bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical Predictors of Minor Head Injury Patients Presenting with Glasgow Coma Scale Score of 14 or 15 and Requiring Neurosurgical Intervention
Authors: Chan CH
Published: December 2017

Introduction

Minor head injury is the most common type of head injury assessed in accident and emergency departments. Emergency physicians have concerns in discharging patients with intracranial injuries which require neurosurgical interventions. The aim of this study is to find out the clinical signs and symptoms which can help to predict who need neurosurgical intervention following minor head injury.

Methods

This was a retrospective case‐control study. Patients with head injury and GCS score of 14 or 15 and requiring neurosurgical intervention were recruited. Another group of patients with head injury and GCS score of 14 or 15 but not requiring neurosurgical intervention were enrolled as control. In all cases, clinical signs and symptoms were collected by chart review of the clinical records retrieved by the computerized Clinical Data Analysis & Reporting System (CDARS). The relationship between clinical features and need of neurosurgical intervention was analyzed by chi‐square test with 95% confidence interval.

Results

A total of 22 cases were found and compared with 288 controls to study on the clinical variables for the prediction of the need of neurosurgical intervention. Six warning signs were found statistically significant by univariate analysis: severe headache (p=0.0206), vomiting more than once (p<0.0006), drop in GCS (p<0.0001), confusion/restlessness (p<0.0001), bleeding from ear (p<0.0001) and skull fracture in the X‐ray (p<0.0001).

Conclusion

Patients with minor head injury presenting with GCS score of 14 or 15 to the accident and emergency department rarely require neurosurgical intervention. Some clinical risk factors can be used as a guide to identify those who need neurosurgical intervention following minor head injury.
An Unusual Cause of Abdominal Pain Seen in the Emergency Room: Isolated Dissection of the Abdominal Aorta in a Patient with Disseminated Tuberculosis
Authors: Yιlmaz C , Akay S , Kuru A , Unal G , Dal O , Ozgenc O , Erkan N
Published: December 2017

Isolated abdominal aortic dissection is rare and usually associated with atherosclerosis, hypertension and cigarette smoking. Herein, we report a 35‐year‐old male patient with isolated abdominal aortic dissection that was associated with disseminated tuberculosis. To our knowledge, this association has not been reported previously.
Neuroleptic Malignant Syndrome after the Addition of Lithium to Risperidone Treatment: A Case Report and Review of the Literature
Authors: Unaldi M , Sayhan MB , Sogüt O , Demirhan R , Güzel B
Published: December 2017

Neuroleptic malignant syndrome (NMS) is a rare but life‐threatening complication of antipsychotic therapy. The classic features of NMS include muscular rigidity, altered mental status, autonomic instability and hyperthermia. NMS is most often associated with conventional antipsychotic usage. It has also been reported with lithium and antidepressants especially when combined with antipsychotics. Herein, we report a case involving a 35‐year‐old man with schizoaffective disorder in whom signs and symptoms consistent with NMS developed after lithium was added to his therapy of risperidone. A firm diagnosis of NMS was made on the basis of his history, physical, laboratory and neuroimaging findings. He was then followed up and treated in the intensive care unit with supportive care measures including aggressive cooling, intravenous fluid hydration, nutrition by nasogastric tube and therapy with bromocriptine. The patient had an uneventful clinical course and was discharged from the intensive care unit after three weeks with no complications related to the NMS.
Poisoning from Wild Mushroom in the Trakya Region: An Analysis of Seven Years
Authors: Kavalci C , Kavalci G , Guzel A , Inal M , Durukan P , Karasalihoglu S , Cevik Y , Sut N , Sayhan MB
Published: December 2017

Introduction

Mushroom poisoning is a medical emergency, diagnostic and treatment dilemma for physicians. Most cases present with self-limiting gastrointestinal symptoms. The regional profile of poisoning epidemiology in Turkey has previously been reported. However, information about mushrooms is still limited. The aim of this study was to identify the epidemiology of wild mushroom poisonings in the Trakya region in a 7-year period.

Materials and methods

The study was designed retrospectively by examining the files of the patients who presented to the emergency department of Trakya University Faculty of Medicine from January 2002 to July 2008.

Results

The overall male to female ratio was 0.88:1. All patients were intoxicated due to accidental pick up and consumption of wild mushrooms from open fields, woodlands and meadows. The most common findings on physical examination were epigastric pain. Fifty-six patients (74.7%) were discharged from the emergency department, 18 patients (24.0%) were hospitalized (one died on the 5th day), and one patient died in the emergency department.

Conclusions

Care should be taken especially for patients presenting late. Patients may have hepatic dysfunction that needs haemodialysis or even liver transplantation.
Extensive Bowel Ischaemia after Nifedipine Overdose
Authors: Lee HKH , Chan YC , Lau FL
Published: December 2017

A 57-year-old woman presented with abdominal distension and vomiting two days after overdosing an unknown amount of sustained-release nifedipine tablets. She had refractory shock requiring calcium chloride, glucagon, insulin-glucose and multiple high-dose inotropic agent infusions in the intensive care unit. Her abdominal computed tomography showed features of bowel ischaemia and exploratory laporotomy reviewed non-salvageable massive bowel ischaemia. She finally succumbed after 22 days of hospital treatment. This case illustrates the importance of awareness of this potentially fatal complication of calcium channel blocker overdose, requiring early recognition and intervention.
Traumatic Separation of the Pubic Symphysis Associated with Severe Rectal Tear: A Case Report
Authors: Teng LS , Jin KT , He KF , Zhang J
Published: December 2017

Traumatic separation of the pubic symphysis is a serious, infrequent and potentially life-threatening medical emergency. Rectal laceration is a rare associated finding. A case of traumatic separation of the pubic symphysis associated with a deep perineal tear is reported. The mechanism of injury, preoperative care and operative management of this type of injury are discussed.
A Case of Pulmonary Pneumatocoele with Splenic Laceration Caused by Vehicular Accident
Authors: Lee DH , Choi YH
Published: December 2017

Traumatic pneumatocoele is an uncommon complication, resulting from air trapping in an area of lung laceration, and may appear a few hours or even immediately after injury. Young adults and children are most commonly affected. Its clinical relevance lies in its rarity, which might mislead emergency physicians to perform unnecessary surgical intervention. We report a 10-year-old boy suffering from traumatic pneumatocoele with spleen laceration caused by blunt trauma. It is important for emergency physicians to be aware of this condition and of its benign course so as to avoid unnecessary operative procedures due to incorrect diagnosis.
Incomplete Cauda Equina Syndrome Presenting with Acute Urinary Retention in the Emergency Department
Authors: Cιftcι H , Ozgonul A , Sogut O , Savas M
Published: December 2017

Cauda equina syndrome (CES) is a rare but serious neurosurgical emergency that can have devastating long-lasting neurologic consequences. CES caused by herniated lumbar discs is rare in the literature. We report an unusual case of incomplete CES due to lumbar disc herniation. The patient presented to our emergency department with acute onset of low back pain, saddle (perineal) anaesthesia, urinary retention and constipation without motor deficit or sciatica. Magnetic resonance imaging (MRI) revealed a large herniated disc originated from the L5-S1 disc space with compression of the cauda equina. This case illustrates that patients with CES accompanying a disc herniation may not have all the characteristic features of CES such as pain radiating to the legs or muscle weakness. We recommend that urgent MRI assessment should be performed in all patients who present with sudden onset of urinary symptoms in the context of lumbar back pain or loss of perineal sensation.
Silver Nitrate Stain Masquerading as an Avulsion Fracture of the Finger
Authors: Tong SHY , Chan WL , Lee YL
Published: December 2017

We report a case of silver nitrate stain on the finger that masqueraded as an avulsion fracture on radiograph. Radiopacity in the proximal phalanx was demonstrated on radiograph after topical silver nitrate was applied to achieve haemostasis to a bleeding laceration on that area. The radiopacity was initially diagnosed as an avulsion fracture. The correct diagnosis of radiopacity corresponding to silver nitrate application was confirmed by correlation of physical examination with radiographic finding. The lesion spontaneously resolved with conservative management. The importance of correlating the clinical site of silver nitrate application with radiographic finding for accurate diagnosis and avoidance of unnecessary surgical intervention is emphasized.
Hydrothorax Due to Extravasation of Intravenous Contrast after Power Injection through Right Subclavian Catheter
Authors: Kang IG , Jeong WJ , Park CS , Ryu HS , Lee MJ , Park SS , Kim HJ
Published: December 2017

We report a case of hydrothorax after receiving intravenous (IV) contrast material by power injector through right subclavian central venous catheter (CVC) line. A 38-year-old woman presented to the local emergency department with hypotension after a pedestrian accident. After resuscitation, CVC was inserted into her right subclavian vein and fluid was administered well before computed tomography (CT) enhancement. Contrast-enhanced CT scan showed a large amount of extravasation of contrast material and fluid collection in the thoracic and pericardial cavities which was not shown in non-enhanced CT scan. During operation, vascular perforation was found in right subclavian vein. This case highlights that emergency physicians must keep in mind the possibility of vessel injury after CVC insertion and contrast material is preferably injected via peripheral IV access.
Accuracy of Plain Abdominal Radiography in the Differentiation between Small Bowel Obstruction and Small Bowel Ileus in Acute Abdomen Presenting to Emergency Department
Authors: Kim SH , Park KN , Kim J , Eun CK , Park YM , Oh MK , Choi KH , Kim HJ , Kim DW , Choo HJ , Cho JH , Oh JH , Park HY
Published: December 2017

Introduction

Our purpose was to evaluate whether plain abdominal radiography (PAR) could accurately differentiate between small bowel obstruction (SBO) and small bowel ileus (SBI) in an emergency setting. We also evaluated the value of known classic signs on the PAR for differentiating between SBO and SBI.

Methods

This retrospective study included 216 emergency room patients who had small bowel distension (maximal small bowel diameter ≥2.5 cm) on the PAR and who underwent successive abdominal computed tomography. One radiologist and one emergency physician retrospectively reviewed PAR in consensus, unaware of the patients' clinical data; they divided the patients into an SBO group and an SBI group according to the radiographic findings. Presence or numeric values of 10 radiographic signs were also recorded. Final diagnoses of SBO and SBI were established by a combined analysis of medical charts, surgical records, radiographic findings on abdominal computed tomography, and small bowel studies. The differential diagnoses based on PAR and the final diagnoses were compared, and the sensitivity and specificity of PAR were calculated. We also evaluated the differences among 10 radiographic signs between the final SBO and SBI groups.

Results

Sensitivity and specificity of PAR for SBO were 82.0% and 92.4%, respectively. Among the 10 radiographic signs, all except maximal colon diameter were statistically significant predictors on the final diagnosis.

Conclusions

PAR is an accurate and effective initial imaging modality for differentiating between SBO and SBI in an emergency setting, and most of the classic radiographic signs have a diagnostic value.
Outcome Evaluation on the Use of Nurse‐Led Transport Kit in Inter‐Facility Transport
Authors: Yeung KL , Chan MWS , Tam PF , Lee LLY , Tong WL , Kalinowski E , Tang SYH , Chan JTS
Published: December 2017

Introduction

Transport kit is a key element to ensure safe inter‐facility transport (IFT). The kit was generally reported by transport staff to be heavy and inconvenient in accessing the required items.

Objective

This study aimed at evaluating the outcome and the feedback from emergency nurses on the use of a new and lighter nurse‐led transport kit (NLTK) in IFT.

Methods

A cross sectional study was carried out in two Accident and Emergency Departments in Hong Kong from 1st January 2008 to 31st March 2008. All cases involving nurse‐led IFT were included into the study. Questionnaires for assessing the rating of satisfaction were distributed to the staff after every mission.

Results

Eighty‐four questionnaires were returned with a response rate of 80.8%. The overall rating on satisfaction before and after the use of NLTK was 14.6±3.0 and 19±3.2 respectively (mean±SD) with statistically significant improvement in terms of its weight, convenience and spaciousness of kit (p<0.05). Conclusion: The new NLTK is more user‐friendly than the traditional kit in nurse‐led IFT.
The Motor Function and Activities of Daily Living Capacity of Seismic Wounded Patients in Intensive Care Unit Ward in 5.12 Wenchuan Earthquake of China
Authors: Zhang JL , He HC , Lin HD , Luo QL , He CQ
Published: December 2017

Objective

To describe the motor function and activities of daily living (ADL) functional status of the seismic wounded patients treated in the intensive care unit (ICU) ward, and to provide insight to the planning on their clinical rehabilitation program.

Method

A prospective study. Trained assessor applied different common testing methods to measure the motor functions of seismic wounded patients treated in ICU: (1) Manual Muscle Testing (MMT) method to evaluate muscle strength; (2) joint angle ruler to assess joint range of motion (ROM); (3) passive joint activities to assess the muscle tension; (4) Modified Ashworth Score (MAS) to assess spasm; (5) balanced response to assess sitting balance and standing balance; (6) international generic Barthel Index Scale to evaluate ADL. Complications as related to rehabilitation were also recorded. Descriptive statistics were employed to describe the epidemiology, pattern of motor function loss and type of injuries.

Results

The most common types of injuries in our sample of seismic wounded treated in ICU were: fracture (70%), nervous system injuries (20%), squeezing syndrome (5%) and pulmonary contusion (5%). The fracture proportion was higher in female than male (about 2:1). Amputation and paralysis occurred more in male than female (about 7:1 and 3:1 respectively). Lung infection as a complication in ICU stay was more common in female than male (4:1). We reported that most of the seismic wounded patient had early loss of motor function during the stay in ICU. Conclusion: Limited ROM, declined muscle strength, abnormal muscle tension, balance dysfunction, alteration of ADL capacity and lung infection are the main dysfunctions occurring among the seismic wounded in ICU ward. Loss of motor function can occur early and therefore active physiotherapy should start even during the stay in ICU.
A Regional Study on Primary Trauma Diversion in Hong Kong
Authors: Suen KW , Chang AML , Au CKH
Published: December 2017

Background

Primary trauma diversion (PTD) allows ambulance crews to transport severely injured patients directly to trauma centres. It has been launched in Kowloon Central Cluster (KCC) of Hospital Authority, Hong Kong since 2006.

Objective

The study investigated the performance of PTD with a view to provide relevant information for further development. The compliance with PTD, under‐triage and over‐triage were the major outcomes measurement. Patients' characteristics and their clinical information were also described.

Method

This was a retrospective descriptive study. We reviewed and analyzed the data in our hospital trauma registry during the study period between 1st July 2006 and 30th June 2009.

Result

One hundred and sixty‐three trauma patients were diverted to our trauma centre during the study period. The mean Injury Severity Score was 11.72 with 90 of them being classified as severely injured. We found that 47 and 73 patients were under and over triage respectively. About 74% eligible trauma patients were diverted to the trauma centre according to PTD criteria.

Conclusion

Although the initial experience of PTD in KCC is satisfactory, more severely injured patients will benefit from our trauma centre service by improving the under‐triage rate. We also foresee a better compliance with trauma diversion in the future.
Acute Anterior Myocardial Infarction after Being Struck on the Chest by a Soccer Ball
Authors: Altekin RE , Er A , Oktay C , Baktir AO , Yanikoglu A , Yalcinkaya AS , Kavasoglu ME
Published: December 2017

Blunt chest wall trauma is one of the non‐atherosclerotic causes of myocardial infarction. Motor vehicle accident is the most common cause of myocardial infarction followed by sports injuries. Myocardial infarction can occur due to traumatic coronary artery laceration with thrombus formation or dissection. Lethal complications may result if accompanying myocardial infarction is overlooked in patients whose chest pain is considered to be solely related to the localised blunt chest wall trauma by the physician and the patient. Here we present a case of acute anterior myocardial infarction secondary to a blunt chest trauma after being struck on the chest by a soccer ball during a recreational soccer game and review the current literature on the diagnosis and treatment of traumatic myocardial infarction.
Pain Perception in Emergency Department Patients with and without Headache
Authors: Yuruktumen A , Karaduman S , Yesilaras M , Guryay M , Fowler JR
Published: December 2017

Objectives

Adequate pain management of emergency department (ED) patients is an important clinical goal. Pain perception in ED patients with headache has been reported to differ from that of other patients with pain. If this were true in our setting, we might interpret pain scores and response to analgesics differently. We compared pain perception in ED patients without pain, patients with headache, and patients with non-headache pain who had blood pressure (BP) measurement and intravenous (IV) cannulation for any reason.

Methods

The study design was approved by our hospital's Ethics Committee. The patients were asked to describe their pain while undergoing BP measurement and IV cannulation with a 0 through 10 (11-point) numerical rating scale. Pain scores were analysed according to the patient's group: no pain, headache pain, or non-headache pain.

Results

For the 278 participating patients (95 patients without pain, 77 patients with headache, and 106 patients with non-headache pain), the pain scores as reported during BP measurement and IV cannulation was not significantly different between the patient groups. On sub-group analysis, females reported higher pain scores during IV cannulation than males (2.8±2.6 vs. 2.3±1.9, p=0.06). In addition, married patients had higher pain scores than unmarried patients during both BP measurement (1.31 vs. 1.03, p=0.004) and cannulation (2.73 vs. 2.16, p=0.089).

Conclusion

The differences in pain experienced in patients with or without headache or other causes of pain during IV cannulation and BP measurement were minor. Based on our findings, gender and marital status should be recorded during studies recording pain levels in ED patients.
An Uncommon Arteriovenous Fistula Resulting from Haemodialysis Catheterization despite Applying Ultrasound Guidance: Malposition of Catheter into Right Subclavian Artery
Authors: Choi HJ , Kang BS
Published: December 2017

Ultrasound-guided central venous catheterization could reduce the complication rate and increase first time success rate. However, without substantial experience and caution, it could lead to serious complications. We presented a rare case of malposition of the temporary haemodialysis catheter into the right subclavian artery with arteriovenous fistula after real-time 2D ultrasound-guided catheterization into right internal jugular vein. After the occurrence of this complication, we learned that emergency physicians should confirm the position of end portion of the catheter within the target vessel's lumen even when the catheterization was done with real-time 2D ultrasound guidance.
Clinical Experience in the Use of Intravenous Lipid Emulsion in Hydroychloroquine and Chloroquine Overdose with Refractory Shock
Authors: Wong OF , Chan YC , Lam SK , Fung HT , Ho JKY
Published: December 2017

Hydroxychloroquine overdose is a rare condition and often results in severe cardiovascular toxicities. We report 2 cases of fatal hydroxychloroquine overdose (1 patient had co‐ingestion of chloroquine). Both patients developed refractory cardiovascular collapse and cardiac arrest soon after the drug overdose. Both of them were treated with high dose adrenaline and diazepam. However, they deteriorated rapidly despite the treatments. In view of similar toxicological profile of hydroxychloroquine to other lipophilic cardiotoxic medications, intravenous lipid emulsion was given as the last resort but both of them died eventually. Based on the clinical experience from these 2 cases, Intravenous lipid emulsion is not effective in reversing the cardiotoxic effects of hydroxychloroquine and chloroquine overdose.
Bronchiolitis Obliterans Organising Pneumonia in a Case of Colchicine Overdose
Authors: Wong OF , Koo CK , Tang KS , Chow KC , Lau CL
Published: December 2017

Colchicine is a commonly prescribed medication. Overdose of colchicine is relatively uncommon but can be fatal. We report a 36‐year‐old female who survived from severe colchicine poisoning and was subsequently complicated with bronchiolitis obliterans with organizing pneumonia. The patient required a long period of mechanical ventilation but eventually recovered on supportive care.
The Prognostic Values of the Admission Electrocardiography, Myocardial Injury Markers and Physical Examination in Patients with Acute Myocardial Infarction
Authors: Ertan C , Cete Y , Kilicaslan I , Goksu E , Kanalici H
Published: December 2017

Introduction

Acute coronary syndromes (ACS) are leading life threatening causes of chest pain, which is one of the most common complaints in the emergency department (ED). The aim of the study was to demonstrate the usefulness of physical examination, ECG and cardiac markers to predict short term outcome of ACS patients.

Methods

A total of 1728 patients with chest pain were evaluated between 1st January 2003 and 31st December 2003 in the ED and 236 of the patients matched our study criteria.

Results

In the study group 184 patients were (78%) male and the mean age was 59.8±12.2 (range=4-92) years old. Age, Killip score, cardiac marker values, the time interval between the beginning of the chest pain and ED entry and the ECG changes were the studied variables. With the logistic regression analysis, Killip score and any rhythm other than normal sinus rhythm on the first ECG were found to be the only independent variables to predict early mortality (p=0.036 and p=0.033).

Conclusion

Simple measures in the ED such as ECG and serum markers of myocardial injury along with the thorough physical evaluation of the physician may predict early negative outcome.
Prospective Observational Study on Heart Rate Variability in Emergency Department Patients with Sepsis
Authors: Wong WCL , Lit ACH
Published: December 2017

Objective

To study the predictive value of heart rate variability in septic patients presented to the emergency department.

Design

Cross sectional study.

Setting

Emergency department.

Methods

Septic patients in the emergency department were recruited according to criteria. Heart rate variability data on time domain and frequency domain were generated from Holter records. Sequential Organ Failure Assessment, clinical progress and laboratory values were used to access the outcomes.

Results

Spectral power of total power (TP), low frequency (LF), very low frequency (VLF) and normalised low frequency (nLF) are shown to be significantly reduced in patients with sepsis who deteriorated (p=0.0070, 0.0032, 0.0005 and 0.0109 respectively). Cut off value 172.5 of VLF can identify all septic patients with potential deterioration.

Conclusions

Application of heart rate variability recording in emergency department is feasible and helpful in early identification of potentially deteriorating septic patients.
Severe Blunt Perineal Trauma in Children: A Retrospective Analysis of 28 Patients
Authors: Sogut O , Boleken ME , Cevik M , Yavuz G
Published: December 2017

Purpose

The current study was designed to determine the common mechanisms of blunt perineal trauma (BPI) and associated injuries in paediatric patient. The initial management and outcome concerning such injuries are discussed.

Materials and methods

The hospital records of 28 paediatric patients who were treated surgically between April 2004 and November 2010 because of BPI were reviewed retrospectively. The initial clinical examination under conscious sedation (EUCS) in each patient was performed by both an experienced emergency physician and a paediatric surgeon to obtain a complete physical examination.

Results

Among the 28 paediatric patients, twenty-two girls and six boys, aged 2 to 12 years experienced BPI. Fall onto a rough surface was the main cause for BPI in 21 patients (75%) and the rest had a motor vehicle-pedestrian crash. Five patients had concomitant anal or rectal injuries. There were concomitant urinary tract injuries in eight patients of whom three had combined lacerations or contusions of the perineum and disruption of the posterior urethra. There was concomitant complete rupture of proximal urethra from bladder in one patient. The remaining 4 patients with urinary tract injuries suffered from periurethral lacerations. The fifteen patients without anorectal or urethral injuries had concomitant vaginal or vulvar lacerations.

Conclusion

All paediatric patients who sustained severe BPI should be checked for multi-system trauma and those undergone routine EUCS to evaluate the extent of concomitant injuries should pay particular attention to the anorectal and urogenital tracts. Primary repair of such injuries is often recommended as the initial treatment of choice.
Acute Brown-Séquard Syndrome following Brachial Plexus Avulsion Injury. A Report of Two Cases
Authors: Zubair M , Ravindran T , Chan CYW , Saw LB , Kwan MK
Published: December 2017

Introduction

Brown-Séquard syndrome is an unusual sequelae of pre-ganglionic brachial plexus injury. There have been sporadic case reports indicating that the cause of this condition is due to tethering of the cord, vascular ischaemia or direct avulsion injury of the nerve roots. This is a report of two patients with complete pre-ganglionic brachial plexus avulsion injuries who developed acute partial Brown-Séquard syndrome due to haematoma.

Cases

Two patients developed acute partial Brown-Séquard syndrome associated with complete pre-ganglionic brachial plexus avulsion injuries. In the first case the neurology recovered fully after the evacuation of the large subdural hematoma. Whereas, in the second case the neurology only recovered after 4 weeks closed observation in view of the compression was due to small epidural haematoma.

Conclusion

Acute Brown-Séquard syndrome occurring in association brachial plexus injury should be investigated with urgent magnetic resonance imaging to exclude any reversible haematoma compression.
Care and Charges for Acute Cerebral Infarction Inpatients in China: A Hospital Based Study in Soochow
Authors: Wen ZM , Zhao HQ , Liu CF
Published: December 2017

Objective

The objective of the present study is to evaluate the current status of care and charges of acute ischaemic stroke in a university teaching hospital in China, and to identify the main determinants of such charges.

Methods

Acute ischaemic stroke patients from July 2009 to June 2010 were considered. We examined demographic data, clinical data, hospital care and outcomes at discharge and hospital charges retrospectively. The influence of medical factors on total charges was analyzed.

Results

The mean initial National Institutes of Health Stroke Scale score of all acute ischaemic stroke patients was 7.2 points. Thirteen percents were total anterior circulation syndrome, 20% were partial anterior circulation syndrome, 7% were posterior circulation syndrome and 60% were lacunar syndrome. The mean hospital length of stay (LOS) was 8.5 days. All patients underwent neuroimaging studies, 2% of whom received thrombolysis, 93% received traditional Chinese medicine injection, 83% received antiplatelet and 6% received anticoagulation therapy, only 29% received in-hospital rehabilitation. The mean hospital charges per patient was ¥9230.2 (US$1357.3), of which 56.2% was attributed to the charges for medications, 13.4% for imaging studies, 12.1% for laboratory examinations. Total hospital charges were correlated strongly with LOS, admission to care unit, and computed tomography angiography or digital subtraction angiography of the brain.

Conclusions

Total hospital charges correlates significantly with hospital LOS, admission to care unit, investigation with computed tomography angiography or digital subtraction angiography of the brain, while clinical syndromes do not influence total charges independently. The cost of drug is the largest portion of the mean hospital charge. A treatment protocol in acute ischaemic stroke might optimise cost. (Hong Kong j.emerg.med. 2011;18:383-390)
New Horizon on Community-Acquired Methicillin Resistant Staphylococcus Aureus (Ca-Mrsa) Skin and Soft Tissue Infection: Nanotechnology Antimicrobial Spray
Authors: Wan KA , Ng MY , Wong YT
Published: December 2017

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in community and hospital is increasing. The development of drug resistance may be attributed to the extensive use of antibiotics. Nanotechnology antimicrobial spray (NTAS), a physical antibacterial agent, is an alternative to antibiotic treatment on wound management. We report a case of MRSA associated skin abscess using NTAS in the wound management. NTAS possesses potent, broad spectrum antibacterial effect while carrying no risk of resistance and minimal adverse effect. Moreover, NTAS facilitates home wound management, thus reducing dependency on public health resources. Further studies are indicated to explore the clinical role of NTAS in an attempt to reduce the use of antibiotics. (Hong Kong j.emerg.med. 2011;18:432-436)
Chemical Necrotising Fasciitis Secondary to Self-Injection of Permethrin Insecticide
Authors: Wong OF , Tsang PHK , Ng HL , Lee HM , Koo CK , Lam SK
Published: December 2017

We report a 65-year-old male with chemical necrotising fasciitis after self-injection of permethrin insecticide. The patient also developed persistent hypoglycemia secondary to massive insulin overdose. There was no evidence of systemic toxicities from the insecticide poisoning. Multiple debridement and skin grafting were performed over his right forearm due to extensive tissue damage. He eventually recovered with impairment of his right hand function. The clinical features and the management of this uncommon route of insecticide poisoning are discussed. (Hong Kong j.emerg.med. 2011;18:441-445)
Use of Typical Antipsychotics Predicts Recurrent Hypothermia for Institutionalised Psychiatric Patients
Authors: Li KY , Lui CT , Tsui KL
Published: December 2017

Objective

To find out the predicting factors of early recurrent hypothermia in patients from a mental institute and the role of use of antipsychotics.

Design

Retrospective cohort study.

Setting

Accident and emergency department of a regional public hospital in Hong Kong.

Method

All adult patients transferred from a mental hospital to the study centre presenting with hypothermia from 1st January 2002 to 31st December 2009 were included. Demographic data, medical history, drug history, patient's mobility status, and the ambient temperature of the presenting date were collected as predicting variable and analyzed using Wei, Lin and Weissfeld model, with time to the next hypothermia as outcome variable.

Results

Forty eight patients with 96 hypothermia episodes were included. The use of typical antipsychotics was associated with a significantly shorter median time to the next hypothermia episode (50.2 to 21 months) (p=0.005 by log rank test). In the Wei, Lin and Weissfeld model, use of typical antipsychotics was the sole significant predicting factor for early recurrent hypothermia (p<0.0001), with hazard ratio of 2.89 (95% CI 1.64‐5.10).

Conclusion

Use of typical antipsychotics is the only significant predictor of early recurrence of hypothermia in institutionalised psychiatric patients.
Simulation Training in Emergency Medicine (STEM): An Integral Component of Residency Curriculum
Authors: Pothiawala S , Lateef F
Published: December 2017

In the field of emergency medicine (EM), health professionals should be able to function effectively in the dynamic, uncertain, time‐pressured, and high‐stakes environment of the emergency department. Simulation training in emergency medicine (STEM) can be a tool to create an environmental milieu which allows developing health professionals' knowledge, skills and attitudes. It amplifies realistic experience in a safe and controlled environment and in an interactive fashion, providing feedback and hence, effective and experiential learning. It also provides a basis for teaching and assessment by simulating encounters on complex issues, multidisciplinary issues, team dynamics, communication skills and professionalism and dealing with challenging patients and family members. This article highlights the current evidence on the usefulness of simulation in training residents in EM and its need to be integrated into the basic framework of the Accreditation Council for Graduate Medical Education ‐ International (ACGME‐I) accredited emergency medicine residency curriculum and assessment in Singapore. This will eventually lead to transfer of skills into real world settings and have an impact on patient safety, and hence improve patient outcomes.
Faucial Pillar Perforation by Glidescope Intubation with Incorrectly Placed Stylet
Authors: Kim YH , Jeon SY , Park JH , Choe JH , Lee SH , Park SJ , Kim KH , Kim JS
Published: December 2017

Glidescope GVL® is frequently used in intubation of difficult airway. We report a case of right side of faucial pillar perforation during intubation with Glidescope®. A rigid stylet can facilitate placing of endotracheal tube quickly but it may also penetrate the soft tissue to cause injuries.
A Case of Electrocardiographic Change Caused by Subarachnoid Haemorrhage Mimicking Acute Myocardial Infarction
Authors: Cheon YJ , Pyun WB , Lee DH , Choi YH
Published: December 2017

A 60‐year‐old woman was admitted to the emergency department due to syncope. The electrocardiogram (ECG) revealed normal sinus rhythm with ST segment elevation in leads I, II, and aVL. There was no stenosis or vasospasm in the coronary arteries. Transient electrocardiographic ST segment elevation which is indistinguishable from that associated with acute myocardial infarction has been reported in patients with subarachnoid hemorrhage (SAH). Until now no case was ever reported with the ECG finding with pattern of posterolateral myocardial infarction in SAH patients. So we describe a patient with SAH mimicking acute myocardial infarction.
Comparison of the Analgesic Effect of an Ice Cube versus 4% Lidocaine Cream in Intradermal Antibiotic Skin Testing
Authors: Shin HJ , Park JM , Kim KH , Shin DW , Park JS , Roh JY , Kim H
Published: December 2017

Objective

This study was performed to compare the analgesic effect of an ice cube with that of 4% lidocaine cream (L.M.X.4®) for intradermal skin testing.

Methods

In this prospective randomised study, healthy adult volunteers were divided into ice cube and lidocaine analgesic pretreatment groups. Randomisation was performed using a randomisation table in blocks of four. Intradermal skin testing was performed after applying ice in the ice cube group and 5 mg of lidocaine cream in the lidocaine group. After the intradermal skin test, the pain intensity was investigated using the visual analog scale (VAS) on questionnaires. We calculated that a minimum of 24 subjects were required for statistical power of 80% at a significance level of 0.05 (two-sided). The groups' VAS scores were compared using the Mann-Whitney U-test.

Results

The study population consisted of 35 volunteers: 17 in the ice cube group and 18 in the lidocaine group. There were no differences in demographic characteristics between the two groups. The median VAS score was 20 (interquartile range: 0-35) in the ice cube group and 70 (interquartile range: 50-80) in the lidocaine group (p<0.001).

Conclusions

The results suggested the utility of an ice cube as analgesic pretreatment for intradermal skin testing in the emergency department.
Is Poisoning by Oral Therapeutic Drugs more Severe? a Retrospective Study on Unintentional Paediatric Poisoning in a Local Emergency Hospital
Authors: Li KY , Lam SK , Lui CT , Fung HT
Published: December 2017

Introduction

Paediatric unintentional poisoning is a common presenting problem in the emergency department. Our study aim to determine whether poisoning caused by oral therapeutic drugs was more severe and causing longer hospital stay. We also aim to review the recent local epidemiology of unintentional paediatric poisoning in Hong Kong.

Methods

We conducted a retrospective review on all consecutive cases of patients aged 0-9 who presented to the emergency department during a study period from 1st January 2006 to 31st December 2007 with unintentional poisoning. Demographic data, clinical presentation, poisoning agent involved, intervention performed and the clinical outcome were analysed. The clinical outcomes of poisoning due to oral therapeutic drugs versus other chemicals were compared.

Results

Sixty one poisoning episodes were included. The most common type of agents involved was oral therapeutic drugs (52.5%); followed by cleaning products and detergents (14.8%). Most cases were benign, 63.9% of the cases showed no clinical and biochemical poisoning effect without any treatment. Poisoning due to oral therapeutic drugs were more severe, 12.5% were classified as poisoning with major effect that required active treatment while no cases of severe poisoning were found in poisoning caused by other chemicals. Significantly fewer cases (40.6%) were classified as no or mild effect in the group caused by oral drugs, compared with those caused by other chemicals (86.2%) (p=0.001). The mean length of stay was also significantly longer in the group with oral drugs (1.7 days) compared with 0.9 days in other chemicals (p=0.047).

Conclusions

In our locality, severe unintentional poisonings were usually due to oral therapeutic drugs. For prevention planning, we should focus on the safety placement of oral medications of family members.
Predictors of Mortality in Septic Shock: Findings for 57 Patients Diagnosed on Admission to Emergency or within 24 hours of Admission to Intensive Care
Authors: Yücel N , Togal T , Gedik E , Ertan C , Kayabas U , Akgün FS , Bayindir Y
Published: December 2017

Objective

To identify the risk factors that influence outcome for patients who are diagnosed with septic shock in the emergency department at presentation or within 24 hours after admission to intensive care unit.

Methods

A retrospective study of 57 adult patients with septic shock was conducted between March 1, 2006 and August 31, 2009.

Results

The patients were 23 males and 34 females with a median age of 67 years (20 to 92 years). Thirty-three (58%) of 57 patients died in hospital and 24 (42%) survived. Multivariate analysis identified low blood pH (OR <0.001; 95% CI <0.001-0.53) and low bicarbonate level (OR 0.81; 95% CI 0.70-0.95) at emergency department or intensive care unit admission as useful predictors of 3-day in-hospital mortality. Low blood pH (OR <0.001; 95% CI <0.001-0.05), low bicarbonate level (OR 0.75; 95% CIs 0.61-0.91), long duration of symptoms (OR 1.49; 95% CI 1.04-2.13), high MEDS score (OR 1.56; 95% CIs 1.06-2.30), and high SOFA score (OR 1.57; 95% CI 1.12-2.20) were risk factors for 14-day in-hospital mortality. Renal failure (OR 7.58; 95% CI 1.28-44.77), lower pulmonary tract infection (OR 3.58; 95% CI 1.10-11.58), high MEDS score (OR 1.42; 95% CI 1.05-1.93) and high APACHE II score (OR 1.34; 95% CI 1.13-1.60) were risk factors for 28-day in-hospital mortality.

Conclusions

Several factors signaling poor short-term outcome for this patient group are low blood pH, low serum bicarbonate level, longer duration of symptoms, lower respiratory tract infection and renal failure. MEDS and SOFA scores might be helpful in the ED to stratify patients with septic shock according to mortality risk.
Hong Kong Poison Information Centre: Annual Report 2011
Authors: Chan YC , Tse ML , Lau FL
Published: December 2017

Objective

To report and analyse the poisoning data of Hong Kong Poison Information Centre (HKPIC) in 2011.

Methods

In 2011, all poisoning cases received by HKPIC were retrieved from its database: Poison Information and Clinical Management System (PICMS) for analysis.

Results

A total of 4,331 poisoned cases were analysed. There were 1,915 male patients (44.2%), 2,411 female patients (55.7%) and 5 patients with sex unknown. More than two-third (68%) of them were between 20 and 59 years old. Common causes of exposure were suspected self-harm/suicidal attempt, unintentional exposure and abusive use. Paracetamol, benzodiazepine, household product, zopiclone, and Chinese herbal medicine were the top five commonest poisons encountered. Majority of the patients were managed supportively, with 12.1% and 8.5% treated by decontamination and antidotes respectively. Most cases had uneventful recovery; 1.0% of the poison exposure resulted in death and 4.8% of the exposure had major outcomes.

Conclusions

This 6th annual report provided updated epidemiological information on poisoning pattern in Hong Kong and emphasized some changes in comparing with our previous reports.
Large Sternocleidomastoid Haematoma after Minor Trauma in a Postradiation Neck
Authors: Cheon YJ , Kang BC , Kim HS
Published: December 2017

Sternocleidomastoid (SCM) muscle haematoma after minor blunt injury is rare. Radiation therapy as a treatment for head and neck tumours e.g. nasopharyngeal cancer can result in complications, including fibrosis, scarring, and atrophy. We report a 51-year-old man suffering from massive haematoma of SCM muscle after minor blunt injury to a postradiation neck. Signs of haematoma were absent during his first visit to the emergency department. Emergency physicians need to be aware that bleeding from a postradiation neck, even after minor trauma, may be life threatening.
Children's Discomfort during Noninvasive Cardiac Output Monitoring by Suprasternal Ultrasonographic Transducer
Authors: Chan SSW , Cattermole GN , Leung MPY , Ho GYL , Graham CA , Rainer TH
Published: December 2017

Objectives

To investigate the level of discomfort/pain in children receiving Ultrasonic Cardiac Output Monitoring (USCOM), as compared to blood pressure measurement.

Methods

Healthy children, aged 3‐12 years old, were recruited from kindergartens and schools as a part of the “Healthy children's vital signs and USCOM values” project. Oscillometric blood pressure was measured, followed by USCOM measurement. The discomfort experienced by the child during each intervention was assessed using the Wong‐Baker FACES pain rating scale. The pain scores (scale from 0‐5) were compared using Wilcoxon signed rank test. A difference in score of one point was considered to be clinically relevant. Gender differences in pain score were analysed using Mann‐Whitney‐U test.

Results

A total of 254 subjects (131 boys, 123 girls) were included. Mean age was 7.9 years with standard deviation (SD) of 2.4 years. The median pain score for USCOM measurement was 1.0 (95% CI=1.0 to 2.0) with interquartile range 1.0 to 2.0. The median pain score for BP measurement was 1.0 (95% CI,=1.0 to 1.0) with interquartile range 0.0 to 2.0. Overall, the pain score associated with USCOM was significantly higher than that associated with BP measurement. However, the difference fails to reach the minimum clinically significant difference of one‐point. No significant difference was shown between boys and girls.

Conclusion

USCOM appears to be tolerated well by healthy children. The discomfort reported during USCOM measurement is comparable to that associated with blood pressure measurements.
Evaluation of Chest Compression Depth during Nine Minutes of Hands‐Only Cardiopulmonary Resuscitation Performed by a Lone Rescuer and its Effect by Age Group: A Pilot Simulation Study Using a Manikin
Authors: Hong CK , Park SO , Choi CS , Lee YH , Sung AJ , Lee JH , Cho KW , Hwang SY
Published: December 2017

Objective

There have been few studies on the use of long‐standing hands‐only cardiopulmonary resuscitation (CPR) by a lone rescuer. This study aimed to evaluate the long‐standing (nine minutes) hands‐only CPR by a lone rescuer, and the change of chest compression depth over time. The effect of age of rescuer on chest compression depth was also studied.

Methods

From a total of 404 adult lay‐persons who participated in CPR training, 91 subjects were enrolled in the simulation trial of nine minutes of hands‐only CPR using a manikin with a Skill‐Reporter™. The quality of the chest compression over time and the effects of rescuer age were analysed.

Results

Of the 91 participants, 74 (81%) fully completed the nine minutes of CPR. No significant differences of incomplete CPR rate between each age group were observed. No significant differences in the degree of reduction in effective chest compressions were observed based on the time course among the different age groups. The total number of compressions decreased abruptly from the six‐minute time point onwards (five minutes vs. six minutes, p=0.038).

Conclusions

Most trained lay‐persons could complete the 9 minutes of hands‐only CPR. The rate of chest compression shows a significant decrease after 6 minute. We do not find a significant difference in the decrease of adequate chest compressions over time among various age groups in this pilot simulation study.