bluuebunny/crossref_metadata_2025 huggingface dataset:
A Six‐Year Observational Study on Acute Limb Ischaemia in a Local Emergency Department in Hong Kong
Authors: Yang SM , Chu NH , Lo CM , Tung WK
Published: December 2017

Introduction

Acute limb ischaemia is an important presentation to accident and emergency department (AED). This study aimed to find out the sensitivity of AED colleagues on diagnosing acute limb ischaemia and any association between delayed diagnosis and poor outcome. Prognostic factors that might be associated with amputation and mortality rates were also investigated.

Methods

This was a retrospective observational study of patients admitted to Kwong Wah Hospital with a diagnosis of acute limb ischaemia over a six‐year period. The risk factors for acute limb ischaemia, the sensitivity of reaching the diagnosis at AED, and outcome in terms of amputation and 30‐day mortality post‐admission were assessed.

Results

The sensitivity of Kwong Wah Hospital AED in diagnosing acute limb ischaemia was 78.3%. Advanced age, lower limb involvement and history of aortic graft were associated with higher risk of mortality. Patients diagnosed and referred by other sources, e.g. private practitioner, were also associated with higher mortality. Male sex, smoking and intravenous drug abuse were associated with higher amputation rate. Atrial fibrillation seemed to be a protective factor against amputation. Delayed diagnosis group comprised 22% of the cases. There was no significant difference in amputation and mortality rates between the early diagnosis and delayed diagnosis groups.

Conclusions

AED physicians should always include acute limb ischaemia into the list of differential diagnoses. Further larger scale studies may be performed to investigate the impact of delay in diagnosis on outcome of patients.
Capnography: An Accurate Method to Assess the Position of the Feeding Tube in a Porcine Model
Authors: Lin CC , Lin CC , Lin HJ , Chen KT
Published: December 2017

Objective

To test the accuracy of capnography in the differential placement of feeding tubes into the trachea versus the oesophagus.

Method

Nineteen pigs were anesthetised, and feeding tubes were placed into their tracheas and oesophagi. A naïve examiner attached a capnography to the tube and evaluated the presence or absence of flow waveforms on the capnography. In the next step experiment, we gave 20 intentional oesophageal ventilations to the animals to create a distended stomach. The feeding tubes were reinserted, and examined by a naïve examiner by capnography.

Results

Capnography demonstrated continuous flow waveforms for the feeding tubes placed in the tracheas, but no waveforms were observed for those placed in the oesophagi. In the next step experiment, we found the same results.

Conclusion

Capnography can be used to accurately determine the placement of tracheal versus oesophageal feeding tubes based on the presence or absence of flow waveforms.
An Unusual Complication following Unconventional Use of High Pressure Injector
Authors: Eroglu SE , Tezel S , Salcin E , Denizbasi A , Onur O , Ozpolat C , Demir H
Published: December 2017

High pressure injection injuries most commonly occur in industrial accidents. In accident due to high pressure gun injuries, the nature of injected materials, the degree of toxicity, and the amount injected will affect the clinical outcome. Early vigorous treatment is essential to reduce morbidity. We reported a case of hand injuries due to inadvertent use of a high pressure injector device for haemostasis. 46‐year‐old male technician tried to stop bleeding from his injured hand by directing air jet from a high pressure injector to the wound resulting in significant subcutaneous emphysema. Adequate training and knowledge on occupational safety should be reinforced to avoid similar accidents.
Intestinal Tract Dilation Caused by Ingestion of Castor Beans
Authors: Liu JF , Ge QM , Pan SM
Published: December 2017

Castor bean is one of the most toxic natural poisons, especially the seeds and pods. We report a patient who ate nearly 30 castor beans heated in a microwave oven. He presented with infectious gastroenteritis like symptoms. Plain abdominal radiograph and abdomen CT studies showed dilated intestinal tract. It was a rare report that a patient after eating so many castor beans could have his clinical manifestation as acute gastroenteritis without any hepatic and renal dysfunction.
Severe Hyperemesis Gravidarum Masking the Presentations of Hyperthyroidism
Authors: Chen TJ , Lin HJ , Chen KT
Published: December 2017

Hyperemesis gravidarum may present with weight loss and tachycardia secondary to dehydration. Its severity correlates with the level of the serum chorionic gonadotropin which can interfere with the assay of the thyroid stimulating hormone. Therefore, hyperemesis gravidarum are at times difficult to be distinguished from hyperthyroidism. Missing hyperthyroidism during pregnancy results not only in inappropriate maternal care, but adverse neonatal outcomes including low birth weight. The authors report a case of hyperemesis gravidarum complicated by the concurrence of hyperthyroidism. Goiter and refractory tachycardia are the useful clues to detect occult hyperthyroidism in patients with hyperemesis gravidarum.
Effects of Drink Driving on Crash Risk Based on Random Breath Test Data
Authors: Li YC , Sze NN , Wong SC , Tsui KL , So FL
Published: December 2017

Introduction

Driving under the influence of alcohol (DUIA) is an important contributor to road crashes, injuries, and fatalities. Legal limits on drivers' breath alcohol concentration (BrAC) were first introduced in Hong Kong during the 1990s. Since then, the number of alcohol-related crashes has decreased. In 2009, police were empowered to conduct random breath tests (RBT) at roadblocks at any time. The availability of comprehensive RBT data allows us to determine the relationship between crash risk and BrAC, while controlling for confounding factors such as temporal distribution, road environment, and traffic conditions.

Method

In this study, we established two negative binomial regression models to analyse the risk of crashes in which people are killed or seriously injured (KSI crashes) and those involving only slight injuries on 182 urban road segments.

Results

Our results indicated that a higher mean BrAC markedly increases the risk of KSI crashes. However, there was no relationship between the risk of crashes involving slight injury and mean BrAC, although the absence of a hard shoulder, the presence of roadside parking bays, the dawn period, and the location noticeably increase the risk of these crashes.

Conclusion

It is worth exploring the benefits of remedial measures if comprehensive information on demographics and the driving habits of individual drivers become available in the future.
Conjunctival Inclusion Cyst
Authors: Lu JH , Chu FY , Chen KT
Published: December 2017

Conjunctival inclusion cysts are the most common cystic lesions of the conjunctiva and are either congenital or acquired; the latter are more prevalent. Some of the major factors that provoke the development of an acquired cyst are surgery, trauma, and chronic inflammation. Here, we report on a conjunctival inclusion cyst that developed following a case of untreated chronic conjunctivitis. To temporarily relieve the patient's symptoms a needle aspiration of the cyst was performed, and the patient was referred to an ophthalmologist for surgical excision of the cyst.
Effective Dose of Remifentanil for Control of Haemodynamic Response to Insertion of the Streamlined Liner of the Pharyngeal Airway
Authors: Kim WJ , Kang H , Yang SY , Shin HY , Baek CW , Jung YH , Woo YC , In JY
Published: December 2017

Objective

To determine the dose of remifentanil needed to achieve successful insertion of the Streamlined Liner of the Pharyngeal Airway (SLIPA™) without the development of hypertension in 95% of the patients.

Design

Randomised controlled trial.

Setting

operating theatre of a university hospital

Methods

A total of 100 ASA I or II patients requiring SLIPA insertion were randomly assigned to receive normal saline (Group C) or one of the four different doses (0.5 µg/kg [Group R0.5], 1.0 µg/kg [Group R1], 1.5 µg/kg [Group R1.5] or 2.0 µg/kg [Group R2]) of remifentanil. Arterial blood pressure and heart rate were recorded at preanesthetic baseline, preinserton, and every one minute during the initial 3 minutes period after insertion.

Results

A Probit model of remifentanil concentration was predictive of successful insertion of SLIPA without the development of hypertension. The ED95 of remifentanil needed to suppress haemodynamic response from SLIPA insertion was 1.39 µg/kg (95% confidence interval, 1.06‐2.61 µg/kg).

Conclusions

A single administration of remifentanil can effectively suppress haemodynamic changes due to the insertion of SLIPA.
Evaluation of the Revised Trauma Score in Predicting Outcomes of Trauma Patients
Authors: Li H , Shen WF , He XJ , Wu JS , Yi JH , Ma YF
Published: December 2017

Introduction

The revised trauma score (RTS) was developed more than 20 years ago. Few studies investigated its usefulness in predicting trauma outcomes. This is especially true for the weighted version of RTS (RTS‐w). The aim of this study was to test the predicting power of RTS‐w for the trauma outcomes including mortality, admission to intensive care unit (ICU), hospital length of stay and ICU length of stay through a comparison with Injury Severity Score (ISS).

Methods

Descriptive data, variables related to the trauma scores and outcomes were collected. The statistical performance of RTS‐w and ISS in predicting the trauma outcomes using receiver operating characteristics (ROC) curves and the area under the curve (AUC) with 95% confidence interval and p value were calculated. The Hosmer‐Lemeshow chi‐squared statistic was performed to measure its calibration.

Results

A total of 3323 patients were enrolled in the study. RTS‐w was significantly better than ISS in predicting mortality of trauma patients (AUC: 0.934 vs.0.880, p<0.0001). However, for the other three outcomes, i.e. admission to ICU, hospital length of stay and intensive care unit length of stay, the performance of RTS‐w was inferior to ISS.

Conclusions

The RTS‐w is a better predictor of mortality than ISS. But its ability to predict other trauma outcomes is not as good as ISS. More studies are needed to identify the predictive ability of RTS‐w for the outcomes other than mortality. Besides, updating the coefficients of the formula may make RTS‐w more accurate.
Effects of Different Treatment Options on the Prognosis of Wasp Stings
Authors: Xia JB , Xu SS , Yang L , Zhang XW , Zhong WQ , Peng AM
Published: December 2017

Introduction

Severe wasp sting injuries often threaten patient's life. We compared the effects of three different therapies on the prognosis of wasp stung patients.

Methods

We conducted a randomised single-blind controlled trial. Patients stung by wasp were randomly assigned to one of the three treatment groups: group A received symptomatic treatment; those complicated with acute renal failure and haemolysis also received haemoperfusion combined with haemodialysis; for patients with severe haemolytic anaemia, plasmapheresis were applied; for patients with haemodynamic instability, continuous renal replacement therapy was used. Group B received intravenous methylprednisolone injection, 80 mg/d for continuous 3 days in addition to the symptomatic therapy; for patients with haemolysis, methylprednisolone 0.5 g/d was injected intravenously for 3-5 days. For group C, in addition to all treatments administrated to group B patients, subcutaneous injection of 0.5 ml 0.1% epinephrine was given immediately after admission. Primary endpoint was mortality. Major complications (gastrointestinal haemorrhage, toxic encephalopathy, haemolysis, and acute left ventricular failure) and serum enzyme spectrum elevate (alanine aminotransferase [ALT], creatine kinase [CK] isoenzyme and serum creatinine) were secondary endpoints.

Results

Of 134 patients recruited, 45, 44 and 45 patients were assigned to group A, B or C respectively. Therapy in group C reduced mortality compared with group A and B (respectively 24.4%, 9.09%, 0.00% for group A, B, C respectively; p<0.001); there was no significant effects on major complications among three groups (p >0.1). The incidence of elevated ALT was significantly lower in group B and group C than in group A (p<0.001). The incidence of elevated CK isoenzyme was significantly lower in group C than in group A and group B (p<0.001).

Conclusions

For patients with concurrent organ impairment by wasp sting, early combination of epinephrine and methylprednisolone with supportive treatment with renal replacement therapy can effectively reduce the incidence of organ damage and mortality.
Prevalence and Predictors of Under-Diversion in the Primary Trauma Diversion System in Hong Kong
Authors: Wong CY , Lui CT , So FL , Tsui KL , Tang SYH
Published: December 2017

Introduction

Primary trauma diversion (PTD) enables direct transfer of major trauma patients to trauma centres for definitive care. This study aimed to evaluate the performance of PTD in the New Territories West Cluster (NTWC) of Hospital Authority and to identify the predictors for under-diversion.

Methods

A cross-sectional study based on local trauma registry. All major trauma patients (defined as ISS>15 or requiring trauma team activation) in the catchment area of the local hospital from September 2007 to December 2011 were included. The appropriateness of diversion decision was independently evaluated by an expert team (a trauma nurse coordinator and an emergency medicine practitioner). The sensitivity, specificity, predictive values, agreement, over-diversion and under-diversion rates were calculated. Potential predictors for under-diversion including age, Glasgow Coma Scale, mechanism of injury, injured body part, and the distance from scene to the trauma centre/local hospital were employed for logistic regression analysis.

Results

There were 141 eligible cases identified. The sensitivity and specificity for PTD were 59.5% and 96.5% respectively. The over-diversion rate was 3.5% and the under-diversion rate was 40.5%. The overall accuracy was around 74.5%. Non-motor vehicle accident (OR 13, 95% confidence interval [CI]=3.5-48.0, p<0.01) and isolated head injury (OR 5.35, 95% CI=1.5-19.5, p=0.01) were 2 independent predictors for under-diversion in PTD.

Conclusions

The overall field triage compliance by the paramedics is satisfactory. Under-diversion rate in NTWC is high. Non-motor vehicle accident mechanism and isolated head injury are 2 significant predictors for under-diversion. Reinforcement in training to avoid potential pitfalls would improve the paramedics' trauma triage performance.
Using an Electronic Bulletin Board Platform in a Disaster Tabletop Exercise
Authors: Wee JCP , Chong WCC , Lim GH
Published: December 2017

Introduction

We evaluate the use of an electronic bulletin board system in a tabletop disaster exercise.

Methods

Two tabletop exercises were carried out during a 5 hour course for 26 members of the Singapore Disaster Site Management Command (DSMC). As the events happened, the participants were updated via the electronic bulletin board. Response to the events was through the bulletin board. A written survey was held upon completion.

Result

Most (96.2%) felt that the exercise had helped identify issues in current operating procedures. The electronic bulletin board was deemed easy to use and learn, and that it helped in their learning (61.5%, 88.5% and 73.1% respectively). Using the electronic platform was an effective (76.9%) and efficient way (65.4%) of conducting the exercises. 53.8% of participants prefer the use of the electronic bulletin board and 61.5% felt that it was more realistic using the electronic platform. However the electronic bulletin board did not improve the participant's understanding of the current operating procedures (43.2%) and their role in DSMC (50%).

Conclusion

The use of the electronic platform is easy and over half of the involved participants thought it is preferred over the traditional tabletop exercise.
Mad Honey Poisoning Presenting with Ventricular Tachycardia and Acute Myocardial Infarction: A Case Report
Authors: Ocak T , Duran A , Basturk M , Sahin I
Published: December 2017

Apart from its role as an important nutrient, honey is used for alternative medicinal purposes. Cases presenting with severe hypotension, bradycardia, atrioventricular block and asystole have been reported following ingestion of honey in northern parts of Turkey, and certain parts of Japan, Brazil and Nepal. Herein, we report a case presenting with ventricular tachycardia and acute inferoposterolateral myocardial infarction after ingestion of mad honey (grayanotoxin). According to our knowledge, such case is being reported for the first time in the literature.
Bochdalek Hernia Presented as a ‘Pop’ Sound in an Adult
Authors: Chum HL , Wong WM
Published: December 2017

Bochdalek hernia is a congenital diaphragmatic hernia in which intra-abdominal organs protrude into the thoracic cavity through an opening in the diaphragm. It rarely occurs in adults. We report one such case in a 24-year-old lady who presented with a pop sound and acute onset of abdominal pain. Imaging investigation confirmed the diagnosis and laparoscopic repair was done. The importance of high clinical suspicion, consideration of Bochdalek hernia as a differential diagnosis of acute abdominal pain and the role of imaging for accurate diagnosis is emphasized.
Aortic Dissection Presented as Paraparesis: A Case Report with Literature Review
Authors: Hui CL , Lau PY
Published: December 2017

One case of acute type B aortic dissection presented with paraparesis and retrosternal chest pain was treated conservatively with warfarin and blood pressure control with good recovery of symptoms. A literature review including 25 cases of aortic dissection presented with paraparesis/paraplegia from year 1980 to 2010 is also presented.
An Assessment of Oxidant/Antioxidant Status and Oxidative Stress Index Levels in Patients with Carbon Monoxide Poisoning
Authors: Zengin S , Kartal S , Al B , Orkmez M , Taysi S , Yildirim C
Published: December 2017

Objective

The purposes of this study is to evaluate the variations of total antioxidant status (TAS) and total oxidant status (TOS) levels in the treatment process of carbon monoxide poisoning (COP) and to learn more about the pathophysiology of COP.

Methods

Between 2011 and 2012, 113 patients were admitted to our emergency department with acute COP, and 50 healthy volunteers were used as a control group in this study. Serum, plasma and erythrocyte components were prepared for all the COP patients on admission. They were repeated at the 90th and 180th minute of treatment. The samples were taken once from the control group. Serum oxidant/antioxidant status levels and carboxyhaemoglobin (COHb) were measured. Ratio of TOS to TAS, known as oxidative stress index (OSI) was calculated.

Results

No correlation was observed among age, gender, COHb level, with the levels of TAS, TOS, and OSI. Admission levels of TOS and OSI in patients with COP were higher than that observed at 90th minutes (p<0.001). These values were also higher in COP patients compared to control group (p<0.001). On the other hand, no statistical differences were observed in TAS levels between the study and control groups (p>0.05).

Conclusions

Our results show that serum TOS and OSI levels increase in COP patients. Oxidative stress should play a role in the pathophysiology of COP. (Hong Kong j.emerg.med. 2013;20:352‐358)
Efficacy and Safety of Tenectaplase versus Streptokinase in Treating ST‐Elevation Myocardial Infarction Patients in Hong Kong: A Four‐Year Retrospective Review in Queen Elizabeth Hospital
Authors: Chau HW , Choi KK
Published: December 2017

Objective

Data were lacking in comparing tenectaplase (TNK) and streptokinase (SK) in treating Chinese ST elevation myocardial infarction (STEMI) patients. We sought to compare these 2 types of thrombolytics in our locality.

Methods

We analysed 196 STEMI patients who received either TNK or SK in our hospital from 2007 to 2011. We compared the mortality and other outcomes of these 2 groups of patients.

Results

In‐hospital mortality has no significant difference between the TNK and the SK groups (8.9% vs 5.3%, p=0.322). Door‐to‐needle time was shorter in the TNK group (31±10 vs 25±7, p<0.001). Hypotension after drug administration was more common in the SK group than in the TNK group (21.1% vs. 3.0%, p<0.001).

Conclusion

TNK is at least as safe as SK in treating STEMI patients, with the advantage of shorter door‐to‐needle time and less frequent hypotensive effect. (Hong Kong j.emerg.med. 2013;20:359‐363)
Hong Kong Poison Information Centre: Annual Report 2012
Authors: Chan YC , Tse ML , Lau FL
Published: December 2017

Objective

To report and analyze the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2012.

Methods

In 2012, all poisoning cases received by HKPIC were retrieved from its database: Poison Information and Clinical Management System (PICMS) for analysis.

Results

A total of 4,814 poisoned cases were analyzed. There were 1,771 male patients (42.3%), 2,399 female patients (57.3%) and 14 sex unspecified patients (0.3%). Middle aged group (30‐39 years) contributed about one‐fifth (20.1%) of the poisoning cases while more than two‐third (67.7%) of them were between 20 and 59 years old. Common causes for poisoning were suspected self‐harm/suicidal attempt (45%), abusive substances use (13.9%) and unintentional exposure (13.0%). Five commonest types of poison exposed were paracetamol, benzodiazepine, zopiclone, bites and envenomation and household products. Majority of the patients were managed with supportive measures, and 15.7% and 11.9% of them were treated by decontamination and antidotes respectively. Most cases had uneventful recovery; 0.6% of the poison exposure resulted in death and 4.7% of the exposure had major outcomes.

Conclusions

This seventh annual report provides updated epidemiological information on poisoning pattern in Hong Kong and highlights important changes in comparing with our previous reports. (Hong Kong j.emerg.med. 2013;20:371‐381)
Hepatic Portal Venous Gas in a Patient with Penetrating Injuries
Authors: Chan CW , Yu CW , Lin CC , Lee CH
Published: December 2017

Hepatic portal venous gas (HPVG) refers to the branching area of low attenuation extending to within 2 cm of the liver capsule in computed tomography scan. The most common causes of HPVG are mesenteric ischaemia in adults and necrotising enterocolitis in infants. HPVG in trauma patients is mostly reported in cases of blunt abdominal trauma. We present a deceased patient who had chest and abdominal wall penetrating injuries with concomitant hypovolemic shock. A computed tomography scan revealed HPVG and pulmonary artery air emboli. The mechanism of the presentation of HPVG in this patient and the possible cause of death would be discussed. (Hong Kong j.emerg.med. 2013;20:382‐384)
Intra-Ocular Mass Diagnosed with Bedside Ultrasound
Authors: Loe S , Dinh VA
Published: December 2017

Patients with ocular masses are rarely diagnosed in the emergency department (ED). Appropriate diagnosis and ophthalmologic follow up is necessary to delay complications. However, in the ED, the fundoscopic examination can be limited. Ocular ultrasound has been shown to be a feasible and readily accessible way to diagnose ocular disorders in the ED. We report a case of a 39-year-old female who presented to the ED with headache, neurological complaints, and vision changes. A bedside ocular ultrasound was performed in the ED which showed a large intra-ocular mass. Our patient received urgent ophthalmologic consultation and was admitted for further work-up revealing an ocular melanoma. Ocular malignant melanomas have a high mortality rate, especially with delay in diagnosis and metastasis. This case demonstrates that bedside ultrasound is a fast and reliable investigation modality to diagnose ocular masses. (Hong Kong j.emerg.med. 2014;21: 48-50)
Pneumomediastinum and Subcutaneous Emphysema after High Pressure Air and Sand Injection Injury to the Upper Arm
Authors: Hirakawa A , Nakatani T , Isayama K , Kano H , Takeyama N
Published: December 2017

We present a rare case of a 47-year-old man who developed pneumomediastinum and subcutaneous emphysema after a high pressure hose accidentally injected air and sand particles into his right upper arm. On presentation, he complained of dyspnoea and chest pain. He had palpable subcutaneous emphysema extending from the upper arm to his neck, face, and trunk. Plain X-ray films and computed tomography showed pneumomediastinum and subcutaneous emphysema, but no sand particles. Conservative treatment was done with close observation, and serial radiographs were obtained. There was complete resolution of the mediastinal and subcutaneous air after about two weeks with no evidence of infection. This was an extremely rare case of pneumomediastinum and severe subcutaneous emphysema occurring after accidental air injection injury to the upper arm. With regard to how air entered the mediastinal cavity, possible pathways are discussed. (Hong Kong j.emerg.med. 2014;21:51-54)
Spontaneous Rupture of Splenic Varices: A Rare but Lethal Complication of Portal Hypertension from Cirrhosis
Authors: Yang CH , Huang YC , Kuo WT
Published: December 2017

Intra‐abdominal varices rupture is a rare but catastrophic complication in cirrhosis. We report our near‐miss experience in a woman presenting with acute abdominal pain and shock. This 55‐year‐old cirrhotic woman presented with sudden onset of epigastric pain. On arrival, her blood pressure was 57/49 mmHg and physical examination revealed epigastric tenderness without rebounding tenderness. Emergency ultrasonography (EUS) showed intra‐abdominal haemorrhage. Computed tomography revealed haemoperitoneum but no extravasation of contrast medium. She received conservative treatment first but laparotomy later for ongoing bleeding. Surgeon identified and ligated a ruptured splenic varix and she was discharged home after nine days of hospitalisation. This case report illustrates the use of bedside EUS in cirrhotic patients presenting with acute abdominal pain. (Hong Kong j.emerg.med. 2014;21:120‐123)
Heart Rate Variability Measurement in Sepsis Patients
Authors: Kim JY , Yoon YH , Park SM , Choi SH , Cho YD , Hong YS
Published: December 2017

Objectives

Inflammation makes an influence on autonomic nervous system and a change in autonomic nervous activity affects heart rate. Heart rate variability (HRV) test can quantify the autonomous nervous activity. In this study, we evaluated the meaning of heart rate variability in sepsis patients.

Methods

Heart rate variability test was performed for sepsis patients and healthy volunteers. Normalised low frequency power, reflecting sympathetic activity, was compared to acute physiology and chronic health evaluation II (APACHE II) score and mortality in emergency department sepsis (MEDS) score in sepsis patients. Then the patients were divided into four groups: 1) severe sepsis patients, 2) sepsis patients admitted to general ward, 3) sepsis patients discharged within 24 hours and 4) healthy volunteers. We obtained averages for the HRV results in all four groups. The receiver operating characteristics curve was examined to determine whether or not HRV variables could be used to triage sepsis patients.

Results

Correlations between normalised low frequency power (LFnu) with APACHE II score and MEDS score were −0.595 and −0.514, respectively. Low frequency power (LF) and LFnu values decreased in sepsis patients with the higher scores observed in the discharged sepsis patients and healthy volunteers. The areas under the curve for the values of LF and LFnu in the admission and discharge groups were 0.746 and 0.635, respectively (p<0.05).

Conclusion

Variables related to heart rate variability are significantly correlated with the severity of sepsis patients. Although the HRV test alone cannot accurately predict the disposition of sepsis patients, in the emergency room setting it helps to assign beds to sepsis patients within the triage system, and avoid over‐population. (Hong Kong j.emerg.med. 2014;21:73‐79)
Acute Allergic Reactions in Emergency Medical Dispatch Centre: Predictors of Hospitalisation
Authors: Godet‐Mardirossian H , Descatha A , Dolveck F , Baer M , Fletcher D , Goddet NS
Published: December 2017

Introduction

We sought to identify symptoms predictive of hospitalisation of patients having the acute allergic reactions managed by an Emergency Medical Dispatch Centre in France.

Methods

A prospective study was conducted from 20th August 2006 to 5th November 2006 on incoming calls to the Emergency Medical Dispatch Centre for the Hauts de Seine province, France. Statistical analyses were used to identify hospitalisation predictors. The validity of predictors identified was tested. We calculated equivalents of sensitivity (probability of presence of the sign when the reaction is severe), specificity (probability of absence of sign when the reaction is not severe), positive predictive value (probability of severe reaction when the sign is present) and negative predictive value (probability of non‐severe reaction when the sign is not present).

Results

A total of 210 calls were included. The following clinical hospitalisation predictors identified had very good specificity and good positive predictive value: facial oedema, sense of choking, respiratory distress, cough, difficulty speaking, dysphagia, abdominal pain, dizziness, collapse, and chest pain. However, none of the selected predictors had a safe negative predictive value (and sensitivity).

Conclusion

This study has identified positive clinical predictors of hospitalisation for acute allergic reactions patients managed by a Medical Emergency Dispatch Centre. The next step will be a multicentre study in order to develop a severity score or a decision‐making algorithm. (Hong Kong j.emerg.med. 2014;21:80‐87)
The Development of Emergency Medicine in South Korea: Academic Productivity in Highly Cited Journals
Authors: Lee J , Kang HG , Lim TH , Oh J , Cho Y , Cho JH
Published: December 2017

Introduction

The purpose of this study was to examine the number of publications by South Korean emergency physicians in highly cited journals and the increase in their numbers. It also sought to assess the impact factors of such publications.

Methods

The present study was a retrospective quantitative literature review of the publications by South Korean emergency physicians from 1996 to 2011 in the category of “emergency medicine” in the science edition of Journal Citation Reports 2011. We analysed the total number of articles published by South Korean emergency physicians and their impact factors.

Results

Between 1996 and 2011, the number of South Korean board-certified emergency physicians increased from 51 to 958, and 230 articles were published in 14 highly cited journals. The total impact factor (IF) of the original articles published during that period was 227.86, and the mean IF was 1.93. More than 10 articles had been published annually in the past 5 years in highly cited journals and there were over 400 South Korean board-certified emergency physicians.

Conclusions

Emergency medicine in South Korea started about 20 years ago, but academic productivity, indicated by at least ten articles annually in highly cited journals, was only achieved in the last five years. The mean IF of these articles was similar to that in other highly productive countries. (Hong Kong j.emerg.med. 2014;21:205-212)
The Reliability of Modified Termination of Resuscitation Rules after Arrival at the Emergency Department
Authors: Kuo Ci , Kuo Cw , Hsu Sc , Lin Cc , Weng Ym
Published: December 2017

Introduction

Pre-hospital termination of resuscitation (TOR) is not a usual practice in many cities. The current study aimed to examine the reliability of the modified basic life support (ED-BLS) and advanced life support (ED-ALS) rules for TOR after patient arrival at the emergency department (ED).

Methods

In this retrospective cohort study, adult non-traumatic cardiac arrest patients who received pre-hospital basic life support and defibrillator (BLS-D) mode of service in Taoyuan County in northern Taiwan during the study period were assessed. Data were retrieved from web-based registry records.

Results

Of the 1612 patients included, 40 (2.5%) achieved survival to discharge. The ED-ALS rule showed higher specificity (ED-ALS rule: 82.5% {95% confidence interval [CI]: 68.1-91.3} vs. ED-BLS rule: 50.0% {95%CI: 35.2-64.8}) and positive predictive value (ED-ALS rule: 99.0% {95% CI: 97.9-99.5} vs. ED-BLS rule: 98.6% {95%CI: 97.8-99.1}) than the ED-BLS rule in terms of predicting no survival to discharge after patient arrival at the ED. Among patients who fulfilled all criteria for the ED-BLS and ED-ALS rule, 20 (1.4%) and seven (1.0%) survived to discharge, respectively. Application of the ED-BLS and ED-ALS rules could have reduced further resuscitation efforts after arrival at the ED by 86.4% and 43.1%, respectively.

Conclusion

For non-traumatic out-of-hospital cardiac arrest patients who receive BLS-D service, the ED-ALS rule has a higher specificity and PPV than the ED-BLS rule to predict no survival to discharge after patient arrival at the ED. Using the ED-ALS rule to terminate resuscitation after arrival at the ED should be prospectively validated. (Hong Kong j.emerg.med. 2014;21:283-290)
Could C-Reactive Protein be a Potential Biomarker of Complicated Acute Appendicitis?
Authors: Lai Cy , Leung Yk , Graham Ca
Published: December 2017

Introduction

The purpose of this study is to evaluate the diagnostic value of C-reactive protein (CRP) to identify complicated appendicitis (defined as perforation, abscess or gangrenous appendicitis) versus simple appendicitis.

Methods

A retrospective study was performed in the emergency department (ED) of Prince of Wales Hospital in the New Territories of Hong Kong. The clinical records of patients admitted to the surgical wards via the ED over 17 months were reviewed by a research assistant. We included all patients aged >13 years who had a provisional diagnosis of “acute appendicitis” or “right lower quadrant pain”. We excluded patients with pregnancy, previous appendicectomy, incomplete medical records or no CRP levels determined before operation and those who discharged themselves from hospital against medical advice after admission. The outcome of this study was the CRP level in relation to the presence of complicated appendicitis. ROC curve analysis was employed to identify the optimum cut-off level of CRP which had the best sensitivity and specificity to identify complicated appendicitis compared to simple appendicitis.

Results

Forty-two patients were diagnosed to have acute appendicitis, 31 of whom had complicated appendicitis. CRP level was higher in the group of complicated appendicitis (p<0.05). We identified an optimum cut-off value for CRP of 40.1 mg/L to discriminate between complicated and non-complicated appendicitis. The sensitivity and specificity of CRP to identify complicated appendicitis were 71.0% and 100% respectively at this cut-off level.

Conclusion

High CRP levels could possibly predict the diagnosis of complicated appendicitis and facilitate more appropriate surgical care. This finding needs to be confirmed in prospective and larger multicentre studies. (Hong Kong j.emerg.med. 2014;21:354-360)
The Role of CT and MRI in Suspected Acute Cervical Spine Trauma
Authors: Friesen B , Brownlee R
Published: December 2017

Objective

To evaluate the accuracy of computed tomography (CT) in evaluation of patients with acute cervical spinal injury.

Design

Retrospective case series.

Setting

Three major public emergency departments in the southern hemisphere.

Methods

We performed a retrospective review of patients with neck injury aged at least 16, with CT cervical spine examinations performed for blunt trauma over a 6 month period (1 January 2011 to 30 June 2011) and magnetic resonance imaging (MRI) cervical spine performed for same indications over two and a half years (12 January 2010 to 22 June 2012).

Results

Acute cervical spine trauma was present on CT in 35 of 783 patients (4.5%) and on MRI in 98 of 206 patients (48%). Eleven of the 35 patients (31%) with CT confirmed trauma did not meet the Hanson criteria; the majority were at least 60 years of age and none had unstable injuries. CT is 100% sensitive in excluding an unstable injury if there is no soft tissue abnormality or fracture (with MRI as gold standard). An abnormal CT (including subtle paravertebral fat stranding) is often non-specific and often cannot reliably confirm an unstable ligamentous injury. Close attention to soft tissue axial and sagittal soft tissue CT reconstructions is important, as abnormalities can be subtle.

Conclusions

An unstable injury can often be excluded if CT is completely normal, without the need for MRI. (Hong Kong j.emerg.med. 2014;21:368-372)
A Case Report of Spontaneous Lesser Omental Haemorrhage
Authors: Zhu Jg , Zhang Zt , Zhao N , Zhang Hm , Han W
Published: December 2017

Spontaneous rupture of the lesser omental artery in the absence of identifiable causes is rare. We describe a case of abdominal apoplexy secondary to a spontaneous lesser omental artery rupture. A 73-year-old woman presented to our emergency department for acute abdominal pain with persistent nausea and vomiting. Abdominal examination revealed mild epigastric tenderness but no signs of peritonitis. Computed tomography of the abdomen suggested a massive volume of blood in the peritoneal and pelvic cavity. The diagnosis was made by exploratory laparotomy revealing haemoperitoneum, a haematoma in the lesser omentum near the antrum with an active bleeder. Choices of investigation modality for diagnosis and treatment are discussed. (Hong Kong j.emerg.med. 2015;22:53-56)
Clinical Efficacy of Metoclopramide to Treat Pain and Nausea in Renal Colic Patients: A Prospective Randomised, Double-Blind, Controlled Trial
Authors: Kaya F Baloglu , Cevik Aa , Acar N , Kaya S , Zeytin At , Can C , Metintas S
Published: December 2017

Introduction

This study aimed to evaluate the clinical efficacy of intravenous metoclopramide for the relief of pain and nausea among the emergency department patients with renal colic.

Methods

Patients were randomised into three groups: tenoxicam (20 mg); tenoxicam (10 mg) plus metoclopramide (10 mg); and metoclopramide (10 mg). Changes in pain and nausea were examined at the 10th, 20th and 30th minute after treatment. The development of side effects would be recorded. After the 30th minute, the need for additional pain and nausea relief was evaluated.

Results

Totally 80 patients were enrolled in each group. There was significant mean pain score difference as measured by visual analog scale (VAS) from 0 minute to 10th, 20th and 30th minute post-treatment for all treatment groups (p<0.001). There was no significant difference in mean VAS decrease from 0 minute to the 30th minute: tenoxicam group: 36 mm [95% confidence interval (CI) 28-43 mm] vs. tenoxicam plus metoclopramide: 45 mm (95% CI 38-52 mm) vs. metoclopramide group: 37 mm (95% CI 30-45 mm) (p=0.163). Similarly, no significant differences in mean nausea scores between the three groups were demonstrated at the 10th, 20th and 30th minute after treatment (p=0.236, 0.330 and 0.652 respectively). After the 30th minute, 43 (53%) patients needed additional pain relieving agent in the tenoxicam group compared to 27 (33%) patients in the tenoxicam-metoclopramide group and 33 (41%) patients in the metoclopramide group (p=0.030). No significant adverse drug reaction events were encountered.

Conclusion

Metoclopramide is as effective as tenoxicam to treat pain and nausea for patients with renal colic in the emergency department. (Hong Kong j.emerg.med.2015;22:93-99)
Acute Bismuth Intoxication: Acute Renal Failure, Tonsillar Ulceration and Posterior Reversible Encephalopathy Syndrome
Authors: Akinci E , Köylü R , Yortanli M , Gümüş H , Köylü Ö , Altintepe L , Cander B
Published: December 2017

Consumption and production of bismuth compounds are increasing, however, little information on the toxic effects and effective methods in removal of bismuth compounds are available. Although bismuth intoxication is currently rare, a careful evaluation should be carried out for possible exposure. We reported a16-year-old female who developed acute kidney failure, tonsillar ulceration and posterior reversible encephalopathy syndrome after an ingestion of 19 grams of bismuth subcitrate for suicidal attempt. (Hong Kong j.emerg.med. 2015;22:121-125)
A Prospective Validation of National Early Warning Score in Emergency Intensive Care Unit Patients at Beijing
Authors: Liu Fy , Qin J , Wang Rx , Fan Xl , Wang J , Sun Cy , Cao T , Liang X
Published: December 2017

Introduction

National Early Warning Score (NEWS) was launched in 2012 by the Royal College of Physicians in UK with an aim to improve the assessment of critical patients and timely detection of clinical deterioration.

Objective

To assess the performance of NEWS in emergency intensive care unit (EICU) patients in Beijing, PROC.

Design

prospective cohort study.

Setting

EICU in a university hospital.

Methods

The inclusion criteria were patients who stayed in the EICU beds under Department of Emergency Medicine, Xuanwu Hospital of Capital Medical University. Data of patients on admission were collected and calculated NEWS. Main outcome measure was death within 24 hours. The ability to predict mortality was assessed by area under the receiver operating characteristic curve (AUROC) analysis.

Results

Data on 540 consecutive EICU patients were collected from 1st January, 2013 to 31st March, 2013. Scores of 7 or more were associated with increased risk of death (OR=16.8; 95% CI 6.6-42.9). The AUROC for death within 24 h of admission was 0.85 (95% CI 0.79-0.90).

Conclusions

NEWS is applicable and feasible for EICU patients in Beijing. This study shows that the prediction power of NEWS for death within 24 hours of acutely ill patients attending Xuan Wu Hospital is comparable to that reported for the United Kingdom patients. (Hong Kong j.emerg.med. 2015;22:137-144)
Outcome after Implementation of Sepsis Guideline in the Emergency Department of a University Hospital in Hong Kong
Authors: Yang Mlc , Graham Ca , Rainer Th
Published: December 2017

Introduction

Internationally, standard care of patients with severe sepsis consists of early detection, early antimicrobial therapy, and aggressive intravenous fluid therapy to maintain tissue oxygenation and perfusion. In this retrospective study, we aimed to examine the management of patients with severe sepsis in a local university hospital emergency department before and after the implementation of a sepsis management guideline.

Method

We collected data on the management and outcome of patients during a three-month period before the implementation of a sepsis guideline (October-December 2009). We then collected similar data one year after the implementation (October-December 2010). Key sepsis management areas and in-hospital mortality rates were compared, as were length of resuscitation, three-month mortality rate, hospital length of stay (LOS) and intensive care unit (ICU) LOS.

Results

Data from 115 patients were collected in the pre-implementation group, while data on 102 patients were collected for the post-implementation group. There were more patients with hypoperfusion in the post-implementation cohort (25.2% vs. 40.2%, p=0.019). There was no difference in background characteristics, average lactate value, average MAP or number of hypotensive patients between the two groups. Significantly more antibiotics were given after the intervention (13.0% vs. 23.5%, p=0.045) and more patients had a lactate level measured (43.0% vs. 73.5%; p<0.001). There was a trend towards better survival for a subgroup of patients with hypoperfusion (48.0% vs. 29.2%, p=0.060).

Conclusions

Implementation of a sepsis guideline leads to more antibiotics being given and more lactate measurement in the emergency department. (Hong Kong j.emerg.med. 2015;22:163-171)
Clinical Outcomes of Trauma Patients after Implementation of a Standardised Diversion Protocol for Trauma Patients in Two Regional Hospitals in Hong Kong
Authors: Mok YT , Ma HM , Leung M , Yeung HC , Lit ACH , Luk HT
Published: December 2017

Introduction

Despite recent advance in prehospital trauma diversion, patients are triaged to the nearest medical facility before transferred to designated trauma centre. A new standardised diversion protocol for trauma patients was implemented on 1st April 2011 to facilitate trauma care. Severely‐injured patients were transferred to designated trauma centre directly from emergency department of the regional hospital after initial resuscitation.

Objective

This study was undertaken to examine clinical outcomes of trauma patients after implementation of the new standardised diversion protocol for trauma patients in the emergency department.

Method

This was a before‐and‐after interventional study on trauma patients presenting to the emergency department in critical or emergency conditions during the study period from 1st April 2011 to 31st March 2012. Patients presented in the two‐year period before implementation of the trauma protocol were used as historical control. Medical records of eligible cases were reviewed. Main outcome measures were 30‐day mortality, length of hospital stay and time to definitive care. Mortality data was compared with oversea standard by TRISS methodology.

Results

There were 153 eligible patients in the study group and 355 in the historical control group. After new arrangement of trauma diversion, W‐statistics improves from ‐1.26 to 0.09. Z‐statistics was ‐2.03 before and 0.09 after implementation. M‐statistics were 0.91 before and 0.88 after the new protocol. Mean time to definitive care was shortened by 33.4 minutes in the subgroup who were transferred to trauma centre after trauma team activation (p=0.005).

Conclusion

A trend of improved outcomes and shorter time to definitive care are observed after implementation of the new trauma diversion protocol. (Hong Kong j.emerg.med. 2015;22:201‐209)
Resident as Teacher: General needs Assessment in Emergency Medicine
Authors: Gan HN , Goh YGK , Tiah L
Published: December 2017

Introduction

Increasingly, residents are involved in the education of medical students, their peers and other health professionals. This study focused on the general needs assessment of the emergency medicine (EM) residents in developing a resident‐as‐teacher curriculum.

Methods

An anonymous and voluntary survey, which consisted of multiple choice and free text questions, was sent to all emergency physicians (EPs) working in the 7 restructured hospitals in Singapore.

Results

A total of 68 (60%) EPs completed the online survey. Overall, 19 (28%) EPs have undergone formal training in teaching. Majority of the EPs felt that it was important for the residents to acquire competent teaching skills at the end of their residency training. All of the EPs were in consensus that there should be formal instruction to the residents on how to teach. The four themes which emerged from the barriers to developing teaching skills in residents were time constraints, lack of faculty development, attitudes of both faculty and residents and a non‐conducive work environment with high service requirements.

Conclusions

To develop the resident as an all rounded Emergency Physician, structured training and formal instruction for the developing of teaching and feedback skills must be included in the residency training. However in order for the new curriculum to be successful and achieve its primary objective of developing the residents' competencies in teaching, barriers hindering both the faculty and residents have to be addressed. Finally, faculty development needs to be done to equip the faculty with the appropriate teaching and feedback tools. (Hong Kong j.emerg.med. 2015;22:226‐234)