bluuebunny/crossref_metadata_2025 huggingface dataset:
Incapacitating Agents: Weapons of Mass Disruption
Authors: Cocks RA , Chan JTS
Published: December 2017

Terrorism, and with it the possibility of hostage taking and sieges, has become a common feature of our times. The gas used to subdue terrorists in Moscow on 26 October 2002, which appeared to be responsible for the deaths of 123 of the 127 hostages killed in the crisis, remains unknown. Much criticism was levelled at the Russian security forces following the rescue of hostages for not revealing the exact agent used. This paper asks the questions: how deeply should doctors be drawn into the non-medical use of drugs and the unorthodox use of medical knowledge, and how can they help to predict and plan responses to misuse by others?
The Prevalence of the Male Pattern in Electrocardiograms of Healthy Chinese Adult Males in Hong Kong
Authors: Ho JKK , Lee KH , Tsui CSY , Ko HF , Lit CH
Published: December 2017

Introduction

The main feature of the male pattern in electrocardiograms (ECG) is ST-elevation at the J-point of >0.1 mV in at least one of the leads V1–4 with concave upward ST-segments. The prevalence of the male pattern in ECG of healthy male foreigners who were 16–58 years old (mostly Caucasians or Blacks) was high (85%). These ST-segment elevations may meet the ECG criteria for fibrinolytic therapy according to the present guidelines for the treatment of ST-elevation myocardial infarction (STEMI), thus resulting in potentially inappropriate management. Clinicians should be aware of this common phenomenon. As yet, the prevalence of the male pattern in healthy Chinese adult males has not been studied specifically.

Materials and methods

Standard 12-lead ECG from 202 apparently healthy Chinese adult males (aged 20–54) were collected and analysed.

Results

The prevalence of the male pattern was 95.5% in our 202 samples (p<0.05). Of these samples of male patterns, 97.4% might have met the ECG criteria for fibrinolytic therapy according to the guidelines of the American College of Cardiology and American Heart Association (2004); but if we followed the guidelines of the European Society of Cardiology (2003), only 21.8% met the criteria.

Conclusions

The prevalence of the male pattern in ECG of healthy Chinese adult males in Hong Kong is high. Clinicians should be more cautious while managing patients with possible acute coronary syndrome to avoid over-diagnosis of STEMI. It seems the European guidelines are safer to follow as regard to the prescription of fibrinolytics for STEMI, especially for junior doctors.
A 6-Year Epidemiological Study of Pulmonary Embolism in an Emergency Department
Authors: Cheng CC , Chung CH
Published: December 2017

Objective

To identify the epidemiology and early clinical features of patients with pulmonary embolism with a view to facilitate making the correct diagnosis.

Methodology

A retrospective study of patients admitted through the emergency department with a discharge diagnosis of pulmonary embolism in the computerised Clinical Management System from 1st January 1999 to 31st December 2004 in a public emergency general hospital in Hong Kong.

Results

Twenty-two patients were newly diagnosed to have pulmonary embolism and included in the study. The patients' clinical features and investigation findings were analysed. Old age and immobilisation were the most common risk factors identified. Nine patients were found to have deep vein thrombosis but none of them complained of calf pain during consultation in the emergency department. Most patients had symptoms of shortness of breath and chest pain on presentation. Fourteen patients had type 1 respiratory failure. The electrocardiogram and chest X-ray findings were non-specific. All the patients with D-dimer done showed positive results. CT scans were used in all patients to make the final diagnosis. Nineteen patients received low molecular weight heparin followed by warfarin and three patients had thrombolytic therapy.

Conclusion

Pulmonary embolism is not a commonly diagnosed disease in Hong Kong. The symptoms are non-specific and it is difficult to make the correct diagnosis in the emergency department.
Outcomes of Patients with Successfully Converted Paroxysmal Supraventricular Tachycardia after Four Hours of Observation in an Emergency Department of a District Hospital in Hong Kong
Authors: Chan HY , Yuen WL
Published: December 2017

Objective

Paroxysmal supraventricular tachycardia (PSVT) is a common problem encountered in the accident & emergency department (AED). Most patients can be successfully converted to sinus rhythm by vagal manoeuvres or adenosine tri-phosphate (ATP) or may even convert spontaneously in the AED. The objective was to test the safety of a protocol in managing this group of patients. The outcomes and recurrence rate of PSVT patients who had been converted to sinus rhythm and discharged from the AED after a period of observation using a simple protocol were studied.

Methods

This was a prospective study on PSVT patients aged between 18–70 years from June 2003 to August 2005. The outcomes and recurrence rates of the PSVT patients within two periods, namely, 24 hours and 90 days after discharge from the AED, were assessed by the computerized system in public hospitals under the Hong Kong Hospital Authority.

Results

A total of 42 PSVT patients after successful conversion were discharged from the AED after four hours of observation. None had recurrence of PSVT within 24 hours. Four patients (9.5%) presented with recurrent PSVT within 90 days after discharge without negative outcomes. The timing of recurrence ranged from 2 to 22 days (mean 15 days). All the four patients had past history of PSVT and three of them had already been on long term anti-arrhythmic medication. One recurrent PSVT patient was arranged to undergo radiofrequency ablation.

Conclusion

PSVT patients successfully converted by vagal manoeuvre or ATP or converted spontaneously can be safely discharged from the emergency department after four hours of observation under the study protocol.
The Use of Ultrasonography in Diagnosing Ruptured Baker'S Cyst in the Emergency Department
Authors: Yeung MF , Chung KL , Kam CW
Published: December 2017

Acute calf pain is a common cause of attendance to the emergency department. Deep vein thrombosis and other differential diagnoses can mimic each other. Emergency ultrasonography can help in making the correct diagnosis. We presented a case with initial clinical presentation suspicious of deep vein thrombosis. However, with the use of emergency ultrasonography, a final diagnosis of ruptured Baker's cyst was made in the emergency department.
Painful Malignant Embryonal Carcinoma of the Testis
Authors: Tan LTH , Ong KL
Published: December 2017

Patients with clinically palpable testicular nodule, regardless of absence or accompanying symptom of pain, require further evaluation. Testicular carcinoma including embryonal carcinoma has varied appearances and the diagnosis can be difficult unless there is presence of local infiltration or distant metastatic deposits. Ultrasound examination is the imaging modality of choice to quickly confirm the clinical findings of testicular mass at the Emergency Department and distinguish a testicular mass from an extra-testicular mass and extent of the disease. Despite presentations in varying stages of disease, the treatment will include orchiectomy.
Undergraduate Emergency Medicine Training: Past, Present and Future
Authors: Wai AKC , Graham CA , Rainer TH
Published: December 2017

This article briefly reviews the development of emergency medicine (EM) in Hong Kong with particular focus on the parallel development of training in EM at the undergraduate level. The practice of EM in Hong Kong started more than 50 years ago but the development of the specialty progressed slowly until the 1980s. Since then, although there have been major advances in postgraduate training, the specialty still features poorly in undergraduate medical training. We compared emergency medicine training in Hong Kong, Australia, USA, UK and Singapore, in order to identify areas in the medical curriculum where EM could contribute more to undergraduate medical training. The growth of EM in Hong Kong depends on recruiting good trainees who are attracted by what they observe and what they learn during their undergraduate EM clerkship.
Pulse Oximetry: A Survey of Knowledge among Staff of an Emergency Department
Authors: Lee LLY , Yeung KL , Lo WYL , Chan JTS
Published: December 2017

Introduction

Pulse oximetry measures arterial oxygen saturation and was introduced into the clinical field since the 1980s. It provides a simple, portable, non-invasive and inexpensive way for monitoring blood oxygen saturation. Previous studies demonstrated that most hospital staff had limited knowledge on the correct use of pulse oximetry and what might affect the readings. This study aimed at evaluating the extent of knowledge in pulse oximetry among the clinical staff of an emergency department.

Method

A 25-item multiple-choice type questionnaire was given to the medical and nursing staff of the Accident and Emergency Department (AED) of the Alice Ho Miu Ling Nethersole Hospital. In addition to demographic information, respondents were required to answer questions relating to the basic principles of pulse oximetry, recognition of physiological factors limiting its accuracy and management regarding hypothetical scenarios. The scores were expressed and analysed on a scale of 0–100.

Results

A total of 44 questionnaires were completed by 27 nurses and 17 doctors with their test scores ranging from 20 to 72 (median=46). Doctors (median=56) did better than nurses (median=44) in general (P=0.036) but this advantage, however, did not apply to questions on hypothetical scenarios where nurses performed better on the contrary. Correlation analysis proved that there was no linear relationship between respondents' test scores and their years of clinical experience (r=0.051, Spearman). This absence of linear relationship also applied to individual doctors (r=0.244, Spearman) and nurses groups (r=0.162, Spearman).

Conclusion

There was insufficient knowledge on the use of pulse oximetry among staff of the AED. The level of understanding did not correlate with their clinical experience. Training programs targeting both the fresh and the experienced staff are recommended.
Case Report: Thoracic Spinal Epidural Haematoma – an Unusual Cause of Chest Pain
Authors: Chan KM , Law KL , Chung CH
Published: December 2017

Chest pain is a common presentation to the emergency department. Aetiologies to be considered are usually cardiac or pulmonary in origin. We reported a rare case of thoracic spinal epidural haematoma initially presenting to the emergency department with chest pain. The patient re-attended the emergency department four hours after discharge with symptoms of cord compression. Magnetic resonance imaging of the thoracic spine showed an epidural haematoma causing cord compression. Surgical decompression was performed with gradual resolution of symptoms. Simply ruling out acute coronary syndrome may not be sufficient in patients presenting with chest pain.
How Do Critically Ill Children Present to a Local Emergency Department?
Authors: Fan KL
Published: December 2017

Objective

To describe the profile of critically ill paediatric patients presenting to a local emergency department.

Methods

This was a retrospective review of all triage Category 1 (critical) children aged from 0 to 16 years presenting to the emergency department of Queen Mary Hospital. The study period was from January 1998 to September 2006.

Results

A total of 277 patients were analyzed. Trauma was a major cause of presentation. It constituted 37.9% of the cases. Of the trauma cases, head injury was the most common. For non‐trauma cases, convulsion was the commonest reason of attendance. Cardiorespiratory arrest was uncommon (3.6%). The overall mortality rate was 7.6%. A high proportion (43.3%) of the patients was managed solely by staff of the emergency department. Resuscitative procedures, such as intraosseous line, were infrequently practised.

Conclusion

Trauma and convulsion were the major presentations of critically ill children. The fact that A&E staff managed a high proportion of the cases alone and the infrequent practice of resuscitative procedures make continuous training in paediatric resuscitation particularly important.
Not to be Forgotten: Tetanus
Authors: Lateef F
Published: December 2017

We describe a patient presenting with altered mental state, generalised stiffening of the body and limbs as a result of acute generalised tetanus. Discussion of the clinical manifestations, diagnosis, initial management in the emergency department and complications is put forth.
The Impact of an Emergency Department Toxicology Team in the Management of Acute Intoxication
Authors: Chung AHY , Tsui SH , Tong HK
Published: December 2017

Objective

To evaluate the impact of the recently established Emergency Department (ED) Toxicology Team of Queen Mary Hospital (QMH) in the management of acute intoxication.

Method

A descriptive comparative study with retrospective data collection from all intoxicated and suspected intoxicated patients over two separate half-year periods in 2001 and 2006, before and after the establishment of the ED Toxicology Team in July 2005. Data on reasons of intoxication, drugs and substances involved, ED treatments, patient disposition, length of stay in ED, length of stay in hospital, patient outcome, and 30-day ED re-attendance and hospital re-admission were collected and examined.

Results

A total of 333 intoxicated patients were included in the study, 171 in 2001 and 162 in 2006. The basic epidemiological data were similar in both groups. There was a marked reduction in hospital admissions from 89.5% to 40.7% (P<0.01) and significant decline in average length of hospital stay from 46.8 hours to 29.2 hours (P<0.05). There was no statistically significant difference in patient outcome, 30-day ED re-attendance and hospital re-admission.

Conclusion

Our findings showed that the establishment of the ED Toxicology Team in QMH achieved significant reductions in hospital admissions and the length of stay in hospital in the management of patients with acute intoxication without jeopardising patient outcome. The results illustrate that the new model has a beneficial role in reducing cost and alleviating stress on hospital bed availability, therefore it can be recognised as a cost-effective means of management of acute intoxication.
How Safe is Intravenous N‐Acetylcysteine for the Treatment of Paracetamol Poisoning?
Authors: Merl W , Koutsogiannis Z , Kerr D , Kelly AM
Published: December 2017

Objective

Paracetamol poisoning remains one of the most common and potentially lethal ingestions. N‐acetylcysteine (NAC) has been proven to be a highly effective antidote. The aim of this study was to determine the rate of adverse drug reactions (ADR) to intravenous (IV) NAC. Our hypothesis was that IV NAC for the treatment of paracetamol toxicity has a low rate of adverse events.

Methods

This was an observational cohort study undertaken by explicit retrospective medical record review. It included patients who presented to the emergency department with paracetamol overdose over the ten‐year period from July 1995 to June 2004. The primary outcome measure was the occurrence of an ADR during NAC administration. Adverse drug reactions were classified as minor (including flushing, urticaria, pruritus, bronchospasm, tachycardia, and non‐ischaemic chest pain) and major (including hypotension, angio‐oedema and death). Data analysis was by descriptive statistics and chi‐square analysis using univariate analysis, Fisher's exact test and Mann‐Whitney U‐test. Inter‐rater agreement was checked for 9% of the sample.

Results

There were 470 cases of paracetamol poisoning. Of these, 320 received IV NAC. Thirty‐six (11%, 95% CI 8–15%) of these patients developed ADRs. There were two major ADRs, one hypotension and one angio‐oedema (0.6%, 95% CI 0.02–2%). Two patients died during hospitalisation, but neither had an ADR to NAC. The most common ADRs were urticaria (20), flushing (15), bronchospasm (12), and pruritus (3). None of the variables analysed was a clinically significant predictor of increased ADR risk.

Conclusion

Adverse drug reactions after IV NAC infusion occur commonly, but most are minor. Treatment of paracetamol poisoning with IV NAC appears to be safe, however a large prospective study would be required to confirm this.
Superior Dislocation of the Patella Treated by Closed Reduction: A Rare Case Report and Review of the Literature
Authors: Lai R , Lau YK
Published: December 2017

Superior dislocation of the patella is a rare condition. We report a 70‐year‐old gentleman with his patella lower pole osteophyte interlocked with the anterior femoral condyles after hyperextension. The patella was reduced successfully with proper reduction technique under sedation. The active range of movement ranged from full extension to 120‐degree flexion a few minutes after reduction. He walked unaided afterwards. There was no knee problem in two years of follow‐up. On reviewing the literature, only 20 cases were reported till year 2007 worldwide and 19 cases could be treated by closed reduction with or without sedation.
Ultrasound-Guided Foreign Body Removal
Authors: Lee GPC , Chung KL , Kam CW
Published: December 2017

A gentleman suffering from right leg penetrating injury presented to a local accident and emergency department. The physical examination did not suggest an embedded foreign body, and he was discharged after local wound dressing. Because of persisting symptoms, he attended another hospital later where an unguided surgical exploration was performed but no foreign body was identified. He was then referred to another hospital, his third one, for further management. The X-ray finding was unremarkable but ultrasound showed a hyperechoic foreign body. Subsequently, ultrasound-guided foreign body removal was performed and a wooden splinter was successfully removed.
Sonographic Diagnosis of Rotator Cuff Tears in Anterior Shoulder Dislocation
Authors: Lee GPC , Chung KL , Kam CW
Published: December 2017

A 61‐year‐old gentleman fell from a tree about two meters high and suffered from a right shoulder injury. The physical examination showed tenderness with marked decrease in range of movement over the right shoulder. X‐ray of the right shoulder showed anterior dislocation. Closed reduction under sedation was performed. After reduction, ultrasound was done and showed a full‐thickness supraspinatus tear. He was referred to the orthopaedic department urgently and an arthroscopic rotator cuff repair was done subsequently.
Superior Mesenteric Artery Syndrome: An Uncommon Cause of Abdominal Pain Mimicking Gastroenteritis
Authors: Lo CM , Lau HK , Kei SK
Published: December 2017

Abdominal pain and vomiting are frequently encountered in the emergency department. We report a 54-year-old man with an uncommon cause of intestinal obstruction – superior mesenteric artery syndrome – who presented with epigastric pain and vomiting. Diagnosis is clinical with radiological confirmation by upper gastrointestinal series or computed tomography scan. Most patients respond to conservative and supportive treatment. A minority may need surgical intervention.
Fluid Resuscitation in Burns: An Update
Authors: Chan JK , Ghosh SJ
Published: December 2017

Fluid resuscitation has been a mainstay in the treatment of major burns for over 50 years. Fluids must be commenced as soon as possible prior to transfer to a specialist unit in order to minimise burn wound conversion and reduce the incidences of burn shock, post-burn renal failure, life-threatening electrolyte disturbances and mortality. Due to the lack of robust evidence, uncertainty exists regarding the type of fluid, the rate of fluid administration and method of monitoring fluid resuscitation in these patients. The advances in our understanding of burn pathology and technology may have rendered fluid resuscitation formulae, such as the Parkland, obsolete. This review aims to provide an up-to-date summary on the controversies and advances in burns fluid resuscitation to aid the emergency practitioner to make informed decisions.
Elevated Heart‐Type Fatty Acid‐Binding Protein Predicts Early Myocardial Injury and Aids in the Diagnosis of Non‐St Elevation Myocardial Infarction
Authors: Naroo GY , Ali S Mohamed , Butros V , Haj A Al , Mohammed I , Alosert M , Terris J , Fikree M
Published: December 2017

Background

Biomarkers play an important role in the early diagnosis, risk stratification and management of patients with the acute coronary syndrome.

Objective

The objective of this study was to evaluate the clinical reliability of heart‐type fatty acid‐binding protein (h‐FABP) in identifying patients with the acute coronary syndrome in the early hours of chest pain.

Methods

Creatine kinase (CK‐MB) (in laboratory), troponin T (in laboratory) and h‐FABP (with point‐of‐care test CardioDetect®) were performed on 791 patients who presented with chest pain with duration since onset ranging from 20 minutes to 12 hours.

Results

Data of the 791 patients were analysed. h‐FABP had a higher sensitivity of 75.76% and a specificity of 96.97% compared with 58.59% and 98.84% for troponin T and 68.69% and 97.54% for CK‐MB respectively (in the first 6 hours). Conclusion: h‐FABP was found to be a better biomarker of cardiac necrosis in the early hours in the diagnosis of non‐conclusive ECG in patients with acute myocardial infarction. (Hong Kong j.emerg.med. 2009;16:141–147)
The Minimum Clinically Significant Difference in Visual Analogue Scale Pain Score in a Local Emergency Setting
Authors: Mark MSM , Au TTS , Choi YF , Wong TW
Published: December 2017

Objectives

To determine whether the minimum clinically significant difference (MCSD) in visual analogue scale (VAS) pain score varies with age, gender, education level and cause of pain (trauma versus non‐trauma) in Chinese patients.

Methods

This was a prospective descriptive study of local Chinese patients 15 years of age or older who presented with pain to the accident & emergency department. On presentation, patients were asked to indicate their current pain severity with a single mark through a standard 100–mm visual analogue scale. Then they would be offered an analgesic for pain‐relief. After 30–45 minutes, the patients were asked to give a verbal categorical rating of their pain as ‘a lot better’, ‘a little better’, ‘much the same’, ‘a little worse’, or ‘much worse’ and to mark the level of pain on a VAS of the same type as used previously. The MCSD in VAS pain score was defined as the mean difference between the current and preceding scores when the subject reported ‘a little worse’ or ‘a little better’ in pain. Data were compared based on gender, age, education level, and traumatic versus non‐traumatic causes of pain.

Results

186 patients were enrolled in the study, yielding 77 evaluable comparisons where pain was rated as ‘a little better’ or ‘a little worse’. Overall, the MCSD in VAS pain score in the group was 17 mm (95%CI 13.6 mm to 20.6 mm). There were statistically significant differences between the MCSD in VAS pain score between genders and causes of pain (trauma versus non‐trauma).

Conclusions

The MCSD in VAS pain scores was found to be 17 mm. There was significant differences in MCSD in VAS pain score in different genders and between trauma and non‐trauma cases.
What Have We Learnt from Bacterial Stool Culture Results? a Retrospective Study of Hospitalised Gastroenteritis Cases in a Regional Hospital in Hong Kong
Authors: Wong HT , Que TL , Ho PL
Published: December 2017

Background

Stool culture is one of the common investigations done for patients with gastroenteritis, and fluoroquinolones have been used frequently for suspected bacterial gastroenteritis.

Objective

To study the yield of bacterial pathogens in stool culture in a local regional hospital for in‐patients with gastroenteritis and the individual pathogens identified. Also, the value of stool culture and the prescription of fluoroquinolones as empirical antibiotics were reviewed.

Methods

This was a retrospective study. All in‐patients with the principal diagnosis of “gastroenteritis” in the year 2007 were reviewed. We excluded pregnant patients and patients under 18 years of age. Patients were divided into two age groups and data were analysed including demographics, clinical findings, admission time and culture results. Antibiotics prescription behaviour was also analysed.

Results

A total of 837 adult patients fulfilled the criteria. Among them, 562 cases had their stool saved and sent for bacterial culture. Eighty‐nine cases were found to have their stool cultures positive for bacteria. The identified pathogens were namely Vibrio parahaemolyticus (38.2%), Salmonella species (34.8%), Campylobacter species (11.2%), Plesiomonas species (10.1%) and Aeromonas species (3.4%) respectively. The yield of positive stool culture was 15.8%.

Conclusion

Vibrio parahaemolyticus and Salmonella species were still the most common pathogens for bacterial gastroenteritis among hospitalized patients in Hong Kong, especially in the young and middle aged. Their occurrence followed a seasonal pattern. Physicians had a tendency to prescribe fluoroquinolones for cases with fever and travel history. Also, the problem of antibiotic resistance did exist. It is important for practitioners to follow local guidelines before ordering microbiological investigations on stool and prescribing empirical antibiotic treatment.
Venomous Fish Sting Cases Reported to Hong Kong Poison Information Centre: A Three‐Year Retrospective Study on Epidemiology and Management
Authors: Chan HY , Chan YC , Tse ML , Lau FL
Published: December 2017

Objective

To study the epidemiology of venomous fish sting injuries, management and clinical outcomes of injured patients reported to the Hong Kong Poison Information Centre (HKPIC).

Methods

All venomous fish sting cases reported to HKPIC from July 2005 to June 2008 were retrieved from its database (DATOX) and the Hong Kong Hospital Authority (HA) Electronic Patient Record (ePR) computer system for analysis.

Results

There were a total of 33 fish sting cases in this study. The average age of the patients was 43 years (range 20 to 84) and 24 patients were males. Most cases were injured by catfish (n=12), followed by stonefish (n=7) and lionfish (n=4). Ten cases sustained fish sting injury whilst at work. Five patients developed fish sting complications including cellulitis, subacute tenosynovitis, abscess formation and foreign body retention. No mortality was recorded. Within 7 cases of stonefish injury, 3 cases were classified as moderate effect outcome. Two patients received stonefish antivenom and none developed anaphylaxis.

Conclusion

The majority of marine envenomations did not result in significant morbidity and required only supportive management. However, stonefish injuries might be associated with an increased risk of severe local symptoms which therefore required aggressive treatment including antivenom.
Ruptured Abdominal Aortic Aneurysm: A 7‐Year Retrospective Observational Study in an Emergency Department of Hong Kong
Authors: Chu NH
Published: December 2017

Objectives

To review the clinical presentations and outcomes of patients with ruptured abdominal aortic aneurysm (AAA) in a regional hospital and its evaluation in the accident and emergency department (AED).

Methods

This is a retrospective observational study of patients admitted through the AED with the discharge or post‐mortem diagnosis of ruptured AAA from 1st January 2002 to 31st December 2008 in a regional pubic hospital of Hong Kong. Their demographic and clinical data were recorded and analysed. The sensitivity of the AED in detecting ruptured AAA or symptomatic AAA was evaluated.

Results

Twenty‐six patients were found to have ruptured AAA and included in the study. All were Chinese. Seventeen patients had repair surgery done by open surgical method. Eighteen (69%) patients were diagnosed to have ruptured AAA or found to have symptomatic AAA in the AED. Three (12%) ruptured AAAs were diagnosed at post‐mortem. The most common presenting symptoms were abdominal pain (73%) and loss of consciousness (46%). Only five (19%) patients had the classical triad of abdominal pain, haemorrhagic shock and a pulsatile abdominal mass. Ultrasound of aorta was performed in 74% of cases in the group with ruptured AAA or symptomatic AAA diagnosed in the AED but none in the delayed diagnosis group (p=0.001). The former group were 3.7 times more likely to proceed to repair surgery (p=0.188) and had surgical repair operation 40.8 hours earlier than the latter group (p=0.006). Systolic blood pressure less than 90 mmHg at any time point before operation was found to correlate significantly with mortality (p=0.029).

Conclusion

A high index of suspicion and prompt recognition of ruptured AAA is of paramount importance. Emergency physicians should familiarise themselves with the clinical presentation and management of patients with ruptured AAA. Emergency ultrasound performed in the AED helps in the early detection of AAA.
Evaluating the Role of a Triage Electrocardiogram Protocol at an Urban Emergency Department
Authors: Lim BL , Vasu A , Lim GH
Published: December 2017

Objective

Our emergency department (ED) performs triage ECG for a variety of complaints to identify patients in need of treatment escalation. The aim of this study was to evaluate the existing triage ECG protocol as a means of treatment decision making.

Methods

This prospective observational study was conducted in an urban ED over one week. We recruited all patients aged 18 years and above with an undiagnosed complaint requiring a triage ECG based on the existing departmental protocol. As part of the protocol, an experienced emergency doctor then reviewed the ECG to determine the need for treatment escalation. Explicit data collection was performed using our electronic database. The outcome measures were proportions of triage treatment escalations, reasons for escalation and disposition status. Analysis was by descriptive statistics.

Results

739 patients were recruited from a total attendance of 3228. The rate of triage ECG was 23%. There were 22 (3%) triage escalations. Usually each escalation resulted from a combination of reasons. These included important ECG changes (77%), abnormal vital signs (5%) and ongoing symptoms (95%).

Conclusions

The triage ECG protocol resulted in important escalations in a small proportion of presentations. Future research is needed to refine guidelines on the use of triage ECG for different ED complaints.
A Case Report of Sodium Hypochlorite Accident
Authors: Lam TSK , Wong OF , Tang SYH
Published: December 2017

Sodium hypochlorite is widely used as an irrigating solution in dental practice. Despite its safe properties, serious complications can result from inadvertent use. We report a patient presenting to the accident and emergency department for sodium hypochlorite accident during dental root canal therapy. The management of this dental emergency condition is discussed.
Incarcerated Inguinal Hernia in Children
Authors: Turkyilmaz Z , Sonmez K , Karabulut R , Demirogullari B , Ozen IO , Kapisiz A , Kale N , Basaklar AC
Published: December 2017

Introduction

The aim of this study was to document the data of incarceration in a group of children with inguinal hernia and to investigate whether incarceration could have been prevented.

Materials and methods

A retrospective study reviewed the records of 3100 children who underwent herniorrhaphy between 1989 and 2007 in one centre, with 113 patients having hernia incarceration. In 16 patients, manual reduction was not attempted because of signs of strangulation, and in the remaining ones, reduction following sedation was not successful. The patients were evaluated with respect to age, postoperative mortality, and morbidity and especially whether he or she had been scheduled for operation in a surgical department. The incidence of incarcerated inguinal hernia and risk factors were analysed.

Results

Of the 113 patients with incarcerated inguinal hernia, 105 were boys (92.9%), with a male to female ratio of 13:1. The majority of the patients were under one year of age (n=73); and 47 were 0‐3 months old. Three laparotomies, 7 small intestinal resection and primary anastomoses, 2 oophorectomy, 7 partial omentectomy and 8 appendectomies were performed. During the 6 months to 18 years follow‐up, testicular atrophy was seen in 4 boys. Two babies died. Scrotal oedema, testicular atrophy and mortality rate were significantly higher in incarcerated hernia patients compared with those without incarceration (all with p=0.001).

Conclusions

Apparently, incarceration may be a preventable problem. Priority should be given to the treatment of inguinal hernias in infants less than 1 year of age, especially those 1‐3 months old, as their risk of incarceration is higher.
Life-Threatening Bleeding from the Pubic Branch of the Inferior Epigastric Artery after Pubic Ramus Fracture
Authors: Lu CK , Lee YC , Sun PL , Liang CL , Liliang PC
Published: December 2017

Isolated pubic ramus fracture with concurrent life-threatening bleeding caused by injury to the inferior epigastric artery (IEA) or its branches has rarely been reported and can frequently be overlooked. This paper reports two cases of isolated pubic ramus fracture with concomitant injury to the pubic branch of the IEA, causing serious bleeding and hemodynamic instability. Pelvic angiography showed leakage of contrast from the pubic branch of the IEA. The complication in both cases was successfully treated with transcatheter arterial embolisation.
Traumatic Rupture of Giant Pulmonary Hydatid Cyst in a Child
Authors: Karamustafaoglu Y Altemur , Gungor A
Published: December 2017

Introduction

Trauma as a cause of hydatid cyst rupture leads to various clinical conditions, especially in children. Current literatures regarding the clinical presentation and management of such patients are rare.

Case report

A 14-year-old child was admitted with chest pain and dyspnoea due to blunt thoracic trauma after falling off a bicycle. Chest computed tomography showed right hydropneumothorax and cystic cavity. After chest tube insertion, massive air leak was observed from the tube. Cystotomy and capitonnage were performed on the right lower lobe via a posterolateral thoracotomy. He was discharged from the hospital in good condition.

Conclusion

Ruptured hydatid cysts into the pleura are difficult to diagnose radiologically. It can be misdiagnosed radiologically as empyema or hydrothorax. In undetermined cases, all the findings may be suggestive but not diagnostic. Operation must be performed early for exploration when the condition is suspected. High complication rate has been found in children who were operated late.
Cervical Spinal Injury and Hyoid Fracture in a Near-Hanging Victim
Authors: Emet M , Saritas A , Aslan S , Uzkeser M , Cakιr ZG , Coskun S
Published: December 2017

Hanging is a kind of strangulation that involves suspension by the neck. A case of near-hanging is reported. The patient was a 56-year-old man with incomplete hanging. His initial Glasgow Coma Scale score was 8. Mild elevation of cardiac biomarkers and hyperglycaemia were found. Hyoid fractures and a slight anterior dislocation of the C6 vertebra were observed. In near-hanging victims, all hypoxia-sensitive organs should be examined carefully. Notwithstanding the different types of hanging (complete vs. incomplete), all victims should be assumed to have cervical injury until proven otherwise.
Short Term Prognostic Value of the Rapid B-Type Natriuretic Peptide Assay on Length of Hospitalisation in Congestive Heart Failure Patients Presenting to an Emergency Department in Hong Kong: A Prospective Observational Study
Authors: Law KK , Yau WH , Ho HF
Published: December 2017

Introduction

Congestive heart failure is a common disease presentation to the emergency department (ED) and most of these patients require hospitalisation for treatment. The aim of this study was to assess the predictive value of B-type natriuretic peptide (BNP) level measured at the ED with respect to the length of hospital stay (LOS) in patients presenting with congestive heart failure (CHF). We also compared whether the BNP level could be a better predictor of LOS than clinical parameters and attempted to establish a cut-off point of BNP level which could differentiate those CHF patients with short hospital stay from the whole population of CHF patients.

Method

Patients with clinical features compatible with congestive heart failure were recruited into the study. Point-of-care test for BNP level was performed. The LOS, 6-month readmission and mortality were retrieved from the computer Clinical Management System of the hospital. Pearson's correlation coefficient was used to test the association of BNP level and the LOS, 6-month readmission and mortality rate.

Result

One hundred and twelve (112) patients were recruited into this study and 20 of them succumbed during hospitalisation. The data of the remaining 92 patients were analysed. The correlation coefficient of BNP level and LOS was 0.088. The correlation coefficient of BNP level and readmission within 6 months was 0.130 while the correlation coefficient of BNP level and 6-month mortality was 0.121. The correlation coefficient of other clinical features and LOS ranged from −0.098 to 0.247. The mean LOS of patients with BNP less than 400 pg/ml was 93.29 hours (95%CI=57.38 to 129.19). The mean LOS of patients with BNP greater than 400 pg/ml was 181.05 hours (95%CI=126.01 to 236.08). Patients with BNP level less than 400 pg/ml tended to have a shorter LOS than those with BNP level greater than 400 pg/ml (p=0.046).

Conclusion

CHF patients with BNP level measured in the emergency department greater than 400 pg/ml tend to have a longer LOS than patients with BNP level less than 400 pg/ml. BNP is not a good predictor for readmission and mortality of these patients.
Evaluation of the Modified Acute Physiology and Chronic Health Evaluation Scoring System for Prediction of Mortality in Patients Admitted to an Emergency Department
Authors: Labaf A , Zarei MR , Jalili M , Talebian MT , Hoseyni HS , Mahmodi M
Published: December 2017

Objective

To evaluate the ability of the Modified Acute Physiology and Chronic Health Evaluation (M-APACHE II) scoring system for the prediction of mortality in patients admitted to a tertiary emergency department in Iran.

Methods

During the study period, all patients aged >12 years who had been admitted to the emergency department of a tertiary hospital in Tehran, Iran were enrolled in the study. Traumatic and poisoned patients and those who died immediately after arriving at the emergency room were excluded. Using the M-APACHE II, risk of mortality was calculated for each patient. Finally, expected and observed mortalities were compared and the accuracy of M-APACHE II for prediction of mortality was determined using receiver operating characteristics (ROC) analysis.

Results

During the study period, 389 cases including 236 males (60.7%) were enrolled into the study. The mean age of the patients was 60.6±19.4 years (range 14 to 98 years). 117 patients died (30%) while the M-APACHE II predicted 129 deaths. The greatest discrepancy between observed and expected deaths occurred at M-APACHE II scores ≥21. The constructed area under the ROC curve basng on predicted and observed death was 0.938 (95% confidence interval 0.915-0.961).

Conclusion

M-APACHE II is an accurate scoring system for predicting mortality in patients admitted to the emergency department. However, further studies are needed to confirm our findings.
Predictors of Mortality in Blunt Multi-Trauma Patients: A Retrospective Review
Authors: Ustundag M , Aldemir M , Orak M , Guloglu C
Published: December 2017

Purpose

The purpose of this study was to identify risk factors predicting mortality in multiple blunt trauma patients so as to prompt appropriate management during trauma resuscitation.

Method

To assess risk factors potentially related to mortality in multiple blunt trauma patients, we reviewed the medical records of 1419 multiple blunt trauma patients who were admitted to the emergency department. The patients were divided into two groups; the survival group (n=1308) and the death group (n=111). Initial data collected on arrival in the emergency department were analyzed.

Results

In the study, 67.4% (n=956) of 1419 patients were male, 32.6% (n=463) were female. The average age was 21.19±0.50 years (range 1-92). After controlling for the factors significantly related to outcome (all p<0.05), death due to multiple blunt trauma was more likely in patients who were of older age, who had major chest injury, who had intra-abdominal solid organ injury and who had low Glasgow Coma Scale (GCS) score and low Revised Trauma Score (RTS).

Conclusion

We conclude that older age, major chest injury, intra-abdominal solid organ injury, low GCS and low RTS were identified as possible risk factors for mortality in multiple blunt trauma patients.
Medical Coverage in Mass Events: The Oxfam Trailwalker 1996 to 2007
Authors: Au CKH , Ho HF , Yip EOY , Ng YW
Published: December 2017

Medical coverage of mass events is quite different from medical practice within hospitals. The environment can be hostile and chaotic. Participants may behave unpredictably due to the effects of alcohol, drugs, or simple surges of adrenaline during sports events. Emergency physicians have provided medical coverage for many events. Together with emergency nurses, they formed core members of the medical teams in these events. It is natural as staffs of emergency departments are trained to handle acute medical and surgical illnesses. In many cases, emergency physicians are medical directors of events and are responsible for organising and coordinating such medical coverage. Local examples are the Sixth World Trade Organization Ministerial Conference in 2005, the Oxfam Trailwalker, and the Equestrian Event of the 2008 Beijing Olympics and Paralympics. It is expected that many more emergency physicians will be invited to organise medical coverage for mass events in Hong Kong. Doctors from other specialties will provide additional assets. Input from doctors specialised in rehabilitation, for example, can implement the concept of rehabilitation in planning medical coverage. This article serves to illustrate the principles used in the medical coverage of Oxfam Trailwalker. Trailwalker was started as endurance training for the Gurkhas in Hong Kong. Walkers formed teams of four to complete the 100 km MacLehose Trail within a 48-hour time limit. Oxfam Trailwalker has a crowd of over 10,000 participants each year. The number of medical contacts is about 1600 to 1800 each year.
Acute Torsion of a Wandering Spleen Causing Acute Abdomen
Authors: Yakan S , Telciler KE , Denecli AG
Published: December 2017

Wandering spleen is a rare clinical entity characterised by splenic hypermobility resulting from laxity or maldevelopment of the suspensary gastrosplenic, splenorenal, and phrenicocolic ligaments. Diagnosis is quite difficult because of the lack of symptoms and signs until splenic torsion have occured. In this article, we present and discuss a 23-year-old caucasian woman presenting with acute abdomen, diagnosed as splenic torsion by ultrasound and magnetic resonance imaging and managed surgically.
A Case Report of Haemorrhagic Fever with Renal Syndrome
Authors: Wong WCL , Lee FT , Tang HL
Published: December 2017

A 42-year-old air-conditioning technician presented with abdominal pain and influenza like illness eventually developed thrombocytopenia and haemoconcentration with renal impairment shortly after admission. The patient required a section of haemodialysis for acute oliguric renal failure with fluid overload. He developed diuresis and his clinical condition was improved with supportive treatment. Hantaan virus infection with haemorrhagic fever with renal syndrome was confirmed by serologic test.
Cardiac Arrest after Blunt Chest Injury in a Patient with Undiagnosed Idiopathic Ventricular Fibrillation
Authors: Wong OF , Lam SK , Chan YH , Tsang PHK , Ng LK , Koo CK
Published: December 2017

We report a case of cardiac arrest occurring in a patient after blunt chest injury with fist during an assault event. The patient survived with prompt cardiopulmonary resuscitation and defibrillation. Subsequent electrophysiology study revealed inducible ventricular fibrillation and automatic implantable cardioverter defibrillator was implanted. The cardiac complications from blunt chest trauma are discussed.
Bicycle-Related Crashes in Hong Kong: Is it Possible to Reduce Mortality and Severe Injury in the Metropolitan Area?
Authors: Sze NN , Tsui KL , Wong SC , So FL
Published: December 2017

Background

Cycling is not the primary mode of commuter transport in Hong Kong, yet cyclists are exposed to a high risk of injury and fatality in road crashes. It is essential to identify the significant factors contributing to severe injury among cyclists in Hong Kong.

Aim

To evaluate the effects of significant factors, including demographics, temporal distribution, cyclist behavior, road conditions, and weather, on the risk of severe and life-threatening injury among cyclists in road crashes in Hong Kong.

Method

The study was nested on a database known as Road Casualty Information System (RoCIS) which is a linked database between police traffic accident investigations reports and hospital injury records. A total of 682 victims were identified during the study period from 1 January 2004 to 31 December 2006. In particular, injured body part, demographics, helmet use, alcohol intoxication, weather conditions, road type and geometry, and collision characteristics of 682 trauma patients were the attributing variables of concern. The primary outcome measure was the injury severity of trauma patients which was classified into three levels: slight injury [Injury severity Scale (ISS) </=8], severe injury (ISS >/=9), and life-threatening injury (ISS >/=25). A multinomial logit regression model was established to evaluate the significance of factors contributing to severe and life-threatening injuries among cyclists in road crashes.

Results

The results indicated that middle-aged and elderly (35-54, RRR=2.48; and 55 or above, RRR=4.39) casualties and favourable weather conditions (2.56) significantly increased the risk of severe injury among cyclists. The presence of severe head injury (RRR=509.24), severe trunk injury (RRR=79.24), and the involvement of motor vehicles (RRR=27.18) substantially increased the risk of life-threatening injury to cyclists.

Conclusions

Middle-aged casualties, the presence of head injuries, and the involvement of motor vehicles all increase the risk of more severe injury in bicycle-related crashes. Safety education and countermeasures should target at middle-aged and elderly cyclists and discourage cycling on the motorway.
Post Traumatic Paediatric Ischaemic Stroke: Case Presentation
Authors: Akinci E , Yuzbasioglu Y , Coskun F
Published: December 2017

Stroke is a disorder, which occurs suddenly as a result of vascular disorders and presents with variable neurological signs. Occlusive vascular diseases in childhood have many causes. Connective tissue disorders such as vasculitis, metabolic disorders, migraine, cyanotic heart diseases, infections, dehydration, nephrotic syndrome, malignancies, haemoglobinopathies, Moya moya disease and trauma are some of these causes. Stroke occurring in children as a result of minor head trauma sustained during falls and sport activities are also reported in the literature. An extensive evaluation is necessary for effective treatment of these children and to show the cause of the infarction. We present a case of a two-year-old patient suffered from acute ischaemic stroke resulting from a short distance fall. (Hong Kong j.emerg.med. 2011;18:169-172)