bluuebunny/crossref_metadata_2025 huggingface dataset:
Analgesia for Adult Distal Radius Fracture Manipulation in the Emergency Department: Demand Valve Nitrous Oxide Compared with Intravenous Regional Anaesthesia
Authors: Goh PL , Lee SW , Goh SH
Published: December 2017

Introduction

This study compared demand-valve nitrous oxide (Entonox) with intravenous regional anaesthesia (IVRA) as analgesia in adults with distal radius fractures requiring manipulation and reduction (M&R) in the Emergency Department.

Materials and methods

All adults presenting to the Emergency Department of Changi General Hospital, Singapore between August to December 2000 with closed distal radius fractures requiring M&R were enrolled. Five parameters were measured: pain perception using visual analogue scale (VAS), patient acceptance, procedure time, complication rate and failed manipulation.

Results

Of the 67 patients enrolled, 32 received IVRA and 35 received Entonox. The average VAS was 2.2 cm for the IVRA group and 5.8 cm for the Entonox group (p<0.0001). The average procedure time was 25.6 minutes for the IVRA group and 11.1 minutes for the Entonox group (p<0.0001). Twenty-seven IVRA patients (84.4%) and 24 Entonox patients (68.6%) would agree to the same analgesia given similar circumstances (p=0.159). Four patients who received Entonox (11.4%) experienced minor complications, while no complications were noted in the IVRA group (p=0.115). Two patients who received IVRA (6.3%) and 8 patients who received Entonox (22.9%) required more than a single attempt at M&R (p=0.086).

Conclusion

The use of Entonox, compared to IVRA, was associated with significantly shorter procedure time but significantly higher pain scores, with no significant difference in terms of patient acceptance, complication rate or failed manipulation rate. Entonox is an effective analgesic alternative to IVRA in adult patients requiring M&R for distal radius fractures in the Emergency Department. Its use is ideal in situations where IVRA is unsuitable or contraindicated.
Airway Foreign Body: A Difficult and Often Neglected Diagnosis in Asthmatic Child in Emergency Department
Authors: Tong YH , Lau CC
Published: December 2017

Foreign body inhalation is not uncommonly encountered in children. Diagnosis could be difficult if parent cannot recall any relevant clinical history. This is especially true for an asthmatic child as respiratory signs and symptoms are believed by most emergency physicians to be attributed to asthma alone. We present a case of inhalation of peanut to the left main bronchus in an asthmatic child who was initially misdiagnosed as exacerbation of bronchial asthma. Meticulous clinical history and careful physical examination supplemented by chest radiograph in full expiration would raise the clinical suspicion of an obstructing foreign body within the bronchial tree. The diagnosis was subsequently confirmed on bronchoscopy and the obstructing peanut was successfully removed. As emergency physicians, we cannot attribute respiratory symptoms in an asthmatic child to be due to asthma alone. In the presence of respiratory symptoms of acute onset, unilateral physical signs and radiological evidence of air-trapping, foreign body inhalation should be considered even in the absence of accurate clinical history. Prompt arrangement for bronchoscopy assessment is recommended.
Female Trauma Patients in the Emergency Department: Should their Injury Prevention Programme be Different?
Authors: Chan KC , Seow E , Lau G , Chan SP , Tham KY
Published: December 2017

Background

(1) To compare the characteristics of female and male trauma patients seen in the Emergency Department (ED) and (2) to determine if injury prevention programmes for women should be different.

Methods

A prospective survey was conducted for 11544 trauma patients, aged 15 years and above, who presented to the ED of an urban public hospital in Singapore over 6 months. The following data were collected: demography, place, type and mechanism of injury and subsequent disposition from the ED.

Results

Almost half (49.5%) the injuries sustained by females occurred at home, with low falls of less than 2 metres being the most common mechanism of injury (52.7%). Victims of domestic violence were predominantly female at p<0.0001.

Conclusion

Injury prevention programs for women should focus on home safety and low falls. Special assistance programs for the victims of domestic violence should be available in the ED as the latter may be their only access to safety.
Severely Injured Patients Presenting to the Singapore General Hospital: a one Year Study
Authors: Lim YH , Yeo A , Koh MP , Wong CY
Published: December 2017

Study objectives

To determine the quantity and resource utilisation in management of the severely injured patients presenting at the Singapore General Hospital (SGH).

Method

All patients who were initially triaged to the hospital Emergency Department's (ED) resuscitation room and all trauma related mortality in the year 1998 were studied. All records were traced and the cases were followed up. Important outcomes studied were mortality and length of hospital stay.

Results

Three hundred and forty‐seven (0.2%) severely injured patients who were initially treated at the ED's resuscitation room were studied. The median age of the patients was 32 years old. Male patients formed 82.1% of the total. The three main causes of trauma in such patients were fall from height, motor vehicle related accidents and penetrating injuries caused by sharp instruments and firearms. Of all the patients, 62.8% were admitted to the ED between 1601 hours to 0759 hours and 30.5% of all severely injured patients were treated at the ED on weekends. One hundred and twenty three (35.4%) patients had emergency surgery within 24 hours of admission to the ED and 42.4% of the patients had an ISS score of 16 or more; 22.8% of patients had ISS score of 25 or more. The mortality of patients with ISS score of 25 or more was 39.2%.

Conclusion

One percent of all new ED patients with trauma were classified as ‘severely’ injured and these occurred mostly outside “normal working hours”. There was significant mortality in patients with ISS score of 25 or more.
Can Tension Haemopneumothorax Have Stable Haemodynamics?
Authors: Siu AYC , Chung CH
Published: December 2017

Tension pneumothorax or haemopneumothorax is a clinical diagnosis. Plain radiography is not advised to confirm the diagnosis and may delay definitive treatment. Unstable haemodynamics is one of the prerequisites for the diagnosis. We report a case in which the patient suffered from haemopneumothorax with all the typical radiological features of tension, but without any clinical sign of unstable haemodynamics. Close monitoring of patients suspected to have pneumothorax is recommended, especially in the radiology suite.
Hunger and Poverty among Elderly Patients Attending an Emergency Department
Authors: Tham KY , Poon SL , Thong SY
Published: December 2017

Background

Singapore is an affluent small nation‐state with a high per capita gross domestic product.

Objective

To determine the prevalence of hunger and poverty among elderly patients attending an emergency department (ED).

Methods

All patients aged 65 years and above who sought treatment at the ED of an urban acute care hospital over one week between 0900 and 1700 hours were surveyed. Two trained interviewers administered a face‐to‐face close‐ended questionnaire. Data collected were demographics, health status and surrogate indicators of poverty and hunger.

Results

Of the 210 non‐critically ill patients approached, data was available for 194 (92.4%), of which 51% were men. The mean age was 76.7 (SD 7.4) years. Majority of the patients were well taken care of but a minority were not coping: 0.5% was homeless, 3.1% had skipped medical appointments in the last year due to lack of money, 1% did not have enough to eat and were not receiving any food aid and 1.5% borrowed money to buy food in the previous six months. Despite their advanced age, there were 12 (6.2%) who were sole breadwinners for their families. Twenty‐one patients (10.8%) were already on welfare assistance and 5.7% received food aid to supplement their basic food needs.

Conclusion

Though the numbers were not alarming, it was worrying that some elderly patients were going hungry or skipping medical appointments due to lack of money or still had family dependent on their income. The ED can help by actively identifying these at‐risk elderly and referring them for welfare assistance.
Nurses' Attitude toward Alcoholic Patients in Accident and Emergency Department in Hong Kong
Authors: Chung JYM , Chan JTS , Yeung RSD , Wan RCH , Ho ST
Published: December 2017

Few studies on the attitude of nurses toward alcoholic patients have been conducted in Hong Kong. The aim of this study was to understand the attitude of nurses toward alcoholic patients in local Accident and Emergency Departments (AEDs). Alcoholism is a stigmatized ‘disease’. Some studies revealed that nurses tended to have negative attitudes toward people with alcoholic problems. This can influence the quality of healthcare provided to this group of patients. As a result, alcoholic patients may not be properly treated. The researchers of this study employed a cross‐sectional survey to gather data from the targeted sample. The Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ) was used to evaluate the attitudes of nurses toward alcoholic patients. In addition, relationships between therapeutic attitude toward alcoholic patients and various independent variables (including experience in specialty, education related to alcohol and alcoholic problems, the degree of support received from co‐workers, and self‐esteem of individuals) were analyzed. Six hundred nursing staff, including registered nurses, enrolled nurses and nursing officers working in AED, were invited to participate in the study. One hundred and ninety (31.6%) of them responded. The findings showed that nurses working in AEDs tended to have negative attitudes toward alcoholic patients. Most of those surveyed got low scores in role security, which indicated they perceived themselves inadequate in both skills and knowledge relating to problem drinkers. The findings also reflected that the degree of support received and self‐esteem correlated with the overall attitude toward alcoholic patients. To conclude, providing more support and training opportunities to nursing staff are conducive to more positive attitude of nurses toward alcoholic patients.
Predictive Value of a 6-Hour Ecg/Troponin Protocol in Patients with Chest Pain
Authors: Man CY , Cameron PA , Cheung WL
Published: December 2017

Introduction

Patients presenting with chest pain and considered to be at low risk of acute coronary syndrome (ACS) may still have coronary heart disease. The potential risk of sudden cardiac death due to arrhythmias or progression to acute myocardial infarction still exists. To minimize this risk, we have designed a 6-hour risk stratification protocol for patients with a low risk of acute myocardial infarction on initial assessment in the Accident and Emergency Department (AED).

Materials & Methods

This was a retrospective observational study with the aim of determining the risk of adverse cardiovascular events in chest pain patients attending an AED. These patients were subject to an ECG and cardiac troponin T tests (cTnT) at 0 hour and at 6 hours (if the two tests were negative at 0 hour), and were put under observation in the AED observation ward during the same period. The main outcome measures were adverse cardiac events at 30 days.

Results

A total of 371 Chinese patients considered to have low risk of ACS were recruited into the protocol. Troponin T tested positive in 19 patients (5.1%) at 0 hour and 8 patients (2.2%) at 6 hours. Amongst the 332 patients that were discharged directly from the AED, there were no re-admissions for cardiac-related deaths, acute myocardial infarction, arrhythmia or heart failure.

Conclusion

The 6-hour ECG and troponin T observation protocol is a useful tool to allow safe discharge of chest pain patients who are at low risk of acute coronary syndrome.
Diagnostic Challenges: Pseudo-Phenomenon in Wolff-Parkinson-White Syndrome
Authors: Sia YS , Wong YT , Kan PG
Published: December 2017

We reported two patients who presented with non-specific chest symptoms with ECG changes mimicking acute myocardial infarction and ventricular hypertrophy. Both of them were finally confirmed to have Wolff-Parkinson-White (WPW) syndrome after spontaneous resolution of the ECG changes. As a matter of fact, other differential diagnosis should be considered with respect to the ST-segment changes. Diagnostic pitfalls can be avoided by detailed analysis of the ECG before commencement of thrombolytic agents.
A Prospective, Randomised Clinical Trial Comparing Oral Diclofenac Potassium and Intramuscular Diclofenac Sodium in Acute Pain Relief
Authors: Ho MK , Chung CH
Published: December 2017

Objectives

To compare the efficacy of oral (PO) diclofenac potassium (Cataflam®) and intramuscular (IM) diclofenac sodium (Voltaren®) in acute pain relief, with a hypothesis of equivalence between the two.

Patients and methods

In this prospective randomised single center clinical study, adult Chinese patients attending the emergency department and suffering from renal colic, acute musculoskeletal injury or arthritis were enrolled. They were randomly assigned either 75 mg of IM Voltaren® or 75 mg of PO Cataflam®. Pain was assessed by the Visual Analogue Scale (VAS) and evaluations were performed at baseline, 30 minutes, 1 hour and 2 hours after treatment. Blood pressure, pulse rate and respiratory rate were also recorded at similar time intervals.

Results

We recruited 46 cases in the Voltaren® group and 45 cases in the Cataflam® group. Both treatment groups showed statistically highly significant reduction (P<0.0001) in pain VAS, systolic blood pressure and pulse rate compared with the baseline. Voltaren® was statistically more effective in pain relief at 30 minutes (P=0.012) and 1 hour (P=0.010) but not at 2 hours (P=0.311) compared with Cataflam®. The changes in blood pressure, pulse rate and respiratory rate were not statistically significant between the two treatment groups at all time points.

Conclusion

IM Voltaren® was more effective in acute pain relief compared with PO Cataflam®.
The Diagnostic Value and Cost-Effectiveness of Creatine Kinase-MB, Myoglobin and Cardiac Troponin-T for Patients with Chest Pain in Emergency Department Observation Ward
Authors: Choi YF , Wong TW , Lau CC
Published: December 2017

Aim

To evaluate the diagnostic value and cost-effectiveness of creatine kinase-MB isomer, myoglobin and cardiac troponin-T for patients with chest pain in emergency department observation ward.

Method

A prospective study was carried out to include all patients presenting with chest pain of suspected cardiac origin and admitted to the observation ward. Electrocardiogram and blood tests for the three cardiac markers were performed at the time of consultation and six to eight hours after admission to the observation ward. Progress of the patients was followed up for 30-day survival or the condition reviewed up to six months and the final diagnoses were documented.

Result

A total of 480 patients were recruited. The incidence of acute myocardial infarction was 1.5%. No one died of cardiac cause within 30 days. Troponin was more accurate than creatine kinase for diagnosing acute myocardial infarction and it was cost-effective. Myoglobin was of no value.

Conclusion

Troponin is recommended as a diagnostic tool for evaluating patients with chest pain in observation ward.
Clinical and Ultrasonographic Diagnosis of Acute Appendicitis
Authors: Tan LTH , Ong KL
Published: December 2017

Appendicitis is one of the most common acute abdominal conditions encountered in the Emergency Department. It is a surgical condition that can affect any person of any age and often with varying clinical presentations. In the majority of cases, the diagnosis is straightforward. However in some, the diagnosis requires a heightened clinical suspicion. The application of adjuvant laboratory tests and diagnostic imaging helps to reduce the associated complications, morbidity and mortality of delayed diagnosis.
Ciguatera fish Poisoning: a Challenge to Emergency Physicians
Authors: Cheng CC , Chung CH
Published: December 2017

Seven patients from two families presented with ciguatera poisoning after fish consumption. They suffered most of the typical clinical features of ciguatera poisoning and were given supportive treatments. Three of them were given mannitol infusion and showed improvement in symptoms. All of them were discharged within two days.
Emergency Medicine: Now a Global Specialty
Authors: Podgorny G
Published: December 2017

First and Past President, American Board of Emergency Medicine Past President, American College of Emergency Physicians First and Past Chairman, Residency Review Committee, Accreditation Council on Graduate Medical Education
Emergent Cranial Computed Tomography in the Evaluation of Adult Non‐Trauma Patients in the Emergency Department
Authors: Lim HC , Wong EH
Published: December 2017

Objectives

To study the utilisation pattern of head computed tomography (CT) for non‐trauma adult cases in an urban emergency department (ED) and the rate of clinically significant CT abnormalities. We also tried to identify any useful clinical indicators that could be used to predict abnormal scans.

Methodology

A one‐year case series of adult non‐trauma cranial CT scans ordered in an urban ED was studied. Patients less than 16 years old, with CT head done prior to presentation and/or attendance precipitated by trauma were excluded. Logistic regression was used to identify significant predictors for abnormal scans. Clinical indicators that were studied included age, altered mental status (AMS), headache and vomiting, elevated blood pressure, previous history of hypertension, Glasgow Coma Scale (GCS) and presence of focal neurological sign (FNS).

Results

183 adult non‐trauma cranial CT scans were included in the study, and 109 (59.6%) CT scans revealed clinically significant abnormalities. Only AMS and FNS were found to be statistically significant in predicting abnormal scans. Patients with AMS had a 2.5 times (95% CI: 1.1 to 5.8) higher odds for an abnormal scan compared to those without AMS, adjusting for FNS. Patients with FNS had adjusted odds of 8.9 (95% CI: 4.2 to 18.8).

Conclusion

This study reports a high (59.6%) rate of abnormal adult non‐trauma cranial CT compared with previous studies. Altered mental status and the presence of focal neurological sign are significant predictors for an abnormal scan. They should serve as useful criteria when devising utilisation strategies for emergency non‐trauma cranial CT in future studies.
Helicopter Evacuation: the Singapore General Hospital Experience
Authors: Lee JMH , Lim SH , Anantharaman V
Published: December 2017

Objective

To review the current state of helicopter casualty evacuations (helicasevac) in Singapore.

Methodology

A retrospective study of helicasevac missions to the Singapore General Hospital over a 12‐year period from 1991 to 2002.

Results

Of the 297 casualties evacuated over 234 missions during the period, 90.2% (268/297) were trauma related and 9.8% non‐trauma. The majority of these trauma casualties were military national servicemen with heat injuries (63.4%, 170/268), followed by external injuries (25.0%, 67/268). The most common medical referrals were for cardiovascular or neurological conditions. Most of the patients brought in were critically ill, unconscious or semiconscious. Most were admitted (88.2%, 262/297). None of the 19 patients who collapsed and were without signs of life prior to helicopter transport survived attempted resuscitation at the emergency department. The usefulness of transferring them with helicopter is doubtful. The on‐scene diagnosis and inpatient diagnosis for the patients were consistent in 98.6%. The air evacuation mission locations were mainly from the surrounding islands of Singapore ‐ 58%, while 17% were from ships traversing the nearby straits e.g. the Straits of Malacca and South China Sea and 19% were from military camps within mainland Singapore.

Conclusion

The criteria for despatching helicopters for air evacuation in Singapore have not been established. There are benefits in terms of transport time and bringing on‐site medical care to casualties at distant offshore locations. The benefit of evacuating urban patients by helicopter is doubtful, especially if they are already in cardiopulmonary arrest.
Hydronephrosis: Case Report of a Rare Cause of the Supine Hypotensive Syndrome
Authors: Shek KC , Chung KL , Kam CW , Yau HH
Published: December 2017

Hypotension poses a diagnostic challenge to emergency physicians who often have to exclude life‐threatening conditions, make correct diagnosis and institute timely treatment. We presented a case of hydronephrosis causing the supine hypotensive syndrome. Management of the supine hypotensive syndrome and the use of emergency bedside ultrasound in evaluating hypotensive patients were discussed.
Alarming Pneumomediastinum but Benign Outcome: a Case Report on Oesophageal Perforation by Foreign Body
Authors: Chung CH
Published: December 2017

A case of oesophageal perforation after endoscopic removal of foreign body is described. A 50‐year‐old female had a sharp fish bone impacted in the cervical oesophagus. After dislodging the bone at endoscopy, she developed neck pain and swelling. Chest X‐ray showed alarming pneumomediastinum and subcutaneous emphysema. However, there was no leakage in the water‐soluble contrast swallow. She was successfully managed conservatively. Early recognition and proper management of such a well‐known complication are important to lower morbidity, especially in view of the fact that endoscopic removal of swallowed foreign bodies is being performed on an outpatient basis in some emergency departments. Special precaution should be given to sharp foreign bodies lodged at the cervical oesophagus.
Differential Diagnosis of Acute Calf Pain and Swelling with Emergency Ultrasound
Authors: Chung KL , Cheung KY , Kam CW
Published: December 2017

Acute calf pain and swelling are common causes of emergency department attendance. Differential diagnoses may mimic each other causing confusion and uncertainty in management. With emergency ultrasound, most of the differential diagnoses for acute calf pain and swelling can be identified with confidence. We present two cases of calf pain and swelling utilising ultrasound to clarify the diagnosis.
Pneumoperitoneum on Supine Abdominal X‐Ray: Case Report and Review of the Radiological Signs
Authors: Chiu HS , Chung CH
Published: December 2017

An elderly gentleman suddenly developed moderate to severe epigastric pain associated with hypotension and tachycardia. A supine abdominal X‐ray was taken. Urgent CT abdomen performed after initial stabilisation revealed large amounts of free gas and fluid in the peritoneal cavity. Emergency Laparotomy revealed a perforated gastric ulcer. Review of the supine abdominal X‐ray showed a number of radiological signs of pneumoperitoneum. As supine abdominal X‐rays are commonly performed in emergency departments, doctors should be competent in interpreting the radiological signs.
Spontaneous Pneumomediastinum: An Uncommon Complication from an Augmented Physiological Belching (Imitating a TV Show Game)
Authors: Shek KC , Lo CM , Ong KL , Kam CW
Published: December 2017

Noisy belching in front of other people, often considered to be an impolite manner, may not be as harmless as it seems. We report on a patient who had spontaneous pneumomediastinum after intentional induction of noisy belching by rapid excessive intake of carbonated drinks (imitating the game played in a popular local television program “The Super Trio Continues…”). The clinical features, investigations and management of spontaneous pneumomediastinum are discussed.
Management of Body Packers in the Emergency Department
Authors: Wong GCK , Lai KK , Chung CH
Published: December 2017

Body packing of illicit drugs is one of the means of drug trafficking. Asymptomatic suspects may be brought in by law-enforcement officers for body search of possible drug packing inside the body. Symptomatic body packers may present with gastrointestinal obstruction or toxicity of the leaking drugs inside the packets. Management strategies are largely determined by the modes of presentation. Asymptomatic persons must be persuaded with every effort for consent to the body cavity search as well as treatment for the safe passage of any packed drugs to avoid possible complications and medico-legal sequelae. Abdominal X-rays and computed tomography can be helpful in confirming the presence of drug packets and in identifying possible packet leakage. Gastrointestinal decontamination, whole bowel irrigation, use of specific antidote as well as operative intervention may be indicated. Emergency physicians must be conversant with the medical and legal aspects of the management of these body packers.
How Efficient can we Treat Presumed Acute Uncomplicated Lower Urinary Tract Infection in Women with 3-Day Antibiotic in the Accident & Emergency Department?
Authors: Li YW , Yuen WL
Published: December 2017

Introduction

Urinary tract infection is a common problem in females encountered in the Accident & Emergency Department. The increasing prevalence of Escherichia coli and other urine isolates resistant to trimethoprim-sulfamethoxazole and ampicillin enhances the use of nitrofurantoin as the first line therapy. A guideline of 3-day antibiotic in presumed uncomplicated cystitis has been proved to be of improved cost-effectiveness.

Objective

To study the outcome and efficiency of 3-day antibiotic treatment in presumed acute uncomplicated cystitis in women in the Accident & Emergency Department.

Methods

This was a prospective study on women aged 18–55 years with presumed uncomplicated cystitis from January to June 2004. A telephone survey was conducted to assess the clinical response, adverse effect and compliance of the treatment.

Results

Initially 83 patients were recruited in the study, but only 76 patients' outcomes could be traced by telephone survey and the computer system in public hospitals. Fifty-eight patients (76.3%) had good clinical response with symptoms resolved usually on day 2. Though 48.1% of the patients reported side effects with mainly gastrointestinal discomfort, most were mild and tolerable. The overall compliance was above 80%.

Conclusion

Three-day nitrofurantoin is an effective, inexpensive treatment for acute uncomplicated cystitis, which is a common disorder in females. Guidelines on the management of this large group of patients would help to conserve health care costs, improve compliance and reduce the emergence of resistance strains.
Persistent Fever and Exanthema in a Family: A Case Report of Mediterranean Spotted Fever
Authors: Ng CP , Chung CH
Published: December 2017

Mediterranean spotted fever (also called Boutonneuse fever) is a notifiable disease in Hong Kong, but its diagnosis can be difficult. We report a case of Mediterranean spotted fever in a middle-aged man who presented with persistent fever, headache, and skin rash. Three weeks ago, his daughter had similar presentations. With a history of similar clinical presentation within family members, the possibility of potential exposure to a common disease vector should be suspected. Establishing an early diagnosis may be possible if this important history is obtained. Early recognition of this disease may lead to early therapeutic intervention, resulting in decreased morbidity and shortened duration of hospital stay.
A Six-Year Prospective Study of Out-of-Hospital Cardiac Arrest Managed by a Voluntary Ambulance Organisation
Authors: Chung CH , Wong PCY
Published: December 2017

Objective

To obtain a database on the epidemiology of prehospital cardiac arrest and its management by a voluntary ambulance service, with the view for developing future strategies and service improvement.

Design

A 6-year prospective study from December 1998 to November 2004, using the Utstein-style template.

Setting

A voluntary ambulance service in Hong Kong.

Subjects and methods

Ambulance members had to complete and submit a specially designed data form after managing a cardiac arrest case, together with the ambulance run record and the automated external defibrillator (AED) computer printout, if appropriate.

Main outcome measures

Survival to hospital discharge and return of spontaneous circulation after resuscitation.

Results

A total of 72 cardiac arrests occurred during the period, with patients' age ranging from 29 to 106 years (mean 73.4). Most cardiac arrests occurred at home (46 or 63.9%). There were 58 witnessed cardiac arrests (80.5%), but bystander cardiopulmonary resuscitation (CPR) was started in only nine cases (15.5%) before the arrival of the ambulance crew. Six patients had evidence of rigor mortis or dependent lividity on ambulance arrival. For the 61 patients with electrocardiogram strips, the initial presenting rhythm on the AED was asystole in 45 (73.8%), pulseless electrical activity in 5 (8.2%), and ventricular fibrillation (VF) in 11 (18.0%). The median call-to-arrival time for VF cases (4.0 minutes) was significantly shorter than that of non-VF rhythms (8.5 minutes) [Mann-Whitney U test p=0.008]. Five patients had return of spontaneous circulation after resuscitation, but only one survived to hospital discharge.

Conclusions

Bystander CPR and ambulance response time are two areas requiring urgent improvement in our locality. As the majority of cardiac arrests occurred at home, the cost-effectiveness of public access defibrillation for Hong Kong is unclear. However, strategic placement of AED at high incidence' locations should be seriously considered.
Out-of-Hospital Cardiac Arrest in a Teaching Hospital in Hong Kong: Descriptive Study Using the Utstein Style
Authors: Wai AKC , Cameron P , Cheung CK , Mak P , Rainer TH
Published: December 2017

Objective

To describe, using the Utstein template, the characteristics of patients presenting with out-of-hospital cardiac arrest to a university teaching hospital in the New Territories of Hong Kong, and to evaluate survival.

Design

Prospective study.

Setting

The emergency department of a teaching hospital in the New Territories, Hong Kong.

Participants

Patients older than 12 years with non-traumatic out-of-hospital cardiac arrest who were transported to the hospital between 1 July 2002 and 31 December 2002.

Main outcome measures

Demographic data, characteristics of cardiac arrest and response time intervals of the emergency medical service presented according to the Utstein style, and also survival to hospital discharge rate.

Results

A total of 124 patients were included (49.2% male; mean age 71.9 years). The majority of cardiac arrests occurred in patients' home. The overall bystander cardiopulmonary resuscitation (CPR) rate was 15.3% (19/124). The most common electrocardiographic rhythm at scene was asystole, whilst pulseless ventricular tachycardia (VT)/ventricular fibrillation (VF) was found in 18.0%. The overall survival was 0.8% (1/124), and survival to hospital discharge was significantly higher for patients with VF or pulseless VT than those patients with other rhythms of cardiac arrest (11.1% versus 0%). The median witnessed/recognised collapse to defibrillation time was 14 minutes. The median prehospital time interval from collapse/recognition to arrival at hospital was 33 minutes.

Conclusion

The prognosis of out-of-hospital cardiac arrest in Hong Kong was poor. Major improvements in every component of the chain of survival are necessary.
Review on the Outpatient Treatment for Pelvic Inflammatory Disease, what is the best for Hong Kong?
Authors: Kung SW , Ng MH
Published: December 2017

Pelvic inflammatory disease is an important risk factor for infertility, ectopic pregnancy and chronic pelvic pain. Although the Centers for Disease Control and Prevention published treatment guidelines for pelvic inflammatory disease in 2002, the effectiveness of treatment has been affected by the emergence of quinolone-resistant Neisseria gonorrhoeae. The prevalence of quinolone-resistant Neisseria gonorrhoeae is highly variable with time and place. In Hong Kong, quinolone-resistant Neisseria gonorrhoeae is over 90%, thus ceftriaxone, doxycycline and metronidazole should be the treatment of choice. For patients sensitive to cephalosporins, azithromycin and metronidazole can be considered as alternative treatments.
Psychological Morbidity among Emergency Department Doctors and Nurses after the SARS Outbreak
Authors: Tham KY , Tan YH , Loh OH , Tan WL , Ong MK , Tang HK
Published: December 2017

Objective

To determine the psychological morbidity among emergency department (ED) doctors and nurses six months after the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak.

Methods

During the SARS outbreak from 13 March to 31 May 2003, the study ED was designated as Singapore's only screening centre for SARS and was closed to all other patients. A self-administered questionnaire survey was conducted in November 2003. Doctors and nurses of the study ED who had patient contact during the outbreak were included. Data collected were demographics and responses to (a) Impact of Event Scale (IES) and (b) General Health Questionnaire 28 (GHQ 28). Scores were assigned to the responses whereby an IES score ≥26/75 or a GHQ 28 score ≥5/28 was indicative of post-event and psychiatric morbidity respectively.

Results

Thirty-eight out of 41 (92.7%) doctors and 58 out of 83 (69.9%) nurses responded. Fewer doctors reported post-event and psychiatric morbidity compared to nurses, with 5 (13.2%) doctors and 12 (20.7%) nurses scoring ≥26 on IES, 6 (15.8%) doctors and 12 (20.7%) nurses scoring ≥5 on GHQ 28. The doctors reported a median of 9.5 (range 0–47) on IES and 0 (range 0–11) on GHQ 28. The nurses reported a median of 15 (range 0–61) on IES and 1 (range 0–25) on GHQ 28.

Conclusions

Six months after SARS, the rates of post-event and psychiatric morbidity were relatively low among the study ED doctors and nurses. The results might have underestimated actual morbidity as the study was conducted six months after the outbreak.
Ambulances: From Antiquity to Modern Times
Authors: Lateef F , Nimbkar NV
Published: December 2017

There has been much evolution and progress in the Emergency Medical Services systems worldwide. Today, it is not just a basic means of transporting the sick and injured to hospitals, but represents organised care and management of patients in the prehospital environment. Survival rates, in many instances, depend upon the proper management of these out-of hospital casualties and patients before they arrive at a healthcare facility. Issues such as state-of-the-art treatment, evidence based care protocols, medical accountability and professionalism have surfaced prominently. From the days of the first land and air ambulances, we have indeed come a long way.
Validation of a Modified Early Warning Score (Mews) in Emergency Department Observation Ward Patients
Authors: Lam TS , Mak PSK , Siu WS , Lam MY , Cheung TF , Rainer TH
Published: December 2017

Objective

The Modified Early Warning Score (MEWS) is a simple physiological scoring system, which can easily be applied at the bedside. The ability of MEWS to identify patients at risk of deterioration in a busy ward was investigated.

Method

In a prospective cohort study, we applied MEWS to patients admitted to the 16-bed emergency department observation ward (EDOW) of a tertiary teaching hospital.

Results

Data on 427 consecutive EDOW admissions were collected from 7 June to 4 July 2004. Main outcome measures were death, intensive care unit (ICU) admission and inpatient hospital admission. Scores of > 4 were associated with increased risk of death (OR 54.4, 95% CI = 4.7–633.7), ICU admission (OR 12.7, 95% CI = 1.1–147.3) and hospital admission (OR 9.5, 95% CI = 3.3–27.9).

Conclusion

MEWS is suitable for bedside application in an EDOW setting and may help identify patients at risk of deterioration who require increased levels of care as hospital inpatients and in ICU. Where experienced staff is not available to closely monitor patients in an EDOW, the use of the MEWS system may aid close monitoring and identification of high-risk patients.
Pain Management in the Emergency Department
Authors: Lim GH , Wee FC , Seow E
Published: December 2017

Objectives

To determine the waiting time for administration of analgesia to patients presenting to the emergency department (ED) with traumatic pain, and to determine how the severity of pain affects the patient's perception of pain and the treatment they receive.

Methods

Consecutive patients aged 18–65 years presenting to the ED during the 2-week study period with complaint of pain secondary to trauma were prospectively recruited. The numeric rating scale (NRS) was used to indicate the level of pain experienced by the patients. They were interviewed using a structured questionnaire and a chart review was also done after the patients had completed their ED visit.

Results

The mean time to analgesia was 77.6 min (95% CI = 63.2–92.0 min). Patients requesting analgesia at triage had a median pain score of 7 (range 0–10) while those who declined had a median pain score of 5 (range 0–10) (p = 0.002, Mann-Whitney U-test). The severity of the injuries sustained did not affect the patient's perception of their pain nor their preference for early analgesia. Indian patients had a significantly higher median pain score (p = 0.048).

Conclusion

Time to delivery of analgesia fell short of our patients' expectations. Assessing pain using the NRS is useful and should be incorporated as the ‘fifth’ vital sign. Process-improvement, healthcare workers and patient education regarding pain management are needed. Patients with a pain score of 7 or more should be offered analgesia at triage. Those with a pain score of 6 or less should still be given analgesia at triage if they request it.
Fatal Pulmonary Embolism in a Teenager: Case Report
Authors: Wong ALN , Malhotra A , Woo WWK , Graham CA , Rainer TH
Published: December 2017

Massive pulmonary embolism is unusual in young people. We present a case of massive pulmonary embolism in a teenage Chinese patient. Initially he presented to the emergency department with dyspnoea and fever. Influenza B was diagnosed during his four‐day stay in the paediatric ward. One week later he suddenly collapsed and presented to the emergency department with chest pain, syncope and dyspnoea. Despite undergoing rapid assessment, along with prompt admission to intensive care and cardiopulmonary resuscitation, he died. Autopsy revealed massive pulmonary embolism, which is rare at this age. Computed tomography pulmonary angiography and early thrombolytic therapy may improve the outcome in similar cases.
Nephrotoxicity Associated with Acute Paracetamol Overdose: A Case Report and Review of the Literature
Authors: Loh CS , Ponampalam R
Published: December 2017

A 29‐year‐old, 65 kg, Chinese man presented to hospital 10 hours after ingesting 30 g of paracetamol (462 mg/kg body weight). The blood paracetamol level was 145 µg/ml at 10 hours post‐ingestion. He had no known risk factors for hepatotoxicity and was treated with intravenous N‐acetylcysteine (NAC). Serum creatinine level rose to a maximum of 455 µmol/L on day 8; it gradually declined without the need for dialysis. Little is known of the risk factors for nephrotoxicity, which may occur with or without concurrent liver damage, suggesting possible primary toxic effects on the kidney. The use of NAC in this case may have prevented the progression to liver failure and reduced the severity of the nephrotoxic effects.
Sudden Onset of Calf Pain
Authors: Tan LTH , Ong KL
Published: December 2017

Avulsion of the myo‐tendinous junction of the medial head of the gastrocnemius muscle is commonly associated with strenuous physical activities such as racquet sports, skiing, and running. The injury is painful, distressing and can be disabling. Ready availability makes ultrasound study the imaging modality of choice in the emergency department.
Isolated Clavicle Fracture with Secondary Pneumothorax: A Case Report
Authors: Kao YH , Goh SH
Published: December 2017

Clavicle fractures complicated by pneumothorax are rare. This case report describes a young man who developed pneumothorax secondary to an isolated clavicle fracture following blunt trauma to his right shoulder in an assault. The pneumothorax was diagnosed on a shoulder X‐ray, and required the insertion of a chest drain. It may be prudent to specifically exclude a pneumothorax in clavicle fractures if the fractured segment is directed towards the lung.
Meeting the Media: Friend or Foe?
Authors: Chung CH , Lai KK
Published: December 2017

For various reasons, the emergency department is an area of interest for the media. As a result, emergency physicians have to prepare for the occasions of being interviewed by the media some day in their career. It is natural to have some anxiety and fear in meeting the media, especially for the inexperienced. However, developing a good relationship with the media would not only benefit the organisation and the specialty, but also the general public as well. This is a review of the preparation, techniques, tricks and pitfalls in dealing with the media, especially in regard to television interviews.
Treatment of Acute Diarrhoea in Adults with Dioctahedral Smectite (Smecta): A Prospective Randomised Study
Authors: Cheung KH , Yuen WL
Published: December 2017

Background

Acute diarrhoea is a common presenting problem to the accident and emergency department. This study aimed to assess the efficacy of dioctahedral smectite (Smecta) in altering the duration and frequency of acute diarrhoea in the adult population in Hong Kong.

Material and methods

This was a prospective, randomised controlled study carried out in the Accident and Emergency Department of Caritas Medical Centre from July 2005 to October 2005. One hundred and ninety eligible adult patients with acute diarrhoea lasting not more than 14 days were randomly assigned either (1) oral rehydration solution (ORS) one sachet three times daily and Smecta one sachet three times daily for two days; or (2) ORS one sachet three times daily for two days. The duration of diarrhoea, daily frequency of diarrhoea, presence of vomiting and fever following treatment were obtained by telephone interviews and mailed questionnaires.

Results

For patients treated with or without Smecta, there was no statistically significant difference in the mean duration and daily frequency of diarrhoea in the first three days.

Conclusion

The use of Smecta did not change the duration or frequency of acute diarrhoea in the adults in this study.
Left Lower Quadrant Abdominal Mass: A Case of Spigelian Hernia Diagnosed by Emergency Ultrasound
Authors: Chung KL , Kam CW
Published: December 2017

Spigelian hernia is rare. The diagnosis of Spigelian hernia is often challenging. We report a case of Spigelian hernia in which emergency ultrasonography diagnosed correctly a Spigelian hernia, which was later confirmed by computed tomography and at surgery. In our opinion, ultrasonography can be an important tool for emergency physicians in cases of abdominal pain or abdominal mass.
Boxer'S Knuckle of Non-Boxer Patients
Authors: Mok KL
Published: December 2017

Boxer's knuckle is the eponym describing injuries to the sagittal band at the metacarpophalangeal joint, resulting in subluxation or dislocation of the extensor tendon, classically in boxers. This condition is often devastating because it can cause severe morbidity not only in professional athletes but also in manual workers. The unique anatomical position of the extensor apparatus system predisposes fingers to this type of injury. With better understanding of the anatomy and pathology of this injury, good functional outcome can be anticipated with appropriate treatment. Two cases of extensor tendon subluxation in non-athletic patients are presented here. The anatomy, diagnosis and current management of this particular injury are discussed.
A Profile of Male Domestic Violence Victims Presenting to an Emergency Department in Singapore
Authors: Seow E , Foo CL
Published: December 2017

Introduction

This is the first study in Singapore to obtain a profile of the male victims of domestic violence.

Methods

The study was conducted in the Emergency Department (ED), Tan Tock Seng Hospital (an urban teaching hospital in Singapore). A structured questionnaire was administered to patients who volunteered or who admitted on questioning by ED staff that an intimate partner had assaulted them. Information was gathered about the demographics, characteristics of the assaults and knowledge of social and legal services.

Results

Fourteen victims were identified. The youngest was 29 and the oldest 63 years of age. Assailants were spouses or ex-spouses. Weapons were used in half of the assaults but injuries were superficial. The majority of the victims revealed that they had been abused previously, although most knew about helplines, family court and personal protection orders.

Conclusion

We hope that this study will raise awareness amongst healthcare workers of the existence of this problem.
Two Cases of Anticholinergic Poisoning from Transdermal Scopolamine Patch
Authors: Chan YC , Tse ML , Lau FL
Published: December 2017

Scopolamine transdermal patch is a form of anticholinergic drug used to prevent motion sickness. We reported two cases of anticholinergic poisoning resulting from scopolamine transdermal patch. The first case experienced local toxicity and presented with right eye mydriasis for five days. The second case developed systemic anticholinergic toxidrome contributed by the scopolamine patch and presented with acute confusion. She was treated successfully by physostigmine, an anticholinergic antidote. The recommendation on physostigmine use was also discussed. We hope that these two case reports will raise the clinician awareness of the potential side effect of this kind of product.
A Case of Acute Insulin Poisoning
Authors: Wong OF , Tsui KL , Kam CK
Published: December 2017

A 32-year-old lady presented to the emergency department for suicidal attempt by self-injection of insulin (Protaphane 210 units). She developed repeated episodes of hypoglycaemia even with continuous intravenous infusion of 10% dextrose solution during observation. However, she did not develop serious complications of hypoglycaemia and was subsequently discharged after conservative treatment. Acute insulin poisoning is uncommon. The management of this uncommon poisoning is reviewed in this case report.
Is Cardiac Monitoring Necessary for Intermediate Risk Acute Coronary Syndrome Patients who Have a Normal Electrocardiogram and Cardiac Markers in the Emergency Department?
Authors: Hoi K , Kelly AM , Chan A , Kerr D
Published: December 2017

This study aimed to investigate the safety of managing selected patients with suspected acute coronary syndrome without cardiac monitoring by determining the rate of complications occurring in chest pain patients classified as intermediate risk according to the National Heart Foundation of Australia guidelines and with normal cardiac marker levels and a normal/unchanged ECG in the emergency department. One patient suffered a critical adverse event within 24 hours (0.3%, 95% CI 0.1–1.7%) and 24 patients suffered other adverse events (6.3%, 95% CI 4.2–9.4%). This study provides further evidence that this group of patients are at low risk of experiencing a critical adverse event within 24 hours of hospital presentation and may be safely managed without continuous cardiac monitoring.