical Chest Compression: A Randomised Crossover Manikin Study
Authors: Yeung FSH , Lam RPK , Wong TW , Chan LW
Published: December 2017

Background

The GlideScope® (GS) has been shown to improve the first-attempt success rate of endotracheal intubation during continuous mechanical chest compressions compared with the conventional Macintosh laryngoscope (ML) in inexperienced hands. Yet, its value for operators with experience of emergency airway management has remained uncertain. We set out to compare their performance in the hands of experienced operators in a manikin receiving continuous mechanical chest compressions delivered by LUCAS®.

Method

This was a randomised crossover study. Thirty-five emergency physicians and intensivists performed intubation using GS and ML in 3 different scenarios: (1) normal airway without chest compressions; (2) normal airway with uninterrupted mechanical chest compressions; and (3) normal airway with cervical spine (C-spine) immobilisation and uninterrupted mechanical chest compressions. The sequence of scenarios and devices used were randomised. The primary outcome was the first-attempt success rate of intubation. Other data including demographics, the time required for successful intubation, complications during intubation, the visual analog scale of perceived difficulty of intubation and the preference on devices in each scenario were also collected and analyzed.

Results

In scenario 1, the first-attempt success rate with both laryngoscopes was 100%. In scenario 2, there was a higher first-attempt success rate with ML but it was not statistically significant (GS 97.14% vs ML 100%, p=1.00). In scenario 3, one participant failed to intubate in the first attempt with each of the laryngoscopes (GS 97.14% vs ML 97.14%, p=0.754). More dental compression was noted with GS but the difference was not statistically significant (GS 42.86% vs ML 22.86%, p=0.126). Overall, the median time for intubation with GS was significantly longer in all 3 scenarios (Scenario 1: GS 18.5s; interquartile range [IQR] 13.8 -22.2s vs ML 11.2s, IQR 9.5-14.2s, p<0.001; Scenario 2: GS 18.7s, IQR 13.1-25.2s vs ML 13.4s, 10.3-15.8s, p<0.001; Scenario 3: GS 20.8s, IQR 16.5-29.2s vs ML 14.0s, IQR 10.5-18.0s, p<0.001). More participants preferred GS in scenario 3, while ML remained the device of choice in the other two scenarios. Conclusion: GS is not superior to ML in terms of the first-attempt success rate of intubation and it takes significantly longer to intubate for experienced operator. Yet more participants prefer its use when the C-spine motion is limited. Further studies are warranted to explore its role in trauma resuscitation. (Hong Kong j.emerg.med. 2016;23:159-167)
Benign Acute Childhood Myositis Associated with Influenza: A Cluster of Cases from a Single Centre in the 2013-2014 Cold Season
Authors: Akturk H , Uysalol M , Salman N , Ciblak M , Torun SH , Uzunhan T , Sutcu M , Citak A , Somer A
Published: December 2017

Influenza associated myositis has generally a clearly defined clinical picture. However, it may cause diagnostic confusion and unnecessary work up due to unfamiliarity with this condition by the medical staff. In this report, retrospective clinical and laboratory data about 10 children with influenza associated myositis diagnosed among all admissions to emergency room of a tertiary referral centre during the cold season of 2013-2014 was presented to increase awareness of this clinical issue. (Hong Kong j.emerg.med. 2016;23:186-191)
Comparison of Risk Stratification Scores for Patients Presenting with Symptoms of Upper Gastrointestinal Bleeding in the Emergency Department
Authors: Lau Hk , Wong Ht , Lui Ct , Tsui Kl
Published: December 2017

Objective

To compare four scoring systems to predict outcomes in patients with symptoms of upper gastrointestinal bleeding presenting to the emergency department.

Method

A single centered prospective cohort study. All adult patients presenting to the emergency department of the studying centre with haematemsis or tarry stool or coffee ground vomiting or coffee ground aspirate from nasogastric tube were included from February 2012 to April 2012. The outcome variables include mortality, length of stay in hospital, blood product transfusion and interventions for bleeding control. The AIMS65 score, pre-endoscopic Rockall score, Glasgow Blatchford Score (GBS) and the modified Glasgow Blatchford Score (mGBS) were evaluated. Diagnostic characteristics were presented and areas under the receiver-operating-characteristic (AUROC) curve were compared.

Results

A total of 129 patients were included in the study. 81 of them (62.8%) had upper endoscopy performed. The mortality rate was 3.1%. Initial haemoglobin level of <10 was an important factor in risk stratification. Validation of the 4 scoring systems showed GBS had highest sensitivities (98.3-100%) and negative predictive values (90-100%) for all outcome variables but could not achieve a good specificity and positive predictive values against the outcomes. Both GBS and modified GBS outperformed the other two scoring systems in the AUROC curves in predicting composite high-risk outcome, length of stay in hospital and blood transfusion.

Conclusion

GBS appeared the best scoring system in the emergency department for screening purpose and to stratify those high risk patients for admission and low risk patients for out-patient management. (Hong Kong j.emerg.med. 2016;23:199-209)
Can Surgery in Patient with Protobothrops Mucrosquamatus Envenomation be Predicted in Emergency Department?
Authors: Su Hy , Li Yh , Tang Cn , Su Ci , Tsai Mj
Published: December 2017

Objective

Protobothrops mucrosquamatus, a Crotalinae snake with haemorrhagic venom, is responsible for the most common poisoning snakebites in Taiwan. Although a specific antivenin has been developed to treat this snakebite, surgical intervention is still needed in some patients because of the progression of tissue injury. Early risk stratification is important to identify the early signs of need for surgery. The purpose of this study was to investigate the early predictors for surgery in patients with P. mucrosquamatus envenomation.

Methods

The medical records of inpatients with P. mucrosquamatus envenomation between 2008 and 2013 were retrospectively reviewed. Clinical information was collected and analysed between surgical and nonsurgical patients.

Results

A total of 60 patients with P. mucrosquamatus envenomation, including 8 surgical patients (13.3%) and 52 non-surgical patients (86.7%), presented to the emergency department during the study period. Compartment syndrome (62.5%) and tissue necrosis (37.5%) were the main reasons for surgery. Comparison between surgical and non-surgical patients showed significantly higher white blood cell count (17.1 × 103/μL vs. 8.5 × 103/μL; p=0.002) and peak D-dimer level (1924.8 ng/mL vs. 730.0 ng/mL; p=0.006) in the surgical group. Ecchymosis (p=0.009), haemorrhagic bulla formation (p=0.002), leukocytosis (p=0.002), elevated peak D-dimer level (>1000 ng/mL) (p=0.005), and rhabdomyolysis (creatine kinase level >1000 IU/L) (p=0.007) were the significant signs relevant to surgery. On multivariate analysis, leukocytosis and ecchymosis were the most significant predictors of surgery in patients with P. mucrosquamatus envenomation.

Conclusions

Patients with P. mucrosquamatus envenomation presenting with leukocytosis and wound ecchymosis will have a high probability of requiring surgical therapy. (Hong Kong j.emerg.med. 2016;23:210-219)
Ketamine-Induced Lower Urinary Tract Symptoms: A Study of International Prostate Symptom Score and Quality of Life
Authors: Wei Yb , Yang Jr , Wu Ww , Chinaegbomkpam  , Jiang Gq
Published: December 2017

Introduction

Ketamine associated cystitis was first reported in 2007. Although many articles have been published concerning the effects of ketamine on lower urinary tract, not much focus had been put on the Quality of Life (QoL). This study was to assess lower urinary tract symptoms (LUTS) and QoL in ketamine abusers.

Methods

One hundred ketamine abusers with LUTS were included in the study. All patients were interviewed by one of the three trained investigators through face-to-face interview. Their LUTS were evaluated by the survey instrument consisting of International Prostate Symptom Score (IPSS) and 7-points Likert-type QoL scale.

Results

Sixty-six of them had moderate symptoms and 16 suffered from heavy symptoms. Eighty-one percent patients reported storage symptoms compared to 41% with voiding symptoms. Mono-ketamine abusers (MKA) had higher scores in IPSS, QoL, storage and voiding symptoms than poly-drug abusers (PDA). Multiple linear regression analysis demonstrated that lower educational background, MKA, and longer duration of ketamine abuse were found to be predicting factors on IPSS and QoL.

Conclusions

LUTS in ketamine abusers are mostly moderate to severe, and their quality of life were wrecked. Mono-ketamine abusers have more severe LUTS and lower quality of life than poly-drug users. Lower educational level, mono-ketamine abuser and longer duration of abuse are independent predictors of severity of LUTS and QoL. (Hong Kong j.emerg.med. 2016;23:227-233)
Delayed Aspiration Pneumonia and Systemic Toxicity in Patient who Inhaled Dry Powder of Fire Extinguisher
Authors: Lee Dh , Choi Yh , Lee Dh
Published: December 2017

A 45-year-old man inhaled fire extinguisher powder. After three days of asymptomatic period, respiratory symptoms and systemic toxicity developed. Patient had cardiac arrest in the emergency department and was successfully resuscitated. The dry fire extinguisher powder contains high concentrations of monoammonium phosphate, which causes severe hyperphosphataemia and hypocalcaemia. Life threatening conditions such as seizures, cardiac arrhythmias, acidosis, and cardiac arrest can develop. When monoammonium phosphate was inhaled, only mild flu-like symptoms can present initially. Therefore, primary physicians need to be aware of the entity and clinical severity of intoxication to achieve early recognition and treatment. (Hong Kong j.emerg.med. 2016;23:234-237)
A Case of Neurologically Intact Survival after Compression-Only Cardiopulmonary Resuscitation by Two Bystanders
Authors: Chen HC , Hung YM , Hsieh FC , Lin SL
Published: December 2017

Conventional cardiopulmonary resuscitation (CPR) requires chest compression and mouth-to-mouth breathing. We report a 55-year-old man in cardiac arrest who received immediate chest compression but without assisted ventilation by two bystanders for 28 minutes until the arrival of the emergency medical team. His consciousness recovered completely on the third hospital day. According to the literature review, “28 minutes” may possibly be the longest period of time of compression-only CPR in out-of-hospital cardiac arrest patients with neurologically intact survival. Thus, this case supports the present CPR guideline that recommends effective chest compression without assisted ventilation by laypersons for patients in cardiac arrest.
Biometeorological Modelling and Forecasting of Monthly Ambulance Demand for Hong Kong
Authors: Wong HT , Lai PC , Chen S
Published: December 2017

Introduction

Given the aging population in Hong Kong and the ever rising demand for emergency ambulance services, this study aimed to examine the effects of seasonality and weather on the demand for emergency ambulance services in Hong Kong. The feasibility of using time series models and selected weather factors to forecast average daily ambulance demand over a month was also assessed.

Methods

Monthly statistics for ambulance demand from 1998 to 2007 were obtained for analysing the effects of seasonality and weather on the demand for emergency ambulance services in Hong Kong. The effectiveness of weather factors in forecasting ambulance demand was also examined by comparing the performance of the autoregressive integrated moving average (ARIMA) model against other commonly used models.

Results

The lowest temperatures during cooler months were found to be negatively associated with average daily ambulance demand (adj-R2=0.38), while the average amount of cloud cover and highest temperatures were found to be positively associated with average daily ambulance demand during hotter months (adj-R2=0.34). When the analysis was stratified spatially by ambulance command units, Hong Kong Island had the highest adj-R2 during cool and hot months, reported at 0.55 and 0.46 respectively. With the inclusion of average temperature, the ARIMA models outperformed other models for both short- and long-term predictions.

Conclusions

Our findings suggest that weather factors, especially temperature, are significantly related to and useful for predicting ambulance demand.
Effectiveness of 100 Beats per Minute Music on Cardiopulmonary Resuscitation Compression Rate Education: A Manikin Study
Authors: Kim KW , Kim JH , Choe WJ , Kim JY , Lee SI , Kim KT , Park JS , Kim JW , Lee Y , Lee JH , Park J
Published: December 2017

Introduction

Recent cardiopulmonary resuscitation (CPR) guidelines emphasize the importance of high-quality chest compression. The aim of this study is to determine the effect of education using music on the chest compression rate.

Methods

This randomised, open-labeled study enrolled 81 medical students. They were randomly divided into three groups. After they were educated in CPR according to the American Heart Association 2010 guidelines, they performed 100 chest compressions using a mannequin capable of collecting each compression depth and speed. After that, the control group received a verbal feedback about their own results. The metronome group was also notified of their own results, and listened to the metronome sound at 100 beats per minute (bpm). The music group listened to the music (about 100 bpm). Twenty-four hours after their CPR education, chest compressions were performed again with the method identical to the first evaluation. The results were compared using multivariate analysis of variances.

Result

Compression rate (bpm): There was a significant difference between the control (mean, 110.4; 95% CI: 104.4, 116.5) and metronome group (mean, 98.5; 95% CI: 91.6, 105.4) after education (p=0.01). There was a significant difference between control and music group (mean, 98.2; 95% CI: 94.6, 101.8) after education (p<0.001) There were no differences between the music and metronome group before or after education (p=0.50, p=0.94). However, the variance of music group was significantly less than the metronome group (p=0.01). Compression depth (inches): there was no difference between the groups according to the CPR education method. (Control: 1.8±0.3; Metronome group: 1.6±0.2; Music group: 1.7±0.3 p=0.09)

Conclusion

Both education method of using music and metronome are more effective than conventional method. However the effect of using music may be better than using metronome.
Severe Glyphosate-Surfactant Intoxication: Successful Treatment with Continuous Renal Replacement Therapy
Authors: Lee DH , Choi YH
Published: December 2017

Glyphosate-surfactant is one of the most commonly used herbicides in the world. Its key component, glyphosate, is a competitive inhibitor of the shikimate pathway, a metabolic pathway found only in plants. However, severe intoxication, including lethal cases by ingestion of, glyphosate-surfactant has been reported. We describe the full recovery of two patients from glyphosate-polyoxyethyleneamine surfactant intoxication and multi-organ system failure following continuous renal replacement therapy. Both patients developed persistent shock, acute kidney injury, lactic acidosis, hyperkalaemia and multi-organ failure despite of resuscitation. We believe that continuous renal replacement therapy should be initiated immediately for removal of glyphosate-polyoxyethyleneamine surfactant in patients with signs of cardiopulmonary compromise, lactic acidosis, and renal failure. We propose the addition of glyphosate-polyoxyethyleneamine surfactant to the list of toxins for which early haemodialysis should be indicated.
Could Hong Kong Primary Schoolchildren be Taught to Perform Compression-Only CPR: A Pilot Study
Authors: Cy CHAN , Ko HF , Tsui SY , Chan OY , Tang TH , Chu YC
Published: December 2017

Objective

To evaluate whether Hong Kong primary schoolchildren could be taught to perform compression-only CPR.

Design

Prospective experimental trial

Subjects

Primary schoolchildren of age 9-12 years old from different Cub Scout packs attended a 2 hour voluntary compression-only CPR training session between late 2014 and mid-2015.

Main outcome measures

Cardiopulmonary resuscitation (CPR) knowledge in the format of pre- and post-test multiple choices questions (MCQ). Psychomotor skills assessment including correct hand position, compression depth, compression rate and chest wall recoil between each compression.

Results

A total of 112 primary schoolchildren attended the training session, in them 72% were boys. Pretest score and post-test score was 2.81/5 and 4.82/5, respectively. The difference was statistically significant (p<0.05). About 96% of subjects had correct hand position at all time during CPR. Mean compression rate was 119/minute. Mean compression depth was 3 cm. About 47% of subjects had 100% complete recoil of chest wall following compression.

Conclusion

Primary schoolchildren above 9 years old are able to acquire essential knowledge and skills in compression-only CPR. Their physical strength may limit their ability to perform effective chest compression; it is still worthwhile to advocate CO-CPR education in primary schoolchildren in Hong Kong in order to raise their interest in this life saving skills and to equip them with essential cognitive skills in emergency situations. To achieve optimal cost-effectiveness and a compression depth of at least 4 cm, body weight of 53 kg or above should be considered as a selection criterion.
Hemichorea Hemiballismus in a Patient with Hyperglycaemic Hyperosmolar State, A Reversible Neurological Outcome of Metabolic Disorder
Authors: Abd-Samat AH , Embong H
Published: December 2017

Hemichorea-hemiballismus (HCHB) is a spectrum of involuntary, non-rhythmic movement affecting one side of the body. Although rare, it has been reported as a presenting feature in hyperglycaemic hyperosmolar state (HHS) known in literature as C-H-BG (chorea, hyperglycaemia, basal ganglia) syndrome. We present a case in which the patient presented with 2-day history of right-sided hemichorea preceded by non-compliance to oral hypoglycaemic agent. Investigations revealed marked hyperosmolarity and hyperglycaemia, consistent with HHS. Computed tomography (CT) brain showed non-enhancing hyperdensities at the contralateral putaminal region. The choreiform improved after initiation of treatment for HHS. The hemichorea-hemiballistic movement can be the presenting feature of HHS, diabetic ketoacidosis or uncontrolled diabetes and is completely reversible with timely management. Nevertheless, CT brain plays diagnostic role and important to rule other more sinister aetiologies. The diagnosis of C-H-BG syndrome should be considered in patients with abnormal movement and hyperglycaemia. The symptom can completely recover if the hyperglycaemia is treated accordingly.
Analytical validation of cardiac troponin I assays in horses
Authors: Rossi Tanya M. , Kavsak Peter A. , Maxie M. Grant , Pearl David L. , Pyle W. Glen , Physick-Sheard Peter W.
Published: December 2017

Human cardiac troponin I (cTnI) assays have been used in equine medicine, often without prior analytical validation for equine use. In the absence of appropriate validation, the clinical significance of assay results is uncertain and can lead to misdiagnosis. We followed the American Society for Veterinary Clinical Pathology guidelines and investigated linearity, precision, limit of quantification (LoQ), and comparative recovery for 6 commercial cTnI assays developed for use in human medicine. Clinically acceptable linearity was observed in assays A–D, whereas assay E did not detect equine cTnI in any sample. Comparative recovery revealed 1–3-fold differences between assay results, and low analyte recoveries (2.2–3.4%) were observed in assay F. Precision was investigated in assays A and B, and found to be within acceptable limits. The LoQ was 1.53 ng/L for assay A, and 0.031 µg/L for assay B. Assays A and B performed within clinically acceptable limits and were deemed suitable for use in equine medicine. Assays C and D did not undergo full validation but had acceptable linearity, which demonstrates their potential for use in equine medicine. Assays E and F are unsuitable for use in horses given issues with detection of equine cTnI. The variability in results between assays indicates that reference intervals and cutoffs for diagnostic decision-making are assay specific and should be established prior to adoption by diagnostic laboratories.