bluuebunny/crossref_metadata_2025 huggingface dataset:
Nurses Treating Patients in the Emergency Department? a Patient Survey
Authors: Ong YS , Tsang YL , Ho YH , Ho FKL , Law WP , Graham CA , Rainer TH
Published: December 2017

Background

Hong Kong residents are familiar with prolonged waiting times in emergency departments (ED), particularly with semi‐urgent or non‐urgent conditions. In the United Kingdom and Australasia, extended nurse practitioners are well established. The aim of this study was to identify whether Hong Kong patients would prefer treatment by ED nurses or traditional care by doctors under various waiting time conditions.

Methods

This was a prospective questionnaire study of patients who had been triaged into category 4 (semi‐urgent) or 5 (non‐urgent) during office hours from 20 to 27 June 2005. Following verbal consent, three waiting time scenarios were considered by the patient using an interviewer‐administered structured questionnaire. Statistical analysis used the chi square test.

Results

Overall, 253 patients were approached and 249 patients [119 (47.8%) male; mean age 48 (SD 19.4) years] verbally agreed to participate (98.4%). Patients were classified into three age groups. When the waiting time for nurse treatment was four hours shorter than doctors, patients aged 15–30 and 31–64 years more often chose nurses (overall 59.3%) for treatment but those aged ≥65 years preferred doctors to nurses (58.1% in favour of doctors), despite the longer waiting time (p=0.013, chi square test). Men also preferred nursing treatment compared to women (p<0.001). When the waiting time for doctors was 4 hours shorter than nurses or the same, 99.2% and 95.5% chose doctors respectively.

Conclusion

When the waiting times are long, Hong Kong patients <65 years would prefer to see suitably trained nurses in preference to doctors. Consideration should be given to providing training for senior nurses to have an extended role in Hong Kong EDs.
Emergency Department Triage Nurse Initiated Pain Management
Authors: Goh HK , Choo SE , Lee I , Tham KY
Published: December 2017

Objectives

1) To determine the time difference to analgesia administration for patients with painful limb conditions using an emergency triage nurse initiated pain management protocol versus analgesia administration by emergency doctors after consultation. 2) To determine the frequency of adverse events following such a protocol implementation.

Methods

For emergency department patients with isolated limb injury or inflammation, a triage nurse initiated pain management policy was implemented in 2004. The protocol did not require the triage nurse to consult a physician. The triage nurse would record the chief complaint, past medical history, allergy, medication, vital signs, and pain severity using a combination of 0 to 10 numerical and face pain scales. Unless contraindicated, the triage nurse would offer intramuscular ketorolac to patients with pain score ≥5. Medical charts of patients fulfilling the inclusion criteria were reviewed from 1 to 30 September 2004.

Results

Two hundred seventy‐three patients were reviewed, of whom 73.3% were men and the overall mean age was 40.1 years (standard deviation SD 19.5). Two hundred and nine patients (76.6%) had pain score recorded at triage, and the median was 6. One hundred and five patients (38.5%) received analgesia, of which 69 were given by triage nurses and 36 by physicians. The mean time interval for analgesia given by triage nurse was 2.5 minutes (SD 8.9) and that for physician was significantly longer (p<0.0001) at 68.2 minutes (SD 59.5). There was no adverse drug reaction observed in patients who received intramuscular ketorolac given by triage nurses.

Conclusion

The time interval for pain relief of emergency department patients with painful limb conditions was reduced when the triage nurse initiated pain management.
Health Status following Major Trauma in the West of Scotland: Pilot Descriptive Study
Authors: Graham CA , Craig N , Gordon MWG
Published: December 2017

Background

Data on the long‐term outcome of major trauma survivors in the United Kingdom (UK) is lacking. This pilot study aimed to investigate the health status of survivors of major trauma without significant head injury in the West of Scotland, and to compare the Short‐Form 12 (SF12) questionnaire administered by telephone (TSF12) to the longer Short‐Form 36 (SF36) questionnaire.

Methods

This was a descriptive, comparative, pilot clinical study. Eligible patients had an injury severity score (ISS) >15, sustained their injuries >2 years ago, abbreviated injury score (AIS) <2 for head trauma and were treated in two Glasgow hospitals. The Short‐Form 36 (SF36) health status questionnaire was completed at home, and the Short‐Form 12 (SF12) questionnaire was administered by telephone (TSF12).

Results

From 141 eligible patients (85% male, median age 35 years, median ISS 19 and median Ps 0.981), 13 patients completed the study. Despite small numbers, mean SF36 scores were significantly lower in four dimensions compared to UK means. SF36 summary scores were non‐significantly below US and UK means. The TSF12 physical summary score was significantly below US and UK means. Correlations between the SF36 and TSF12, and SF12 intra‐class correlations were high. One‐way ANOVA showed significantly lower mental summary scores for patients with spinal injuries.

Conclusions

This small study suggests that non‐head injured survivors of major trauma have lower health status than the UK average. The TSF12 appears to be a practical alternative to the conventional SF36 and warrants larger scale evaluation.
A Lady with Alarming Neck Swelling after Minor Head Injury
Authors: Chan KF , Wong WB , Ho MK , Chung CH
Published: December 2017

A 52‐year‐old woman with hidden ankylosing spondylitis for years attended the emergency department after a minor head injury. Rapid and alarming neck swelling appeared shortly after the initial consultation. Although the physical examination and the lateral cervical spine X‐ray did not suggest fracture, a later CT scan revealed a fracture line. A high index of suspicion and early use of the halo device are needed in order to prevent irreversible neurological damage in such patients.
Serotonin Syndrome with Tramadol and Dextromethorphan
Authors: Kung SW , Ng MH
Published: December 2017

Serotonin syndrome is an iatrogenic drug‐induced synaptic serotonin concentration related toxidrome. A 29‐year‐old man developed agitation, tachycardia and myoclonus of limbs after an intramuscular injection of 100 mg tramadol. He had recently been given multiple medications, including dextromethorphan (DXM) by a private doctor for flu‐like symptoms. The patient was stabilised with diazepam, midazolam and supportive treatment. Both tramadol and DXM could cause the serotonin syndrome, but usually in combination with monoamine oxidase inhibitors or serotonin reuptake inhibitors. This was the first reported case in the English literature of serotonin syndrome with tramadol and DXM. Therefore, a detailed drug history and knowledge of potential serotonergic drugs are important.
The Use of Ultrasonography to Assess Patients with Right Lower Quadrant Pain in the Emergency Department
Authors: Siu AYC , Chung CH
Published: December 2017

Acute appendicitis is always a clinical challenge to emergency physicians. Clinical examination or blood tests are notoriously unreliable in making the diagnosis, especially in the early phase of the disease. Computed tomogram can facilitate the diagnosis, however it is usually not easily accessible to emergency physicians. Bedside ultrasonography is now frequently used by emergency physicians in various situations for the assessment of patients. This study aimed at exploring the potential use of bedside ultrasonography in the diagnosis of acute appendicitis in patients presenting with right lower quadrant abdominal pain.
Admission Gatekeeping and Safe Discharge for the Elderly: Referral by the Emergency Department to the Community Nursing Service for Home Visits
Authors: Chiu SLH , Lam FM , Cheung C
Published: December 2017

Objective

To assess the gatekeeping effect and discharge safety in elderly referrals to the community nursing service (CNS) in a major accident & emergency department (AED).

Methods

Descriptive review analysis of the referrals in 2002–2004.

Results

Altogether 333 patients were accepted, comprising 5% of the total CNS referrals in the hospital: 323 were aged ≥65 (median age 81), 13.8% were living alone, 21.6% had unscheduled return to the AED within 14 days, and 11.7% in 15–28 days. The ≤14 days and 15–28 days admission to hospital was 15.0% and 6.0%, with 4.8% and 0.6% patients admitted with the same or related diagnosis as the first visit respectively, including missed fractures and stroke. One patient died 17 days after discharge. Eight of the 162 falls returned within 28 days with a second fall. Overall, 317 admissions were avoided with 1,978 bed‐days saved. Living alone was strongly associated with unscheduled return and admission ≤14 and ≤28 days, while age was not. The six categories of community nursing care were fall‐related, tube care, skin and soft tissue care, pain control, medical and diabetic care. Injections were given for cellulitis, pain, and diabetics. Forty‐nine patients had phone follow‐ups.

Conclusion

The gatekeeping effect of AED referrals to CNS remained small. The commonest referrals were falls with head injury. It was safe to discharge the elderly for CNS care. A wide range of home nursing care was feasible. CNS referral could decrease elderly return visits with falls. Living alone was strongly associated with return visit and admission.
Metabolic Acidosis Complicating Ingestion of Disinfectant Floor Cleaner Containing Butoxyethanol
Authors: Fung HT , Lam KK , Wong OF , Lai CH , Kam CW
Published: December 2017

Butoxyethanol intoxication has seldom been reported. We describe a case of ingestion of butoxyethanol‐containing cleaner resulting in high anion gap metabolic acidosis, which resolved after treatment with ethanol and haemodialysis. The presentations and treatments of previous cases are highlighted. Discussion is centred on the toxicological pathway of butoxyethanol and the role of alcohol dehydrogenase inhibitor.
A Case of Nonfatal Non‐Collapsed Patient with Extreme Hyperkalaemia
Authors: Lim YH , Hendricks J
Published: December 2017

This is a report of a non‐collapsed patient with nonfatal, extreme hyperkalaemia of 10.7 mmol/L. The patient's hyperkalaemia was initially treated in the Emergency Department and then transferred to the Department of Renal Medicine of another hospital for further stabilisation. There have only been a few reported cases of successful management of extreme hyperkalaemia in excess of 10.0 mmol/L.
Isolated Pulmonary Cryptococcosis in an Immunocompetent Patient Presenting with Right Shoulder Pain: A Case Report and Review of the Literature
Authors: Cheung RKH , Ng F , Wong CT , Tsui WMS
Published: December 2017

Cryptococcosis is an important systemic fungal infection occurring predominantly in immunocompromised patients. We report a case of isolated pulmonary cryptococcosis in an ambulant middle-age lady who presented to the emergency department with right shoulder pain. The clue to lung pathology was right apical haziness best seen in the apical lordotic radiograph. The diagnosis was established by transbronchial lung biopsy. She did not have underlying immunosuppression or extrapulmonary disease. She was closely observed without anti-fungal therapy, and showed radiographic improvement during the five-month period of follow up.
Capillary Refill Time in Adults Has Poor Inter-Observer Agreement
Authors: Anderson B , Kelly AM , Kerr D , Jolley D
Published: December 2017

Objectives

Capillary refill time (CRT) has been taught as a rapid indicator of circulatory status but to be a useful clinical test, CRT needs to be reproducible when performed by another health care worker. No inter-rater agreement studies have been reported for adult patients. The aim of this study was to determine the inter-observer reliability of CRT in a sample of adult emergency department (ED) patients. Methods This prospective observational study included clinically stable ED patients with a variety of conditions from two community EDs. A doctor and a nurse each measured CRT by estimation to the nearest half-second using a standard method on each patient. They were blinded to each other's measurements. The primary outcome of interest was inter-rater agreement. Secondary outcome was agreement in classification as normal or abnormal according to accepted definitions. Data was analysed using bias plot analysis, correlation, absolute percent agreement and kappa analysis. Results Totally, 209 patients were enrolled; 51% were female and 86% were Caucasian. Median CRT was 2 seconds (95% CI 2–2.35 seconds). The mean difference between measurements by the different observers was 0 second, however the 95% limits of agreement were very wide (–1.7 to +1.9 seconds). Agreement was 70% for classification of ‘normal’ or ‘abnormal’ using the 2-second definition of normal, with a kappa of 0.38. Conclusion Interobserver agreement in measurement of CRT was poor in adult subjects with wide limits of agreement. This is a serious threat to the appropriateness of this test for use in clinical practice.
A Retrospective Study of Geriatric Patients Presenting with Fever to an Accident and Emergency Department in Hong Kong
Authors: Leung YY , Ma KK , Tsang WT , Lau CL , Ko S , Chan WL , Ng F
Published: December 2017

Objectives

To study the characteristics and outcome of geriatric patients presenting with fever to an emergency department in Hong Kong and to analyse the factors affecting their length of stay.

Methods

Retrospective study. Patients aged ≥65 who complained of fever, or with temperature ≥37.5°C (aural) presenting to the Accident and Emergency Department (AED) of Caritas Medical Centre in Hong Kong from 14 November 2006 to 13 December 2006 were enrolled. The demographic data, clinical information and outcomes were studied. The characteristics of short stay and long stay patients were compared.

Results

There were 370 patients in the study. Their median age was 80. Of these patients, 64.9% were category 3 or above, i.e. urgent, emergent or critical. The most common chief complaints were fever, shortness of breath, dizziness and cough. The admission rate was 81.9%. The median length of stay in hospital was 4.3 days. The most common hospital discharge diagnoses were chest infection, urinary tract infection, and fever with unknown cause. The discharge rate within 48 hours was 24.6%. With further analysis, temperature, walking ability, triage category and neutrophil count were significantly different between short stay (≤48 h) and long stay (>48 h) patients. For those discharged alive either from the AED or ward, 20.1% re-attended the AED within 14 days of discharge, and 17.5% of those previously discharged were admitted again for fever or other problems.

Conclusion

Elders with fever are a major challenge to the AED and health care facilities. The admission rate for this group of patients is usually high. Elders with poor walking ability, high triage category, high temperature and neutrophil count were prone to have longer stay.
Accidental Ecstasy Poisoning in a Five-Year-Old Boy
Authors: Kung SW , Chan YC , Tse ML , Lau FL , Chiu WK
Published: December 2017

We report a 5-year-old child with fever and confusion after ingestion of a tablet of methylenedioxymethamphetamine (MDMA). He was treated successfully with supportive measures and titrated doses of benzodiazepine. In children with unexplained fever, sympathetic hyperactivity, confusion or convulsion, MDMA poisoning should be considered.
A Manikin Study to Compare Video‐Optical Intubation Stylet versus Macintosh Laryngoscope Used by Novice in Normal and Simulated Difficult Airway Intubation
Authors: Tsui KL , Hung CY , Kam CW
Published: December 2017

Objective

To compare Macintosh laryngoscope with video‐optical intubation stylet on rates and time durations of successful tracheal intubation in normal and simulated difficult airway.

Design

Crossover experimental study.

Setting

Intubation training laboratory.

Methods

A group of novices (58 medical students) attempted intubation on manikin under normal and simulated difficult airway (grade 3 larygnoscopic view) settings using both Macintosh laryngoscope and video‐optical intubation stylet. The success rate, duration to intubate and occurrence of complications (oesophageal intubation and incisor breakage) when using the two different devices were measured and compared. The time results were analysed by paired t‐test and categorical results by chi square test or Fisher's exact test.

Results

The success rate to intubate difficult airway using video‐optical intubation stylet (0.92) was significantly higher than using Macintosh laryngoscope (0.59) (p=0.002). The mean time taken to intubate difficult airway using video‐optical intubation stylet was significantly shorter than using Macintosh laryngoscope by 10.90 seconds (p=0.004). Oesophageal intubation rate was significantly higher when using Macintosh laryngoscope to intubate difficult airway compared to video‐optical intubation stylet (p=0.002). There was no significant difference on the rate of incisor breakage between the two instruments.

Conclusions

Novice can learn to use both Macintosh laryngoscope and video‐optical intubation stylet to intubate successfully after a short training. Video‐optical intubation stylet is an effective “Plan B” instrument because it shortens the duration and increases the rate of successful intubation in difficult airway situations.
A Diabetic Patient with Abdominal Pain and Lactescent Serum
Authors: Lui CT , Tsui KL , Kam CW
Published: December 2017

We present the case of a poorly controlled diabetic patient suffering from acute onset of abdominal pain and vomiting. A blood sample taken at the bedside revealed lactescent serum and provided an important clue to the patient's status of having severe hypertriglyceridaemia. The clinical diagnosis of hypertriglyceridaemia‐induced acute pancreatitis was correctly made in the accident and emergency department. Clinical photos of the lactescent serum are shown. The incidence, risk factors and management of this particular type of acute pancreatitis are discussed.
Transition into an Emergency Nurse Practitioner: A Sharing of Self‐Reflection
Authors: Chung JYM
Published: December 2017

The role of the Emergency Nurse Practitioner (ENP) has been established in other countries for a few decades, such as the United Kingdom (UK) and the United States where it has developed rapidly in these countries. The concept of the nurse practitioner is to empower those nurses who have a sound clinical base and specialty skills to enable them to make autonomous judgements and decisions regarding patient care. Evidence shows that the expanded role enables greater continuity and consistency in the delivery of “holistic care”. Moreover, the ENP service also helps the accident & emergency department to be more effective in its use of available nursing and medical resources. In view of the situation in Hong Kong, because of the unsatisfactory primary health care system, health care providers in emergency care have to deal with huge numbers of patients with minor illnesses and injuries. Patients in this category have to wait for long periods to see a doctor. So the development of the role of ENP for the management of minor injury would be a good option to better utilise departmental manpower to meet patient needs. The author has finished training for minor injury in UK which prepared emergency nurses to take up the ENP role in accident & emergency departments. In this article, the author will share her ENP training experience in the whole process of learning.
Nuchal Pain Predicts Subarachnoid Haemorrhage in Severe Headache Patients
Authors: Lui CT , Tsui KL , Kam CW
Published: December 2017

Objective

To find out predicting symptom(s) of non-traumatic subarachnoid haemorrhage in conscious patients without neurological deficit presenting with the primary complaint of severe headache.

Design

Case control study.

Setting

Regional public hospital, Hong Kong.

Subjects

Non-traumatic subarachnoid haemorrhage (ICD 9 coding 430) patients, who were conscious and with normal neurological examination, presenting to the accident and emergency department with severe headache between April 2005 to March 2007 were searched from the hospital database. The control group was recruited prospectively from the accident and emergency department during the period from November 2007 to April 2008.

Results

A total of 33 cases were compared to 57 controls to study on five selected symptoms and the likelihood to predict risk of subarachnoid haemorrhage. All five symptoms were significant by univariate analysis at significance level of 25%: nuchal pain (p<0.001), transient syncope (p=0.137), dizziness (p=0.026), vomiting (0=0.016) and presence of precipitating events (coitus, defecation or quarrel) (p=0.132). Only nuchal pain was statistically significant in the multivariate logistic regression analysis (OR=11.44; 95% CI=2.14 to 61.19) with age and gender controlled.

Conclusions

The presence of nuchal pain as a presenting symptom significantly increases the likelihood of non-traumatic subarachnoid haemorrhage by ten times among severe headache patients with normal neurological examination. Other symptoms like transient syncope, dizziness and vomiting are non-specific and do not predict a higher chance of occurrence of subarachnoid haemorrhage.
The Impact of Enhanced Intensive Care on Outcome of Major Trauma Patients in a Regional Hospital in Hong Kong
Authors: Chan ANL , Lit ACH
Published: December 2017

Objectives

To describe an updated epidemiology of major trauma cases presenting to a regional hospital in Hong Kong and to analyse the impact of enhanced intensive care on the outcome of major trauma patients.

Methods

This was a retrospective comparative study. In late 2004, we amended our trauma care system with enhancement of intensive care in the management of major trauma patients. An 18-month period was chosen before and after the amendment respectively and patients' data and crude mortality rate between the two periods were compared. Stratified analyses based on mechanism of injury, injury severity and physiological parameters were also performed. Finally, a TRISS analysis was included.

Results

Altogether 163 and 155 patients were included in our study from the two periods respectively. The majority involved blunt injury and one third of them had injury severity score (ISS) greater than 15. Road traffic accidents and fall from height remained as the two leading causes of major trauma. The median length of stay in the intensive care unit increased for one day (p<0.01) in the later period but the median total length of stay in hospital remained the same. The mortality rate decreased from 10.4% to 9.7% (p=0.82).

Conclusion

With enhanced intensive care, there is an apparent decrease in mortality of major trauma patients but its significance needs to be determined with a larger scale study.
Ophthalmic Injuries from a Spitting Chinese Cobra
Authors: Fung HT , Choy CH , Lau KH , Lam TSK , Kam CW
Published: December 2017

A man sustained conjunctivitis of the left eye after being spat by the venom of a Chinese cobra (Naja atra). He received fluid irrigation, topical antibiotic and topical steroid treatment. The conjunctivitis resolved without sequalae after 4 days. Various treatment options are discussed.
Ultrasound Diagnosis of Anterior Shoulder Dislocation
Authors: Yuen CK , Mok KL , Kan PG , Wong YT
Published: December 2017

We describe the ultrasound evaluation technique and sonographic findings of a case of anterior shoulder dislocation. The sonographic features of anterior shoulder dislocation include: “sign of widening of subacromial space”, “sign of disappearance of humeral head”, “artery/vessel sign”, “humeral head below coracoid process sign” and “empty glenoid fossa sign”. It is a safe, real time, readily available, convenient, and well tolerated diagnostic technique. The time to confirming the diagnosis of anterior shoulder dislocation may be shortened and hence close reduction in a timely manner may be achieved. We suggest the use of high resolution ultrasound for confirmation of the diagnosis of anterior shoulder dislocation and relocation of the humeral head after close reduction. The potential of using ultrasonography to replace pre-reduction radiograph should be explored.
An Unusual Case of Fever with Purpuric Skin Rash
Authors: Lee GPC , Chung KL , Kam CW
Published: December 2017

A 45 years old gentleman with good past health developed on-and-off fever, malaise, bilateral lower limb rash, shortness of breath and palpitation for two weeks. Physical examination showed purpuric skin rash over both lower limbs. The cardiovascular examination showed a pansystolic murmur, best heard at the apex. Bedside echocardiography was performed in the emergency department and revealed vegetation over the mitral valve leaflet with severe mitral regurgitation. He was admitted to the medical ward with a provisional diagnosis of infective endocarditis and subsequently received a mitral valve replacement.
Exercise‐Associated Hyponatremia: A Local Case Report
Authors: Lau MY , Choi YF
Published: December 2017

Most of us know the risk of dehydration during endurance exercise under extreme heat. We report a case that occurred in cool weather and when there was an abundant supply of fluid – the so‐called exercise‐associated hyponatremia. It is a potentially life‐threatening condition and has led to at least seven fatal outcomes reported in the literature.
A Case of Fatal Metformin Overdose
Authors: Chung AHY
Published: December 2017

Metformin is a widely used antidiabetic agent that is generally considered safe. Reported here is a fatal case of acute metformin overdose in a 73‐year‐old male patient. The rapid clinical deterioration is described to illustrate the possible severity of toxicity. It is followed by a literature review on the topics concerning acute metformin intoxication. Pathogenesis and clinical features on metformin‐associated lactic acidosis, as well as the current recommendations in management are discussed in details.
Atrial Myxoma Presenting with Aphasia Alone: A Case Report
Authors: Saritas A , Emet M , Kocaturk H , Aslan S , Cakir ZG
Published: December 2017

Atrial myxomas are the most common primary heart tumours. Symptoms are produced by mechanical interference with cardiac function or embolization. Neurological symptoms may occur approximately in one third of the patients. We report a patient who was admitted to the emergency department with only a complaint of complete aphasia and without other neurological signs and symptoms. Transthoracic echocardiography demonstrated a large mobile mass sized 4 × 4.5 cm prolapsing into the left ventricle through the mitral valve from the left atrium, suggesting the diagnosis of atrial myxoma. After surgery, aphasia resolved completely. Our objective is to inform clinicians that aphasia alone can be a symptom of atrial myxoma.
Subcortical Parenchymal and Right Lentiform Nucleus Haemorrhages in a Lightning Victim
Authors: Emet M , Aslan S , Cakir ZG , Onbas O , Sengul G , Saritas A
Published: December 2017

We report a 12‐year‐old lightning victim with right subcortical parenchymal and right lentiform nucleus haemorrhages documented by computed tomography (CT) and magnetic resonance imaging (MRI). A linear entry burn with an area of singed hair on the scalp was obvious. Neurological examination did not show any lateralized deficit. Cranial nerves were intact. A laceration on the right external auditory canal, elevated cardiac enzymes and electrocardiographic changes were also recorded. The boy was discharged on the sixth day. Prolonged loss of consciousness in lightning victims may suggest intracranial injury. Although brain CT can demonstrate intracranial haemorrhages, MRI is mandatory to show subcortical parenchymal haemorrhage in lightning victims.
Adult Acute Epiglottitis: Predictors for Airway Intervention and Intensive Care Unit Admission
Authors: Lam PK , Choi YF , Wong TW , Lau CC
Published: December 2017

Objectives

(1) to characterise the clinical features of acute epiglottitis in adults in Hong Kong; (2) to identify predictors for airway intervention and uneventful recovery without intensive care unit (ICU) admission. Modified Early Warning Score (MEWS) was also applied in risk stratification.

Methods

A retrospective cohort study of 122 consecutive laryngoscopically confirmed cases admitted to Pamela Youde Nethersole Eastern Hospital from 1998 to 2007.

Results

The mean patient age was 51 years (range 18–84 years) and the male‐to‐female ratio was 1.9 to 1. Sore throat, dysphagia and odynophagia were the commonest symptoms and the median MEWS on presentation was 1 (range 0–10). Nine patients (7.4%) required airway intervention (5 orotracheal intubations, 2 nasotracheal intubations and 2 tracheostomies) and one patient died. Univariate analysis showed that recurrent attack (OR 35.0, 95% CI 2.77–442.69, p=0.013), dyspnoea (OR 17.41, 95%CI 2.09–144.79, p=0.001), stridor (OR 30.0, 95%CI 2.42–372.65, p=0.016) and MEWS equal to or greater than 4 (OR 5.81. 95%CI 1.16–29.17, p=0.049) were significantly associated with airway intervention. Only stridor remained a reliable predictor in multivariate analysis (OR 88.46, 95%CI 5.48–1427.45, p=0.001). Performance of MEWS in prediction for airway intervention was evaluated with the Receiver Operating Characteristic (ROC) curve. The area under curve (AUC) was 0.71 (95%CI 0.503–0.909). Forty‐five patients did not require ICU admission (36.9%). Multiple logistic regression showed that absence of hoarseness (OR 3.10, 95%CI 1.10–8.79, p=0.033), absence of fever (OR 3.2, 95%CI 1.25–8.16, p=0.015) and MEWS <1 (OR 7.07, 95%CI 1.31–38.07, p=0.023) were predictors of uneventful recovery without ICU care.

Conclusion

A selective approach should be adopted in airway management but those with stridor on presentation should have their airway secured without delay. MEWS cannot replace clinical judgement but a low MEWS on presentation may help in identifying low risk patients who can be managed safely without ICU admission.
Traumatic Liver Injury in Hong Kong: The Management Strategy and Outcome
Authors: Chong CN , Cheung YS , Lee KF , Rainer TH , Lai BSP
Published: December 2017

Introduction

Management of liver injury is challenging and evolving. The aim of this article is to review the outcome of traumatic liver injury in Chinese people in Hong Kong.

Materials & methods

Records of 40 patients with hepatic injury who received treatment at the Prince of Wales Hospital between December 2000 and May 2005 were reviewed. Demographic data, severity of liver injury, Injury Severity Score (ISS), haemodynamic status and Glasgow Coma Scale (GCS) score on admission, investigations made, concomitant injuries, management scheme, and outcome of patients were analysed.

Results

There were 23 male and 17 female patients with a mean age of 31.3 (SD=15.4) years. Road traffic accident was the most common injury mechanism (65%). Half of the patients were treated by non‐operative management (NOM). None of them required surgery during subsequent management. Patients in the operative management (OM) group had a significantly higher ISS (p=0.026), but there was no significant difference in the mortality rate between the OM and NOM groups. Patients with stable haemodynamic status and who were treated non‐operatively had a significantly shorter hospital stay (p=0.006). High grade liver injury (OR=8.0, 95% CI=1.2 to 53.8, p=0.03) and ISS greater than 25 (OR=21.6, 95% CI=2.0 to 225.3, p=0.01) were independent risk factors for mortality on multivariate analysis.

Conclusions

Non‐operative management of liver injury can be safely accomplished in haemodynamically stable patients, with the possible benefit of a shorter hospital stay.
Case Report: Cola Can Stay‐Tab Ingestion in an 8‐Year‐Old Boy
Authors: Karabulut R , Sönmez K , Türkyilmaz Z , Başaklar AC
Published: December 2017

Foreign body ingestion is a common problem in children. The most commonly ingested objects are coins, toy parts, bones, pins, and disc batteries. The radiolucency of the pull‐tabs or stay‐tabs of Cola cans constitutes another difficulty. In cases with ingested Cola can stay‐tabs, as was in our patient, diagnosis should be confirmed at least by oesophagogram to avoid potential complications.
The Role of Serum Ferritin, Pro‐Brain Natriuretic Peptide and Homocysteine Levels in Determining Ischaemic Stroke Subtype, Severity and Mortality
Authors: Üstündağ M , Orak M , Güloğlu C , Öztürk E , Tamam Y , Kale E
Published: December 2017

Background

In ischaemic stroke, there are many biochemical and immunological reactions secondary to a reduced cerebral blood flow. The purpose of this study is to investigate the correlation between stroke subtype, stroke severity, mortality, and serum ferritin, pro‐brain natriuretic peptide (pro‐BNP), homocysteine values before a specific treatment is given to stroke patients in the emergency department.

Methods

Consecutive acute ischaemic stroke patients admitted between December 2007 and April 2008 were enrolled into the study. Serum ferritin, pro‐BNP and homocysteine levels were studied before specific treatment was carried out. Stroke subtypes were determined according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) and Oxfordshire Community Stroke Project (OCSP) criteria. The severity of stroke was determined by the National Institutes of Health Stroke Scale (NIHSS). Fifteen healthy individuals who matched the study group in terms of sex and age were chosen as control.

Results

Ninety‐two patients were included in the study. There was a significant difference in the serum ferritin, pro‐BNP and homocysteine levels between patients who died and those who survived (p=0.013, p<0.001 and p=0.003 respectively). Serum ferritin, pro‐BNP and homocysteine levels were higher in all stroke subtypes than in the control group. Comparing among stroke subtypes, only serum pro‐BNP levels were higher in the cardioembolic stroke group than in the atherothrombotic stroke and lacunar stroke groups (p=0.003 and p<0.001 respectively); and only serum pro‐BNP levels were higher in the total anterior circulation infarct group than in the posterior circulation infarct and lacunar infarct groups (p=0.010 and p=0.017 respectively). Pro‐BNP levels were significantly higher in patients with NIHSS score >15 than NIHSS=8‐15 and NIHSS=1‐7 (p=0.016 and p<0.001 respectively).

Conclusion

Ferritin, pro‐BNP and homocysteine levels were raised in acute ischaemic stroke patients. However, only serum pro‐BNP level is clinically useful in predicting stroke subtype, severity and mortality that could provide an insight to the choice of treatment.
Dengue Perimyocarditis: A Case Report
Authors: Goh PL
Published: December 2017

Dengue is the most important mosquito borne viral disease in the world. It is endemic in South and Southeast Asia, Central and Latin America, and Africa. One of its manifestations is dengue shock syndrome (DSS), a medical emergency with a very high mortality. Cardiac involvement is a known but infrequent feature of dengue. Cardiac dysfunction may complicate management of hypotension in DSS. We report a case of a 16‐year‐old male presenting with fulminant DSS as well as perimyocarditis that both confounded the clinical picture and complicated the clinical management.
Subacute Combined Degeneration of the Spinal Cord
Authors: Tan LTH , Ho KKF , Fong GCY , Ong KL
Published: December 2017

We report a case of a 79‐year‐old gentleman presenting with numbness of both hands. A magnetic resonance imaging of the cervical spine demonstrated features suggestive of subacute combined degeneration of the spinal cord which was further supported by a low serum vitamin B12. This is a reversible condition if early diagnosis can be made and vitamin B12 therapy promptly given. Delayed treatment can result in irreversible neurological impairment.
Early Diagnosis of Acute Myocardial Infarction by Bedside Multimarker Test at an Emergency Department in Hong Kong
Authors: Ho CH , Cheng W , Chu G , Ho HF
Published: December 2017

Introduction

Cardiac biomarker measurement can aid diagnosis of acute myocardial infarction. The present study evaluates the efficacy and efficiency of point‐of‐care multimarkers measurement of myoglobin, creatine kinase (CK‐MB) and troponin in identifying patients with acute myocardial infarction.

Method

We prospectively enrolled consecutive patients (N=105) in the emergency department who were being evaluated for possible acute myocardial infarction. Point‐of‐care testing (POCT) of myoglobin, CK‐MB and troponin I (TnI) was performed in all patients. Central laboratory measurement of troponin I was also performed simultaneously. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and receiver operating characteristic (ROC) curve were evaluated.

Result

The specificity and positive likelihood ratio of TnI (POCT) and TnI (laboratory) were 98%, 13.0 and 98%, 21.8 respectively. The areas under curve of the ROC curve of TnI (POCT) and TnI (laboratory) were 0.692 and 0.725 respectively.

Conclusion

A high positive likelihood ratio for acute myocardial infarction through point‐of‐care testing can help timely diagnosis and just‐in‐time appropriate management for patients presenting with chest pain.
Full Text Publication Rates of Studies Presented at an Asian Emergency Medicine Scientific Meeting
Authors: Tan PCF , Graham CA
Published: December 2017

Purpose

Study findings can reach a worldwide audience only after a paper is published in the peer‐reviewed literature; this is regarded by many as the definitive contribution to global exchange of knowledge. The abstract to publication (A:P) rates for free papers presented at an emergency medicine meeting in Asia has not been investigated before. The purpose of this study was to determine the full publication rate of abstracts presented as oral presentations at the Third Asian Conference on Emergency Medicine (ACEM) in Hong Kong in 2004.

Methods

A detailed literature search of the MEDLINE database was performed using first and last authors' names and appropriate key words up to January 2008.

Results

A total of 54 free paper abstracts were presented at this conference as oral presentations. Ten (18.5%) abstracts had subsequently been published as full articles by the end of January 2008. The full‐text articles were published in eight different journals.

Conclusions

The A:P ratio of abstracts for oral presentations at ACEM 2004 was 18.5%, lower than that of similar meetings in the US and Australasia. It is normal for less than half of the abstracts presented at meetings to be published as full papers in refereed journals, largely due to the inability to overcome the barriers that present at each stage towards publication. Lack of researcher time due to pressure of clinical work and English language skills may play an important role in Asia.
Three Cases of Aconite Root Poisoning Due to Bikhama in a Hong Kong Nepalese Family
Authors: Chan CP , Au CKH
Published: December 2017

Aconite is one of the most toxic plants. Aconite is used by herbalists for pain relief. Toxicity occurs due to misidentification, contamination, adulteration and mis‐processing. Patients usually present with classical symptoms of aconite poisoning such as perioral paraesthesia, gastrointestinal upset, and generalised burning sensation. Cardiac manifestations include hypotension and ventricular tachycardia. Since aconite is a life‐threatening herb commonly used in all cultures, every clinician should be aware of this poison. This report recorded three cases of aconite poisoning in a Nepalese family who were managed in a major urban hospital in Hong Kong. They all presented with variable severity of aconite poisoning after mistakenly ingesting aconite. Management was performed basing on the clinical features, as laboratory confirmation of aconite poisoning was not immediately available. All three patients survived and did not suffer from any consequences.
A Dangerous Gastric Bleeding Cause: Dieulafoy'S Lesion
Authors: Ekçi B , Gökçe Ö , Ekici I , Akyüz Ü
Published: December 2017

Bleeding is a complication of gastrointestinal vascular malformation and may be an emergency. Dieulafoy's lesion is rare but the aberrant submucosal artery may cause gastrointestinal bleeding. It is most commonly located in the proximal part of the stomach. Endoscopy is used for diagnosis and treatment. Mass lesions, diffuse lesions and severe bleeding may require surgery. Wedge resection or lesion suturing may be selected for gastrointestinal haemorrhage.
An Unusual Cause of Haematuria: Renal Arteriovenous Malformation Mimicking Caliceal Dilatation at Ultrasonography
Authors: Yιlmaz C , Arslan M , Gonullu H , Erkan N
Published: December 2017

We report a 37‐year‐old woman admitted to the emergency service with macroscopic haematuria and flank pain due to renal arteriovenous malformation (AVM). Ultrasonography showed apparent dilatation of the left renal caliceal system, whereas intravenous pyelography (IVP) demonstrated multinodular pelvicaliceal impressions with no caliceal dilatation. The final diagnosis was established with conventional angiography. Renal AVM may mimic caliceal dilatation on ultrasonography. Demonstration of multinodular pelvicaliceal impressions at IVP and lack of caliceal dilatation are clues for the correct diagnosis in this particular situation.
Ticks in the External Auditory Canal
Authors: Dalgic A , Kandogan T , Kavak H , Ari A , Erkan N , Ozuer MZ
Published: December 2017

Ticks attack a wide range of vertebrates including humans, and are important vectors of numerous pathogens, e.g. virus, rickettsia, and protozoa. We present a case of ticks found in the external auditory canal. A 12‐year‐old girl presented to the emergency service with one‐day history of right‐sided earache. Otological examination found a tick blocking the external auditory canal. The tick was removed under local anaesthesia with a light microscope. After the tick was removed, another tick was detected in the external auditory canal. The second tick was not adhered to the ear canal skin and was mobile. It was also removed completely. The patient's post‐procedure course was uneventful. A broad spectrum antibiotic, an analgesic, and an antihistamine were prescribed. Both ticks were sent to the infectious disease laboratory for investigation of Crimean‐Congo haemorrhagic fever. They turned out to be Hyalomma species.
Convulsion Due to Meningoencephalitis in Hepatitis a Virus Infection
Authors: Lee DH , Choi YH , Cho KH , Lee HM , Yun SY
Published: December 2017

Hepatitis A virus (HAV) infection usually has a self‐limited clinical course and sometimes remains subclinical. HAV infection rarely causes neurologic problems. There are only a few case reports on seizure and meningoencephalitis associated with serologically confirmed hepatitis A infection. We report a case of a 27‐year‐old man admitted to the emergency department due to confusion after an episode of generalised tonic convulsion. Laboratory test results included AST 441 units/L and ALT 1294 units/L. A diagnosis of hepatitis A was confirmed by the finding of serum IgM‐HAV antibody. HAV infection should be considered one of the aetiologies of meningoencephalitis.
An Analysis of Escalator‐Related Injuries in an Emergency Department
Authors: Lee DH , Kim CW , Kim SE , Lee SJ
Published: December 2017

Background

Escalator‐related injuries have been considered uncommon and most likely to occur in children. In this study, we described the epidemiology of these injuries with focus on the aged population in order to determine whether escalators are safe for the aged, and to obtain information to help in preventing escalator‐related injuries.

Methods

A prospective survey was taken to identify the number and nature of these injuries from May 2004 to December 2008. We enrolled patients who had sustained escalator‐related injuries. A standard list of questions and answers were recorded by the emergency physician. A total of 104 questionnaires were completed during the study period.

Results

The average patient age was 59.2±24.0 years (range 1‐94). There were 64 (61.5%) females. Only 11 (10.6%) were younger than 15 years old, and 59 (56.7%) were aged 65 or above; 35 (59.3%) of the aged people were injured while standing on the escalator. However, out of the 45 patients younger than age 65, 22 (48.9%) were injured from walking on a moving escalator. Head injury was the commonest site of injury overall and all were due to fall or slipping down.

Conclusions

Escalator‐related injuries are not as rare as previously believed and the aged population 65 years old or above is the highest risk group. In particular, walking on a moving escalator was the main cause of injury in people under age 65. Therefore, primary prevention strategies are needed to prevent users from walking on escalators, especially young people, and educate aged people the safe utilization of escalators to prevent slip and fall injuries.
The Value of Point‐Of‐Care Fatty Acid Binding Protein in Patients with Chest Pain in Determining Myocardial Infarction in the Emergency Setting
Authors: Cete Y , Eken C , Eray O , Goksu E , Kiyan S , Atilla R
Published: December 2017

Introduction

Detecting patients in the early hours of acute myocardial infarction is still a challenge for emergency physicians. Fatty acid binding protein (FABP) was thought to be released into the intravascular space earlier than cardiac troponins. The aim of this study was to determine the diagnostic value of point‐of‐care FABP test either in diagnosing or excluding myocardial infarction during the initial admission of patients presenting with typical chest pain to the emergency department.

Methods

This study was performed in a tertiary care emergency department. Patients with typical chest pain were included into the study. Point‐of‐care FABP was studied during the initial admission and two hours after admission. Patients were diagnosed as myocardial infarction or not ultimately by ECG and troponin levels.

Results

A total of 224 patients were included into the study, 73 of them (32.6%) were diagnosed as acute myocardial infarction. FABP had a sensitivity and specificity of 41.0% (95%CI 29.7 to 53.2) and 100% (95%CI 97.6 to 100) and myoglobin had a sensitivity and specificity of 57.5% (95%CI 45.4 to 69.0) and 90.7% (95%CI 85.0 to 95.0) during the initial admission. Cardiac troponin T had a sensitivity of 45.2% (95%CI 33.7 to 57.2) and specificity of 100% (95%CI 97.0 to 100) during the initial admission. Two hours after admission, FABP had a sensitivity of 56.0% (95%CI 40.0 to 71.0) and specificity of 99.0% (95%CI 96.4 to 100) respectively.

Conclusions

Point‐of‐care FABP is good at diagnosing acute myocardial infarction in patients presenting with chest pain. However, FABP was found to be not better than either myoglobin or cardiac troponin T in excluding acute myocardial infarction in patients presenting with chest pain.