bluuebunny/crossref_metadata_2025 huggingface dataset:
A Study of Orotracheal Intubation in Emergency Departments of Five District Hospitals in Hong Kong
Authors: Choi YF , Wong TW , Lau CC , Siu AYC , Lo CB , Yuen MC , Tung WK , Ng P , Kam CW , Mui TK , Yuen WL , Lim B , Lit ACH
Published: December 2017

Objective

To study the success rates and complications of orotracheal intubation in emergency departments of five district hospitals in Hong Kong in order to identify ways for improvement.

Method

This was a prospective observational study. The emergency department doctors performing the intubation were asked to complete an intubation study form immediately after the procedure over a period of four months. Data collected included vital signs, experiences of intubators, method of intubation and complications.

Results

A total of 347 cases were collected and 93% of them were non-trauma cases. Fifty-two percent (52%) of the cases were in cardiac arrest before intubation. Rapid sequence intubation (RSI) was applied in 36% of the cases. Junior doctors first intubated about 72% of the patients. Successful intubation was achieved in 1 and 2 attempts in 70% and 89% of the cases respectively. In 10 cases (3%), secondary methods such as laryngeal mask airway, Combitube, Trachlight or cricothyroidotomy were needed. The overall complication rate was 7.8% and the complication rate in the RSI group was 15.3%. The complication rate was even higher (20%) if intubation without medication was used in non-cardiac arrest patients. Significant drop in blood pressure was the most common complication and it could be attributed to the use of midazolam as induction medication. The success rate was found to correlate with the experience of the first intubator (p<0.05) and the laryngeal view (p<0.001). The complication rate increased with repeated attempts (p<0.001) and was higher among junior doctors (p<0.05). Early use of elastic gum bougie was associated with lower complication and higher success rates.

Conclusion

Orotracheal intubation in the emergency department was associated with high complication rate. Many complications came from junior intubators. Hypotension was the most common complication. Potentially avoidable complications may be a result of failure to use RSI in non-cardiac arrest patients and failure to use bougie in cases of poor laryngeal view.
Acute Infectious Diarrhoea in Adults: Identifying Clinical Parameters Associated with Specific Pathogens
Authors: Chan SSW , Ng KC , Lam PKW , Lyon DJ , Cheung WL , Rainer TH
Published: December 2017

Introduction

Infectious diarrhoea may be caused by viral, bacterial or protozoan agents. The objective of this study was to explore the possibility of correlating presenting clinical and demographic features with the specific types of stool pathogens subsequently identified.

Materials & Methods

A retrospective study was performed in the setting of an Accident & Emergency (A&E) department of an urban acute-care hospital in Hong Kong. The inclusion criteria were adults (age ≥16); presentation with features of acute infectious diarrhoea; treated as out-patients with or without observation; and with stool cultures requested from A&E. All consecutive culture-positive cases (n=130) satisfying the above criteria were included. The control-group (n=119) consisted of a random sample of culture-negative cases during the same study period. For each of the six pathogens identified, statistical analyses were performed to compare differences in clinical features amongst three groups: (i) cases positive for the specific pathogen; (ii) cases positive for other pathogens; and (iii) cases with negative culture.

Results

Salmonella was associated with significantly higher body temperatures at presentation. Vibrio parahaemolyticus (VP) was associated with a significantly shorter duration of diarrhoea and of abdominal pain at presentation. Other variables were not helpful in predicting the type of stool pathogen.

Conclusion

In patients presenting with acute infectious diarrhoea in an A&E setting in Hong Kong, Salmonella and VP may be suspected according to the clinical features identified in this study.
Emergency Management of Paraphimosis
Authors: Chung Ch
Published: December 2017

Objective

To review the treatment modalities available for paraphimosis, with special emphasis on those applicable to the emergency department.

Data source

Relevant medical literature was searched through MEDLINE, EMBASE, CINAHL, and Cochrane Database. Manual search was performed in books on Urology, General Surgery and Emergency Medicine available in the Hospital Library. Further information was obtained through the Internet at < www.infoseek.com >. References cited in articles were also retrieved.

Study selection

Key words for the literature, Internet and textbook search were ‘paraphimosis’ and ‘treatment’. All available years of study were reviewed.

Data extraction

Relevant full text articles were obtained through the hospital library network. Original articles, review papers, medical practice, case reports, and relevant book chapters were reviewed.

Data synthesis

There were no prospective, randomised, controlled studies available. The majority were case series and expert experience or opinions only. Currently, a multitude of non-invasive and invasive treatment options are available, including manual reduction, help of non-crushing tissue forceps, puncture technique and dorsal slit.

Conclusion

All treatment methods are within the capability of the emergency physician. Hospitalization should rarely be required, unless there are serious complications.
Outpatient Management of Deep Vein Thrombosis: a Model with a Breakdown of the Continuum of Care
Authors: Paes C , Kelly AM
Published: December 2017

Objectives

For emergency department (ED) patients with deep venous thrombosis (DVT) treated as outpatients, to determine treatment duration, complications and follow-up arrangements, in particular thrombophilia screening.

Methods

Explicit, retrospective medical record review of patients with an ED discharge diagnosis of DVT over a three-year period. Data collected included demographics, location of DVT, duration of treatment, complications, hospital admission, mortality, follow-up arrangements and referral for thrombophilia screening. Main outcomes were the duration of treatment, rate of complications and requirement for hospital admission, follow-up arrangements and referral for thrombophilia screening for patients treated as outpatients.

Results

Two hundred and fourteen patients with DVT were identified, of whom 74 [35%] were treated as outpatients. For this group, the median duration of treatment was eight days. There was one death from advanced neoplasia, two proven pulmonary emboli (PE) [2.7%, 95% CI 0.74–9.3%] and one suspected PE [1.4%, 95% CI 0.24–7.3%]. One patient had a recurrence of DVT within three months [1.4%, 95% CI 0.24–7.3%]. Few patients received specialist follow-up [25/74, 34%]. In 20 cases [27%], thrombophilia screening was neither performed nor recommended, despite no obvious cause for the DVT.

Conclusion

Outpatient treatment of selected DVT is safe, although there is a small incidence of non-fatal PE. Follow-up and screening arrangements were sub-optimal in the study sample and treatment duration was long. An ambulatory care model with direct physician control is recommended to improve follow-up arrangements, monitor service performance and ensure that the service evolves with new evidence and processes.
A Pilot Study on the use of Tramadol Hydrochloride for Pain Control in an Emergency Department
Authors: Siu AYC , Chung CH
Published: December 2017

Introduction

Tramadol hydrochloride is a synthetic μ,-opioid agonist. It has been used in the control of moderate to severe pain. Most of the studies on tramadol were related to post-operative pain control. Data on acute pain control in the emergency setting were limited. This study reported on the initial evaluation of tramadol for pain control in an emergency department.

Materials and methods

It was a prospective observational study. Patients aged 16 years or above attending our emergency department with moderate to severe pain were recruited. Patients with known allergy, current psychiatric medication, intake of alcohol, major systemic illness and opioid dependence were excluded. All patients received 100 mg intramuscular tramadol injection. A 10 cm Visual Analogue Scale (VAS) was used to assess the pain severity before injection, 30 minutes and 60 minutes after injection. Vital signs and side effects were also recorded.

Results

Forty patients (M: 24, F: 16) were recruited from October to December 2002. Their mean age was 53.5 years. The majority of them suffered from acute musculoskeletal pain or arthritis. Tramadol was shown to be effective in pain control. The VAS decreased by 1.90 (p<0.001) and 3.38 (p<0.001) at 30 minutes and 60 minutes respectively. Four patients reported nausea and three patients vomited.

Conclusion

Tramadol appeared to be a safe drug to be used in the emergency setting. Only a few insignificant side effects were reported. The comparison of efficacy with other analgesics requires further studies.
Feasibility Study Comparing Oral Paracetamol and Oral Non-Steroidal Anti-Inflammatory Drugs for Treating Pain after Musculoskeletal Injury: a Randomised, Double Blind, Controlled Trial
Authors: Man SY , Woo WK , Lam PKW , Rainer TH
Published: December 2017

Objectives

To investigate the efficacy and safety of oral paracetamol compared with oral non-steroidal anti-inflammatory drugs (NSAIDs) or combination therapy in relieving pain after limb injury in an emergency department.

Design

Double blind, randomised, controlled study.

Setting

Emergency department of a university hospital in the New Territories of Hong Kong.

Subjects

50 adult patients with painful isolated limb injuries.

Main outcome measures

Primary outcome measures were pain relief at rest and with limb movement, and adverse events.

Results

There was no statistical difference in the mean reduction in pain score between oral paracetamol and oral NSAIDs in the first two hours of treatment or over three days. Patients' pain reduced significantly over three days but it was unclear whether this was due to natural healing rather than analgesic medication. There was no significant difference in pain relief between paracetamol and NSAIDs over three days treatment. All combinations appeared to be safe with no major adverse effects reported in the study.

Conclusion

Oral paracetamol may be as effective and as safe as moderate dose of NSAIDs in the management of musculoskeletal pain. A larger study is required to confirm this hypothesis.
Massive Spontaneous Haemopneumothorax and Ecstasy Abuse
Authors: Ng CP , Chau LF , Chung CH
Published: December 2017

A 33-year-old man developed spontaneous haemopneumothorax after taking ecstasy in a ‘rave party’. Massive haemorrhage occurred after chest drainage and decompression. Both the adverse effects of ecstasy and risk behaviours at the party might have contributed to the development of the spontaneous haemopneumothorax.
The use of Prophylactic Antibiotics in Trauma
Authors: Yuen ECP
Published: December 2017

Infection is an important cause of morbidity and mortality in trauma. In this literature review, the microbiological profiles and the use of prophylactic antibiotics in various traumatic situations are discussed. This review includes abdominal and chest trauma, craniocerebral trauma, long bone fractures, open globe injuries and animal bite injuries.
How Much do we Know about ST Elevation?: Case Report of a Patient with Acute Coronary Syndrome in the Observation Ward
Authors: Ho KK , Chan CM , Lee KH , Lit CH
Published: December 2017

The identification of acute coronary syndrome continues to challenge even experienced clinicians. Emergency physicians have the responsibility to identify, treat and admit those patients with true acute coronary syndrome to the appropriate units. This article described a case of acute coronary syndrome that developed in the observation ward, with discussion on some recent reviews of standard electrocardiogram analysis. It is very important to point out that controversy over the measurement of ST elevation exists which may adversely affect patient management.
Go‐Kart Related Injuries: A Local Scene
Authors: Ng CP , Chung CH
Published: December 2017

Objectives

To study the characteristics and nature of injuries relating to go‐kart in the local setting and to compare the findings with those reported in the medical literature.

Methods

A prospective survey of patients with go‐kart related injuries attending the accident and emergency department of a public district hospital in Hong Kong within the year 2002. The data were analysed and compared with previous studies.

Results

Forty‐two patients were collected in the study. The mean age was 26 years. Ten patients (23.8%) were at or below the age of 20 years. Twenty‐nine patients (69.0%) were males. Out of the 42 patients, all were riders except one who was a bystander. Thirty‐three patients (78.6%) had injuries in indoor tracks. Ten (23.8%) patients were admitted and five (50%) of those admitted required operations. There was no fatality. Twenty‐seven patients (64.3%) had only single injury. Most (64.2%) were minor soft tissue injuries. However, fractures or dislocations occurred in 13 patients (31.0%). Two patients (4.8%) suffered from internal organ injuries. Isolated head and facial injuries occurred in 11.9% of patients. All were simple concussion. Nine patients (21.4%) suffered from isolated lower limb injuries, with more than half sustaining fractures or dislocations. Collision with other karts (40.5%) was the most frequent mechanism of injury. Riding in outdoor track was associated significantly with increased admission when compared with indoor track (77.8% vs 9.1%, p<0.001). There was no association between rider's age, gender, previous riding or injury experience, or the presence of briefing before the race with the rate of admission.

Conclusion

Go‐kart racing and working on racing track can be a recreation or occupation with potential dangers. In our study, characteristics of patients, mechanisms and types of injuries were similar to other western studies. Accidents on outdoor tracks appeared to be more serious and more likely admitted than those on indoor circuits. Special safety precautions on outdoor events may help to reduce the severity of injuries. However, drivers with more riding or injury experiences were not exempted from severe injuries. Moreover, presence of briefing before the race did not help reduce the admission rate either. Perhaps, a safe and careful attitude of the rider and a seriously conducted briefing by a qualified instructor would be more important to reduce accidents. Further proper large scale controlled epidemiological studies will definitely help to improve the understanding of go‐kart related injuries.
Trans‐Abdominal Ultrasound‐Guided Suprapubic Puncture of a Non‐Deflating Foley Catheter Balloon
Authors: Lee WMM , Tsui KL , Kam CW
Published: December 2017

Failure of a Foley catheter balloon to deflate is a frustrating problem to both the patient and the doctor. We report a case of non‐deflating Foley catheter balloon successfully deflated by needle puncture via the suprapubic route under trans‐abdominal ultrasound guidance by emergency physicians. The procedure is simple and safe. We believe that all emergency physicians with adequate knowledge and minimal training can acquire the technique. The choices of different methods to deflate the balloon are also discussed.
Short-Haul Flight: Is it a Risk to Pulmonary Embolus?
Authors: Wahab M Abd , Hassan Aa Abu
Published: December 2017

Introduction

Pulmonary thromboembolism (PTE) still remains a diagnostic challenge to junior doctors working in emergency departments. Being aware of the condition and its associated risk factors can improve the diagnostic accuracy. Association between passenger travelling long-haul flight and PTE has been well documented; however its association with short-haul flight is very rare and controversial. This case report illustrates the possible linkages between short-haul air travel with the development of classic non-fatal PTE.

Clinical feature

A young Indian gentleman after travelling four hours on a flight complained of progressive worsening of breathlessness when he arrived at Kuala Lumpur. Clinically he was tachypnoeic and tachycardiac. The electrocardiogram showed T inversion in leads III and aVF, and S wave in lead I. Oligaemia was shown on the chest X-ray and hypoperfused areas were seen on the spiral computed tomographic angiogram.

Treatment

He was started on unfractionated heparin, switched to low molecular weight heparin, and then warfarin and subsequently admitted to the coronary care unit.

Outcome

He was discharged well on day 7 after admission with warfarin and medical advice before returning to India.

Conclusion

Non-fatal PTE is at times difficult to diagnose and requires a high index of suspicion. Its association with healthy passengers of short-haul flight is not well established and this case report illustrates the possibility of linkages.
Nebulizer versus Inhaler with Spacer for Beta-Agonist Treatment in Acute Bronchospastic Disease
Authors: Lee GPC , Sung WY , Fung HT , Kam CW
Published: December 2017

Objectives

To compare the efficacy of nebulized wet aerosol with metered-dose inhaler with a spacer (MDIS) in the management of acute bronchospasm.

Methods

It was a retrospective study by reviewing the clinical records of patients with acute exacerbation (chief complaint of shortness of breath) of asthma or chronic obstructive pulmonary disease (COPD) presenting to the Accident and Emergency Department (AED) of Tuen Mun Hospital from 1st to 30th November 2002 and 2003 respectively. All patients received beta-agonist by nebulizer, in the year 2002 (pre-SARS period) while all patients received treatment by MDIS in the year 2003 (post-SARS period). Treatment outcome measures included admission rate, length of hospitalisation for those admitted and AED re-attendance within 7 days for those discharged from the AED.

Results

Altogether 821 patients were recruited in this retrospective study, 522 belonged to the nebulizer group and 299 were of the MDIS group. The two groups had similar demographic characteristics. Concerning the admission rate (47% in the nebulizer group and 41% in the MDIS group; p=0.089) and re-attendance rate (7% in the nebulizer group and 6% in the MDIS group; p=0.607), the differences were not statistically significant. For the length of hospital stay, it was shorter in the nebulizer group than the MDIS group (3.65±SD 1.88 days vs 4.10±SD 1.94 days; p=0.035). However, the admission rate in the adult subgroup (61% in the nebulizer group and 47% in the MDIS group; p=0.002) was shown to be statistically significant. In multivariate analysis, usage of nebulizer, increase in respiratory rate and age were associated with a higher admission rate. Increase in SpO2, absence of co-morbidity and asthma patients were associated with a lower admission rate. Increase in age, respiratory rate and usage of MDIS were associated with an increase in hospital stay. Asthma was associated with a decrease in AED re-attendance rate as compared to COPD.

Conclusions

This retrospective study showed that both nebulizer and MDIS were effective for beta-agonist therapy in acute bronchospasm in AED with respect to hospital admission rate and AED re-attendance rate, but the length of hospital stay was slightly prolonged when using MDIS.
A Prospective Epidemiological Study of Acute Poisoning in Hong Kong
Authors: Chan YC , Fung HT , Lee CK , Tsui SH , Ngan HK , Sy MY , Tse ML , Kam CW , Wong GCK , Tong HK , Lit ACH , Wong TW , Lau FL
Published: December 2017

Objective

To update our epidemiological knowledge of acute poisoning in Hong Kong.

Methods

A multi-centred prospective study was conducted for six months in six major accident and emergency departments in Hong Kong. A specially designed form was used to collect demographic data, type of poison involved, cause of poisoning, management, disposal as well as final outcome of the poisoned patients.

Results

A total of 1,467 patients (male: 588, female: 879) were included in the study. Most of them were young adults (32% were between 20 and 40 years old). Suicidal attempt (64%) was the most common cause of poisoning. Notably, 379 (26%) patients took more than one poison. Among the 2,007 counts of poison taken, sleeping pills (24%) and analgesics (18%) were the most commonly used drugs and paracetamol was the commonest single ingredient involved in poisoning. Most patients were treated with supportive measures, and about 40% and 15% of the patients were given gastrointestinal decontamination and specific antidotes respectively in their management, in which activated charcoal and N-acetylcysteine were the most common. Concerning disposal from the emergency department, 91% of the poisoned cases required in-patient management. Most patients had an uneventful recovery but 5 (0.3%) had significant disability and 21 (1.4%) died. Suicidal carbon monoxide poisoning was the leading cause of mortality in our study.

Conclusions

Most acute poisonings in Hong Kong were suicidal in nature and paracetamol was the commonest agent. Activated charcoal was the most commonly used decontamination method and most patients had an uneventful recovery.
Outcome of Out-of-Hospital Cardiac Arrest in a Regional Hospital in Hong Kong
Authors: Lau CL , Lai JCH , Hung CY , Kam CW
Published: December 2017

This study evaluated the resuscitation outcome of adult patients presenting with non-traumatic out-of-hospital cardiac arrest (OHCA) to a regional hospital in Hong Kong. Out of 876 patients of non-traumatic OHCA, 12.7% survived to hospital admission. Only 0.5% of the 876 patients survived to hospital discharge and at one year after discharge. The number needed to treat (NNT) for prehospital asystolic cardiac arrest to have one survival to discharge was 795.
A Re-Emerging Ancient Disease: A Case Report
Authors: Lam HY , Kan PG
Published: December 2017

There have been repeated outbreaks of leptospirosis reported all over the world. Being one of the largest cities in the world, Hong Kong is no exception. We report a local case involved in an outbreak of the disease with a typical route of acquisition but rare complications. A brief account on the epidemiology of both Hong Kong and Southern China is given. Discussions on the pathophysiology of the disease and its complications are also presented.
A Study on Trauma Documentation in Accident and Emergency Attendance Records
Authors: Law CY , Wong TW , Lau CC
Published: December 2017

Aim

To study the adequacy of trauma documentation in accident and emergency (A&E) attendance records.

Method

We reviewed the A&E attendance records of major trauma requiring trauma-team care in the resuscitation room from January to June 1999 and July to December 2001. Thirty-eight items including the history, symptoms and signs of injury were scored with reference to the teaching of the Advanced Trauma Life Support course. The mean score and rate of documentation of each item were calculated. Additional items on biomechanics and environmental factors of injury were also examined. The performance of emergency medicine trainees and non-emergency medicine trainees was analysed.

Results

A total of 128 records were included, 46 and 82 records being from 1999 and 2001 respectively. The maximum documentation score was 38. The mean documentation score in 2001 was 23.27; and this was significantly better than 20.37 in 1999 (p < 0.05). The documentation rates of pre-hospital, biomechanics and environmental items were poor. Notably, 15 out of the 38 items were preformatted in the A&E records and 11 of these preformatted items had documentation rates of > 80%. Emergency medicine trainees had better scores in 2001 than in 1999. However, non-emergency medicine trainees did not show improvement in their documentation.

Conclusion

Trauma documentation has improved since 1999 for emergency medicine trainees. Preformatted charts may increase the rate of documentation. Information on pre-hospital care and injury mechanism was not well documented.
Streptococcus Suis: What Has Been Found in the past Decades?
Authors: Sia YS , Kan PG , Wong YT
Published: December 2017

Streptococcus suis (SS) infection has aroused tremendous attention recently. We report a restaurant worker who suffered acute confusion due to SS meningitis. Sporadic cases have been reported in Hong Kong since 1981. Little was known in the past about its characteristic fulminant clinical deterioration. We explored the literature and discuss the epidemiology, pathogenesis, clinical manifestations and management of this disease.
Bizarre Parosteal Osteochondromatous Proliferation (Nora's Disease)
Authors: Lam FCY , Tsang TK , Fung HS , Wai MW , Shu SJ
Published: December 2017

Finger pain is a common presenting symptom. While some of the causes are rare and easily forgotten, they may be significant. Bizarre parosteal osteochondromatous proliferation is a rare benign tumour. Malignant transformation has been described. The distinctive radiological features and its differential diagnoses are discussed.
Case Series of Paraquat Poisoning in Tuen Mun Hospital
Authors: Wong OF , Fung HT , Kam CW
Published: December 2017

Paraquat is highly toxic to human and is widely used in agriculture as a contact herbicide. However, it is easily accessible in agricultural product shops. Seven cases of paraquat poisoning were treated in Tuen Mun Hospital from 1998–2005. The mortality (4 out of 7) was very high. One patient died after oral exposure to paraquat despite immunosuppressive and antioxidant therapies. The mechanism of toxicity and potential new therapies of paraquat poisoning are discussed in the article.
A Case of Disseminated Intravascular Coagulopathy Developing Rapidly after a Suspected Bamboo Snakebite
Authors: Chan KF , Chung CH
Published: December 2017

We present a case of disseminated intravascular coagulopathy developing rapidly after being bitten by a snake suspected to be Trimeresurus albolabris in a 67-year-old man. The unusually fast onset of coagulation disturbances and the later renal complication should alert emergency physicians that snakebites (including Trimeresurus albolabris) can be devastating if not managed promptly.
Video‐Assisted Airway Management: Experience in a Hong Kong Emergency Department
Authors: Hung WCY , Tsui KL , Yau HH , Kam CW
Published: December 2017

Video‐assisted airway management is a new concept for monitoring and managing both normal and difficult tracheal intubations, with the aid of video‐transmission of the view from the tip of intubating devices such as stylets or intubating laryngoscopes. Its principle, practical application and local experience are illustrated by some sample cases and its future development is discussed.
An Overview of an Emergency Department Short Stay Ward in Hong Kong
Authors: Fung HT , Tsui KL , Kam CW
Published: December 2017

Objectives

To describe the structure and service pattern of a short stay ward (SSW) named as Emergency Observation and Pre-admission Ward (EOPW) in Hong Kong. The effectiveness of the EOPW was to be examined.

Methods

This was a retrospective observational cohort study. The facilities, staffing and operation of the EOPW were described. Consecutive patients admitted to the EOPW in the year 2006 were retrieved from the hospital computer database. Admission diagnoses, length of stay (LOS) and destination of disposal were the main outcome variables measured. The ICD coded admission diagnoses were categorised into 24 diagnosis-related groups. Different diagnosis-related groups were compared with respect to the selected efficacy cutoff points of LOS less than 24 hours and hospital admission rate less than 30% respectively.

Results

The service of the 30-bed short stay ward as started in year 2003 was a pilot project in Hong Kong. In year 2006, 10,111 patients were admitted and the mean age was 54.2 years. The five commonest diagnosis-related groups were psychiatric disease, chest pain, dizziness, musculoskeletal pain and poisoning. The overall hospital admission rate and the mean LOS were 26.8% and 23.4 hours respectively and were below the efficacy cutoff points. Musculoskeletal pain, chronic obstructive pulmonary disease and acute urinary retention were the three diagnostic groups with both LOS and hospital admission rate above the efficacy cutoff points.

Conclusion

This first SSW in Hong Kong was demonstrated to be effective according to the analysis result of the 2006 data. SSW has become an integral part of emergency medicine and provided an alternative way of effective management in contrast to traditional inpatient management for various selected disease conditions.
Traditional Chinese Medicine Use among Emergency Patients in Hong Kong
Authors: Tse ML , Lau FL
Published: December 2017

Introduction

Traditional Chinese Medicine (TCM) use has been believed to be common in Hong Kong but no data existed on its prevalence among emergency patients. We conducted a prospective survey to study the prevalence of its use, the type of TCM use, frequency and nature of associated adverse reactions.

Methods

All accident & emergency department (AED) attendances at the United Christian Hospital were screened by the triage nurse and attending doctor for TCM use and its type in a consecutive 31 day period. The causal relationships between the TCM and their presenting illness were also assessed and decided by the doctor in-charge.

Results

291 out of 21,475 patients (1.4%) reported TCM use within one week. Among them, 117 (40.2%) consumed Chinese herbal medicine, 75 (25.8%) took proprietary Chinese medicine, 1 (0.3%) took both, 96 (33.0%) received topical treatment and 2 (0.7%) were unclassified, with 22 out of the 291 TCM users (7.6%) presented for TCM-related toxicity. Most complications were mild, the commonest ones being dermatitis after topical treatment (68.2%) and allergic reaction after oral intake (22.7%).

Conclusion

A small number of patients took TCM treatment shortly before AED consultation. Most TCM-related toxicities were mild and the commonest reactions were dermatitis and systemic allergy.
The Walkers who Finished Oxfam Trailwalker 2005: Who Were They?
Authors: Au CKH , Ng YW , Ho HF
Published: December 2017

In Oxfam Trailwalker, walkers formed a team of four to compete in the 100 km MacLehose Trail within 48 hours. In 2005, 3724 walkers participated in this event. About 82% of these walkers finished the trail. This study aimed at examining those successful walkers. Variables that might affect the finishing time were studied. A total of 231 walkers were recruited. Their training history was obtained. Their body weight, height, Q-angle of both knees, arch index and arch ratio of both feet were recorded. Those walkers who could not complete the trail were excluded from analysis. Data from 202 walkers were analysed. The results showed that mature walkers did better than young ones (p=0.004). Male walkers performed better than female walkers (p=0.019). Experience in previous events was a factor to success (p=0.000). High training hours for hiking might lead to a more favourable finishing time but the finding was not statistically significant (p=0.449). Body mass index, Q-angle of knees and foot shape did not show any statistically significant relationship with the finishing time. In conclusion, except for age, gender and experience, no special trait could be identified from these successful walkers. It would be very reassuring for those who intend to take part in Oxfam Trailwalker and yet not possessing the genetic advantage of an elite sportsman.
Subutex®Abuse Presenting to the Emergency Department: A Case Series
Authors: Chew HC
Published: December 2017

Introduction

Subutex®(sublingual buprenorphine hydrochloride) tablets are prescribed to alleviate symptoms of opiate withdrawal in addicts undergoing a cessation programme. Although Subutex®is safe and effective, parenteral abuse is an emerging phenomenon. A variety of complications may present due to the different areas that patients inject themselves.

Aim

We present a case series of four patients who presented to the emergency department following complications of Subutex®abuse. The complications included deep venous thrombosis, limb ischaemia and epidural abscess with osteomyelitis of the spine.

Discussion

Sublingual buprenorphine was launched in Singapore in 2002. It is currently the preferred alternative to methadone for treating opiate dependency locally. Despite safeguards, instances of abuse of buprenorphine exist. These medications can be passed or sold to others not on a cessation programme. Two of the 4 patients in this series obtained Subutex®illegally. Parenteral abuse of Subutex®is of grave concern. In Australia and France, between 23–37% of Subutex®users have abused it in this fashion.

Conclusion

Subutex®abuse is not uncommon in Singapore. Complications especially from parenteral use can occur and may result in serious morbidity. A high index of suspicion among physicians must be maintained in patients with unusual limb infections, ischaemia or venous thrombosis. Tighter regulations on prescription and consumption of Subutex®may be useful in preventing these complications, in addition to increasing public awareness and education of the risks of parenteral abuse for patients on cessation programme.
Two Cases of Gelsemium Elegans Benth. Poisoning
Authors: Fung HT , Lam KK , Lam SK , Wong OF , Kam CW
Published: December 2017

A couple of spouse mistook the Gelsemium elegans Benth. collected in countryside for Mussaenda pubescens Ait. f. and suffered toxicity soon after ingestion. One went into respiratory failure necessitating intubation and the other developed dizziness. The morphological differences between Gelsemium elegans Benth. and Mussaenda pubescens Ait. f. may not be easily recognised by the general public. Close monitoring and respiratory support are the cornerstones of management.
A Randomised Control Trial Comparing the Efficacy of Tramadol and Paracetamol against Ketorolac and Paracetamol in the Management of Musculoskeletal Pain in the Emergency Department
Authors: Lee HKH , Ting SM , Lau FL
Published: December 2017

Background

This study aimed to compare the efficacy, acceptance and side effects of intramuscular tramadol and ketorolac in combination with oral paracetamol in the emergency setting.

Materials and methods

This was a randomised, double blind controlled trial. Patients aged 18 years or above with moderate to severe musculoskeletal pain were recruited. Patients with known allergy, currently on psychiatric medication, with alcohol or opioid dependence, during pregnancy and with major systemic illness were excluded. Tramadol 100 mg or ketorolac 30 mg was given intramuscularly together with paracetamol 500 mg per oral. They were then bed rested in the observation ward for one hour. Visual analogue scale (VAS), satisfaction score, vital signs and side effects were recorded.

Results

Altogether, 78 (M: 43, F: 35) subjects were recruited from June to September 2005, with equal number in each arm. The mean age was 39.9 for the tramadol group and 43.9 for the ketorolac group. Most of them suffered from back pain (66.7%). There was a significant difference in VAS improvement between the two groups (0.88; P=0.01). However, there were no significant differences in patients' satisfaction score and admission rate. The incidence of side effects was similar between the two groups (tramadol 19, ketorolac 17), mainly dry mouth, and none were major. The tramadol group had more nausea.

Conclusion

The analgesic effect of the tramadol and paracetamol combination is as effective as the ketorolac and paracetamol combination. Tramadol is well tolerated and relatively safe. It is also cheaper than ketorolac. Hence, we recommend tramadol and paracetamol combination for acute moderate to severe musculoskeletal pain in the emergency setting.
Mechanical Cardiopulmonary Resuscitation Device in an Accident and Emergency Department: A Case Report and Literature Review
Authors: Chan LW , Wong TW , Lau CC
Published: December 2017

We present a case of resuscitation of a 38-year-old lady with ventricular fibrillation using the Lund University Cardiopulmonary Assist System (LUCAS), a mechanical cardiopulmonary resuscitation (CPR) device. Return of spontaneous circulation was obtained after prolonged resuscitation but the patient eventually succumbed nine days after admission to the coronary care unit. The role of mechanical CPR devices in resuscitation in the accident and emergency department is discussed.
Three Cases of Peripartum Cardiomyopathy
Authors: Lam TSK , Lo CM , Kam CW
Published: December 2017

Dyspnoea and dizziness are very common presentations in the emergency department. We describe three female patients complaining of dyspnoea and dizziness during their postpartum period. Clinical manifestations and diagnosis of peripartum cardiomyopathy is discussed.
A Lady with Confusion and Seizure after Ingestion of Lidocaine for Dyspepsia
Authors: Li YK , Lee FT , Lau FL
Published: December 2017

We report a 29-year-old lady who developed confusion, agitation and seizure after the ingestion of a self-mixture of 3 grams of lidocaine with antacid for treatment of dyspepsia. She developed two episodes of seizure requiring diazepam, propofol and intubation. There was no significant cardiac toxicity and she was discharged on day 3. This is the first reported adult case of seizure in the literature after intentional ingestion of lidocaine for treatment of dyspepsia. The use of local anaesthetic in gastrointestinal cocktail for dyspepsia and its safety are highlighted. Advances in the management of local anaesthetic overdose are also discussed.
Two Cases of Chloral Hydrate Overdose
Authors: Wong OF , Lam TSK , Fung HT
Published: December 2017

Chloral hydrate overdose is associated with cardiac toxicities, gastrointestinal tract injuries, central nervous system and respiratory depression. Among all the complications, cardiac arrhythmias are particularly concerning and frequently reported in the literature. The majorities of fatalities from chloral hydrate overdose are due to refractory cardiac arrhythmia. Chloral hydrate‐induced arrhythmias are resistant to most of the standard anti‐arrhythmic agents but have good response to propranolol. We report two cases of severe chloral hydrate overdose presenting with alarming cardiac rhythm disturbances. One of the patients was successfully treated with intravenous propranolol in the accident and emergency department. The management of chloral hydrate overdose in particular to its cardiac toxicity is reviewed.
Case Report of Carbon Monoxide Poisoning in a Pregnant Patient: Mother Died, Baby Survived
Authors: Cakir Z , Emet M , Caner I , Aslan S , Saritas A
Published: December 2017

Carbon monoxide poisoning in pregnant women is a relatively rare condition. We report a 32‐year‐old woman in her 32nd week of pregnancy found unconscious in the bathroom. On arrival, her pulse and blood pressure were undetectable. Cardiopulmonary resuscitation was applied. The mother's carboxyhaemoglobin level was 57%. Due to foetal distress, Caesarean section was performed in the emergency department. The baby was intubated due to the absence of spontaneous respiration. The level of carboxyhaemoglobin in the cord blood was 32%. After staying in the newborn unit for 47 days, the baby was discharged with a sequela of cerebral palsy.
One More ‘T’ for the Mnemonic of the Management of Pulseless Electrical Activity: Tension Pneumoperitoneum
Authors: Wong WY , Wong OF , Wong HT , Fung HT
Published: December 2017

The approach in Advanced Cardiac Life Support provided by the American Heart Association and the European Resuscitation Council guidelines for the management of pulseless electrical activity emphasizes on the search of reversible causes. Tension pneumoperitoneum is an uncommon surgical emergency encountered in the accident and emergency department. We report a case of pulseless electrical activity secondary to tension pneumoperitoneum in an elderly woman. Restoration of spontaneous circulation was immediately achieved after needle decompression. The management of tension pneumoperitoneum is discussed.
Haemopericardium and Liver Laceration Associated with Airbag Deployment
Authors: Lee DH , Park TU , Kim CW
Published: December 2017

Airbags and seat belts are safety devices in automobiles. First invented in the 1950s, they are now commonplace in most automobiles. However, a seat occupant may sustain unexpected injuries even if the airbag deploys in a car collision. We describe a patient who was suspected of simultaneously sustaining haemopericardium and liver laceration during the “punch out” and “membrane force” phases of airbag deployment. The patient's vital signs stabilised after an emergency pericardiocentesis was performed. In a car accident when high‐energy injury is suspected despite airbag deployment, computed tomography of the chest and abdomen or echocardiography should be considered because of the possibility of abdominal solid organ and chest injury.
Medical Research Ethics: What We Need to Comply When Obtaining Informed Consent from Human Subjects?
Authors: Tay CSK
Published: December 2017

Patient safety and well‐being are very important to safeguard in medical research. A subject's life cannot be sacrificed for the benefits of future mankind, as medical ethics of autonomy dictate the respect of an individual. By reference to the Declaration of Helsinki, this article discusses the ethical principles and processes in obtaining a valid and proper informed consent from the research subjects who should freely consent and voluntarily participate in the clinical research, including the ‘contents’ of the informed consent and the ‘skills’ of obtaining informed consent.
News Board for Emergency Incidents
Authors: Chan TN , Lo CM , Tung WK , Lee H
Published: December 2017

In the past, intra‐hospital communication during disaster incidents relied heavily on pagers, phones or direct verbal communication. Other communication channels may include facsimile transmission, email and “walkie‐talkie”. There was often delay or inadequacy of information dissemination. This article introduces the “News Board for Emergency Incidents” recently launched in our hospital intranet as an efficient communication channel to convey up‐to‐date information to other hospital staff during major incidents. The background and process of development of this new communication modality is discussed. We also try to explore possible future development of such “news board” via intranet broadcast.
A Retrospective Study on Intracerebral Haemorrhage Reduction by Mri versus Ct in Intravenous Thrombolysis for Acute Ischaemic Stroke
Authors: Yun YH , Chung JY , Kang MJ , Huh JT , Park KW , Cha JK
Published: December 2017

Introduction

Multimodal MRI may be an effective tool for selecting suitable acute ischaemic stroke patients for thrombolysis, reducing the risk of haemorrhage. In this study, we demonstrated the usefulness of our central alerting system to reduce door‐to‐needle time for thrombolysis following MRI. This system allowed timely intervention and reduced the rate of symptomatic haemorrhage.

Methods

We reviewed the records of 73 patients with hyperacute ischaemic stroke who received intravenous (IV) tissue plasminogen activator (t‐PA) between January 2006 and December 2007 following the adoption of a central stroke alerting system in our hospital.

Results

Of the 73 patients who received IV t‐PA, 44 were based on CT and 29 on MRI findings. The door‐to‐needle time was 10 minutes longer for the MRI group (49.9±23.2 min) compared to the CT group (39.6±19.7 min) but it was still within the recommended 60 minutes time frame. On the other hand, the rate of symptomatic haemorrhage was lower, though insignificantly, in the MRI group (0%) compared to the CT group (13.6%) (p=0.08).

Conclusions

In this study, we demonstrated that the combination of diagnostic MRI and a central alerting system might reduce the rate of symptomatic haemorrhage without compromising the door‐to‐needle time.
Prolonged Qt Interval after Fexofenadine Overdose in the Presence of Hypokalemia and Hypocalcaemia
Authors: Aksakal E , Ulus T , Taş H , Ocak T , Sevimli S
Published: December 2017

A 23‐year‐old healthy woman was admitted to our emergency department because of syncope and unconsciousness. She had taken 20 tablets of fexofenadine (total 2400 mg) and 9 tablets of furosemide (total 360 mg) for suicide. The electrocardiogram demonstrated bradycardia (48/min) and markedly prolonged QTc interval (684 msec). Endotracheal intubation and nasogastric tube insertion were performed. Gastric lavage was implemented and activated charcoal was given. A transient pacemaker was implanted. Hypokalemia and hypocalcaemia were also present and the electrolyte disturbances were corrected. The heart rate and QTc interval returned to normal limits after treatment. She stayed in our hospital for seven days. She recovered completely and ventricular arrhythmia was not seen during the hospitalization period.
An Unusual Cause of Delirium in a Psychiatric Patient: Abrupt Clozapine Discontinuation
Authors: Wong OF , Fung HT , Lam TSK
Published: December 2017

Rapid clinical deteriorations have been reported after abrupt discontinuation of clozapine. A 42‐year‐old psychiatric patient presented with ingestion of hand‐disinfectant solutions causing transient impairment of his conscious level. His clozapine therapy was discontinued for a short period of time and he developed delirium with normal results of investigations for underlying organic causes. His delirium resolved rapidly after the reintroduction of clozapine. The withdrawal effects of abrupt discontinuation of clozapine are discussed in this article.
Controlling Seizures in Children: Diazepam or Midazolam? Systematic Review
Authors: Doshi D
Published: December 2017

Introduction

Diazepam is commonly used to treat acute childhood seizures, but difficulty gaining intravenous access and variability of absorption after rectal administration can limit its efficacy. Midazolam is a water soluble benzodiazepine that has a rapid onset of action after intranasal or buccal administration and provides an alternative to diazepam in the control of acute childhood seizures.

Methods

A literature search was performed to identify papers comparing the efficacy and tolerability of midazolam and diazepam in the management of childhood seizures.

Results

Intranasal or buccal midazolam are at least as effective as rectal or intravenous diazepam in controlling acute childhood seizures. In all robust studies reporting a significant difference, time to gain seizure control was shorter in patients treated with midazolam than those treated with diazepam, predominantly due to shorter drug administration time. The incidence of seizure recurrence was lower in patients treated with midazolam than diazepam. Respiratory depression was uncommon in both groups.

Conclusion

Intranasal or buccal midazolam provides a safe, effective and acceptable alternative to intravenous or rectal diazepam in the management of acute childhood seizures.