bluuebunny/crossref_metadata_2025 huggingface dataset:
Beware of the Migrating Chest Pain and Widened Mediastinum: Case Series on Aortic Dissection
Authors: Chung CH , Lai KK
Published: December 2017

Objective

Aortic dissection is not a rare life-threatening emergency. Undiagnosed and untreated aortic dissection is associated with a high mortality. A review of cases in the hospital may provide a baseline picture to guide clinical decisions.

Design

Retrospective case review for a period of 3 years and 4 months.

Setting

District general hospital near the Hong Kong – Shenzhen ‘border’ with 24-hour Accident & Emergency service but without cardiothoracic surgical capability.

Population

All cases coded as ‘aortic dissection’ in the computerized ‘Clinical Management System’ of the hospital.

Main outcome measures

Date, sex, age, history of hypertension, presenting symptoms, pulse deficit, chest X-ray findings, pericardial effusion, A&E diagnosis, type of dissection and patient outcome.

Results

From August 1998 to November 2001, 26 cases of aortic dissection were identified. There were 19 males and 7 females. Age range was 26 to 90 years (mean 65.04 ± SD 15.04, median 66.50, mode 65). In the plain chest X-rays, widened superior mediastinum (>8 cm) was present in 19 patients (73.1%) and pleural effusion in three (11.5%). Pericardial effusion was found in six patients (23.1%). As regard to outcome, 11 were discharged home (42.3%), 14 were transferred to cardiothoracic surgical unit (where two subsequently died) and one died in the hospital.

Conclusion

The prevalence of aortic dissection may be more common than is generally appreciated by emergency physicians. Owing to its variable clinical presentations mimicking other diseases, the diagnosis of aortic dissection is easily missed. Higher clinical vigilance should be exercised for this potentially deadly condition.
A Case of Convulsion: Brugada Syndrome
Authors: Shum CK , Tse ML , Lau FL , Chan WK
Published: December 2017

A healthy 28-year-old man presented with multiple brief episodes of convulsion. He was found to have ventricular fibrillation which required defibrillation in the emergency department. After exclusion of organic heart diseases, Brugada syndrome was diagnosed and required implantable cardioverter defibrillator (ICD) implantation. The case emphasized the recognition of malignant cardiac dysrrhythmias as a cause for seizures. The management in the emergency department was discussed.
Respiratory Distress after Consumption of Sea Snails
Authors: Yuen CW , Ng MH
Published: December 2017

Consumption of shellfish is common in Hong Kong. However, some shellfish contain toxins which when ingested may lead to fatal toxicity. We report a case of paralytic shellfish poisoning presenting with throat discomfort progressing to respiratory distress and requiring intubation and mechanical ventilation. The patient recovered and was discharged 10 days after admission with no further complication.
Spontaneous Pneumomediastinum
Authors: Chu FKC
Published: December 2017

Spontaneous pneumomediastinum is a condition although uncommonly seen, has been well documented. This condition is defined as presence of gas or air within the mediastinum that occurs spontaneously. In this case report, we describe a patient with spontaneous pneumomediastinum who presented with sore throat, chest and neck pain. No risk factors could be identified. He was treated conservatively and had an uneventful outcome.
The use of Personal Protective Equipment in Hazmat Incidents
Authors: Yeung RSD , Chan JTS , Lee LLY , Chan YL
Published: December 2017

Medical personnel are at risk when handling victims of Hazmat incidents. Special clothing and respiratory equipment are required to protect them from absorbing these toxic materials through inhalation or through dermal contact. Personal Protective Equipment (PPE) refer to both clothing and equipment used to shield or isolate individuals from chemical, physical and biological hazards that may be encountered at a hazardous materials incident.1,2 No single type of PPE can protect all hazards and incorrect use can cause harm to the wearer. In general, the greater the protection, the greater the associated risks.2 Therefore, the level of PPE selected should be the one that can provide adequate level of protection.
Training and Willingness to Perform Bystander Basic Life Support
Authors: Rainer TH
Published: December 2017

Objectives

To evaluate the perceived ability and willingness of people to perform basic life support (BLS), to relate this to those most at risk of sudden cardiac death, and to identify groups of National Health Service (NHS) staff who could benefit from training in BLS.

Design

Prospective, survey.

Setting

The Accident and Emergency (A&E) department based at Glasgow Royal Infirmary.

Subjects

All patients, accompanying persons and NHS staff who were able, willing and waiting in the A&E department.

Methods

Subjects were asked to complete a proforma with questions relating to their experience and training in BLS. Their recognition of the importance of defibrillation in the light of current European guidelines for BLS was tested.

Results

718 proformas were completed. Fifty‐seven percent non‐clinical NHS staff had received no training in BLS. More than 50% subjects had relatives with risk factors of Ischaemic Heart Disease yet had no training in BLS. Seventy percent ambulance men and 50% clinical NHS personnel would perform mouth to mouth ventilation before calling an ambulance where they were required to perform BLS, as a bystander. Seventy percent non‐clinical NHS personnel and non NHS subjects would call an ambulance first.

Conclusions

Non‐clinical NHS personnel form a hospital based group that could be trained in BLS, some of whom could assume an instructor role. A proportion of clinical and emergency personnel would not prioritise an early call for a defibrillator over BLS in the out of hospital setting.
ST Elevation is not Always Equivalent to Acute Myocardial Infarction: a Case of Brugada Syndrome
Authors: Choi YF , Siu AYC , Wong TW , Lau CC
Published: December 2017

Acute myocardial infarction (AMI) is one of the most alerting situations in emergency department. Electrocardiogram (ECG) is one of the most important diagnostic tools and the decision about thrombolytic therapy is usually based upon ECG findings when clinically suspicious. However, ST segment elevation is not always equivalent to acute myocardial infarction. We present a rare syndrome whose ECG shows persistent ST elevation not related to AMI.
An Analysis of Unscheduled Return Visits to the Accident and Emergency Department of a General Public Hospital
Authors: Ng CP , Chung CH
Published: December 2017

Objectives

To identify the reasons for unscheduled return visits to a public emergency department and possible strategies to reduce unscheduled return visits.

Design

Cross-sectional survey.

Setting

A public emergency department in Hong Kong.

Patients

Unscheduled return visits within 48 hours in a three-month period from 14 January 2000 to 15 April 2000.

Main outcome measures

Patients' epidemiological characteristics, reasons, complaints and outcome of the unscheduled return visits.

Results

During the study period, 3.3% (1,060) of the attendance was unscheduled return visits within 48 hours as recorded in the computerized A&E Information System of the hospital. However, only 738 patients (70%) responded to the questionnaire. These 738 patients formed the study population for further analysis. Illness-related factors accounted for 87% of the total unscheduled return visits. Patient-related factors were responsible for about 10% of unscheduled return visits. Doctor-related factors accounted for about 3% of unscheduled return visits. There was only one system-related unscheduled return visit. For the outcome of return visits, about 76% (559) was discharged after the second consultation. About 5% (40) was referred to specialist clinics. Around 24% (179) of patients was admitted. Of those admitted, 78% (140) was illness-related, 13% (23) was patient-related and 9% (16) was doctor-related. Upper respiratory tract infection was the most frequent complaint (34%), followed by painful conditions (23%) and injuries (10%). For children at or below 10 years of age, upper respiratory tract infection (60%) and febrile illness (15%) were the most frequent complaints.

Conclusions

The study found that the reasons for return visits were multiple. These “unscheduled return visits” should not be automatically regarded as poor indicator of service. Better patient education, organized family practice system, upgrading of professional training and targeted audit are possible means to reduce unscheduled return visits.
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure in Emergency Department: a Qualitative Review
Authors: Lee HFL
Published: December 2017

The roles of noninvasive positive pressure ventilation (NIPPV) as a treatment modality for patients presenting with acute respiratory failure (ARF) to the emergency department (ED) have not been clearly identified. The major advantages of NIPPV are avoiding patient's discomforts and complications relating to endotracheal intubation and mechanical ventilation. This review is to explore the current evidence on the effectiveness of NIPPV in various subgroups of patients with ARF. The rationales, advantages, complications and contraindications in the usage of NIPPV will also be discussed. There is robust evidence to support the use of NIPPV in severe acute exacerbation of chronic obstructive airway disease (COAD). A modest amount of favourable evidence supports the use of Continuous Positive Airway Pressure (CPAP) in cardiogenic pulmonary oedema, although the potential for harm has not been excluded. There exists no solid evidence supporting the use of NIPPV in asthma and pneumonia. Early institution of NIPPV in the ED is appropriate, feasible, likely to be beneficial and without major complications. Further good quality studies to evaluate the roles of NIPPV for ARF in the ED setting are needed to define which groups of patients can gain most benefit from this type of treatment.
Delayed Rupture of Occult Splenic Injury: a Case Report
Authors: Chan CKM , Chiu HS , Chung CH
Published: December 2017

We report on a case of splenic rupture that presented eleven days after a trivial injury. Possible explanations of the delay in presentation and ways for early detection are discussed. Emergency physicians should always bear this entity in mind before discharging patients with left thoracoabdominal injury.
Is There a Doctor on-Board?: Medical Liability during in-Flight Emergencies
Authors: Lateef F , Tay CSK , Nimbkar N
Published: December 2017

Provision of emergency medical care to passengers during flights on commercial aircraft is an issue which concerns many physicians. As world population ages and air travel increases, the number of medical events on board aircrafts is also expected to increase. This paper discusses the liability of the physician-passenger who volunteers and renders care as well as advises the crew, on certain actions. Complex medico-legal issues will be mentioned and there will be a brief discussion on the in-flight environment and unscheduled landings.
A Retrospective Review of Patients with Radiological Missed Fractures in an Emergency Department in Hong Kong
Authors: Ng VCH , Lau FL
Published: December 2017

Aim

To review the clinical spectrum and outcome of radiological missed fractures in the Accident and Emergency Department of United Christian Hospital (UCH) in 2002.

Method

In UCH, radiologists report all X-Rays taken in the Accident and Emergency Department (AED) within 48 hours. The study period was from 1st January 2002 to 31st December 2002. AED notes, relevant clinical records and all X-rays of patients with suspected missed fractures as reported by radiologists were reviewed for information on clinical features, treatments and outcomes.

Results

A total of 286 cases of missed fractures were found. Fourteen (4.9%) involved the skull and maxillofacial region, 83 (29.0%) involved the chest region, 53 (18.5%) involved the spinal region, 72 (25.2%) involved the upper limbs and 64 (22.4%) involved the lower limbs. Of these 286 cases, 137 (47.9%) were followed up in AED, 90 (31.5%) were referred to specialist clinics for further management, 26 (9.1%) required admission to hospital for further assessment and treatment, and 33 (11.5%) defaulted follow up. Furthermore, 87 (30.4%) of these 286 missed fractures required a change in management plan: 3 missed fractures required operative intervention (internal fixation) and 84 missed fractures required some form of external immobilisation. This group of patient did not lodge any complaint or claim.

Conclusion

A&E doctors missed quite a number of fractures that might result in significant morbidity. However, a reporting system by radiologists within 48 hours from discharge can pick up all these missed fractures, and may prevent complaints and litigations.
Lightning Injury: Changi Hospital Experience
Authors: Tan HH , Goh SH
Published: December 2017

Introduction

Lightning injury is a major concern in Singapore, which has one of the highest incidences of lightning activity in the world. This study examined the frequency and type of lightning injuries that presented to an Accident and Emergency (A&E) department situated in the east of Singapore to identify the groups at risk and the spectrum of injuries sustained.

Materials and methods

This is a case series study with a sample size of 24. Cases that were seen in the A&E department of Changi General Hospital from July 1997 to June 2002 with the International Classification of Disease diagnosis code of E907 for lightning injury were collected and analyzed.

Results

In our study, 83% lightning injuries were work-related and 79% occurred in those below 40 years old. In the work-related category, a significant proportion occurred at the airport (45%) with most of the incidents occurring while working near or in contact with the aircraft (7 out of 9). The other major proportion occurred at construction sites (40%) with a significant number of cases occurring while in contact with cranes (6 out of 8). There was one telephone-related injury. In the non-work related incidents, two out of four occurred while playing golf. Most of the injuries (87.5%) were minor with no long-term morbidity. There was one death and one critical case requiring cardiopulmonary resuscitation. The latter survived and recovered quite remarkably. One patient had serious depression requiring prolonged treatment.

Conclusion

Precaution should be taken during lightning-prone weather conditions in workplaces that involve large metal structures like cranes and aircrafts and in open space. This also applies to recreational sports like golf. Lightning injury, though rare, is not uncommon and emergency room doctors should be conversant with the treatment of this condition and its complications. Immediate basic and advanced cardiac life support administered to a lightning casualty who collapsed can be life saving.
Ventricular free wall Rupture after Myocardial Infarction
Authors: Lateef F , Nimbkar N
Published: December 2017

Patients with their first myocardial infarction (MI), who present to the emergency department many hours after the onset of chest pain, who appear to be improving but suddenly develop new chest pain and unexpected hypotension (with or without signs of cardiac tamponade), should be suspected of having ventricular free wall rupture (VFWR). The mainstay of treatment is surgery. These patients may be managed with the administration of fluids, cautious use of inotropes and echocardiographic scanning, which should be performed on an emergent basis, while being prepared to be moved to the emergency surgical suite. However, at no cost should surgery be delayed. This paper reviews the current literature of VFWR after MI, a condition which remains difficult to diagnose, in many aspects, to this day. The review examines the historical background, incidence, postulated risk factors, clinical presentation, investigations and management.
Accidental Organophosphate Insecticide Poisoning: a Fatal Child case with Hazards to Emergency Department Staff
Authors: Lau CL , Chung KL , Kam CW
Published: December 2017

A 2-year-old boy was accidentally poisoned by one spoonful of organophosphate insecticide and presented in cardiac arrest. Spontaneous circulation was restored after initial resuscitation and antidote therapy (atropine and pralidoxime) but the boy finally succumbed with multiple complications. We reviewed the literature on the clinical features and management of acute organophosphate poisoning, and the appropriate protective equipment for preventing secondary poisoning of healthcare workers.
Should Differential White Cell Counts be Reported as Percentages or Absolute Counts in Patients with Severe Acute Respiratory Syndrome?
Authors: Rainer TH , Cameron PA , Smit DV
Published: December 2017

Background

Severe acute respiratory syndrome (SARS) is associated with a lymphopenia, thrombocytopenia and neutrophilia and suspected cases may be admitted to hospital on the basis of such abnormalities. Laboratories may report changes as percentages or absolute counts.

Objective

To investigate whether absolute or percentage differential counts were more predictive of patients with SARS pneumonia.

Design

Prospective observational study.

Setting

SARS clinic of an emergency department in Hong Kong.

Subjects and methods

Whole blood and differential counts were performed on 506 patients presenting to a SARS screening clinic. Ninety-six patients subsequently developed SARS pneumonia.

Results

Sixty-nine patients had abnormal lymphocyte absolute counts on first attendance at clinic of which 37 (54%) developed SARS pneumonia. This compared with 142 subjects with abnormal percentage lymphocyte values of which 50 (35%) developed SARS pneumonia. The area under the ROC curve for absolute lymphocyte counts is 0.851 (95%CI 0.816 to 0.881) and for percentage lymphocytes is 0.736 (95%CI 0.694 to 0.775). The area under the ROC curve for absolute monocyte counts is 0.535 (95%CI 0.489 to 0.580) and for percentage monocytes is 0.635 (95%CI 0.591 to 0.678). The area under the ROC curve for absolute neutrophil counts is 0.591 (95%CI 0.546 to 0.636) and for percentage neutrophils is 0.703 (95%CI 0.660 to 0.744).

Conclusion

Reporting absolute rather than percentage values for differential leucocyte counts are more accurate predictors of SARS pneumonia.
Patients who Self-Discharge from the Emergency Department: a Three-Month Telephone Survey
Authors: Lim YH , Anantharaman V
Published: December 2017

Study objectives

To determine the main causes and outcomes of patients who self-discharged from the Emergency Department (ED).

Methods

Records of all patients who self-discharged from the ED of a tertiary level hospital were traced and telephone interviews were conducted. The duration of the study was from 15 July 2002 to 14 October 2002.

Results

There were 28,898 new attendances during the period of study and of these, 450 (1.6%) patients signed the self-discharge form. Of the 357 patients recruited into the study, the majority signed the self-discharge form because of refusal of admission to inpatient units (52.1%) or the ED observation ward (43.4%) for further treatment. One hundred and thirteen (31.7%) patients acknowledged that they were unwell during the interview and 85 (23.8%) patients sought some form of medical attention after leaving the ED.

Conclusion

Most of the patients who self-discharged from the ED were for personal reasons and very few were due to financial reasons.
Acute Ischaemic Stroke: Management, Recent Advances and Controversies
Authors: Wong GCK , Chung CH
Published: December 2017

Acute ischaemic stroke is a major cause of death and disability. It may become an enormous burden to the patients themselves, their families as well as the health care systems. Patients at risk of airway, breathing and circulatory compromise should receive prompt resuscitation. Vital parameters and neurological status should be closely monitored. Attentions to blood pressure, temperature and sugar profile are important. The significance of early and correct diagnosis and subsequent treatment cannot be over-emphasised. There have been tremendous recent advances in different treatment modalities in acute stroke management. Various recanalisation modalities include intravenous and/or intra-arterial thrombolysis, acute defibrinogenation, anti-platelet treatment and anticoagulation. Carotid endarterectomy and endovascular strategies are recommended in selected patients. Advanced neuro-imaging techniques and neuroprotectants are being evaluated. Multidisciplinary stroke teams have been shown to improve patient survival and functional outcome. Pre-defined algorithms and protocols should be in place to expedite smooth and effective delivery of stroke service. Future directions should be aimed at exploring safer recanalisation modalities and extending the limit of the current 3-hour treatment window for thrombolysis.
Horse-Related Injuries: a Local Scene
Authors: Ng CP , Chung CH
Published: December 2017

Objectives

To study the characteristics and nature of injuries relating to horse riding in the local setting and to compare the findings with those reported in the medical literature.

Methods

A prospective survey of patients with horse-related injuries attending the accident and emergency department of a public district hospital in Hong Kong within the year 2002. The data were analysed and compared with previous studies.

Results

Fifty-five patients were collected in the study. The mean age was 32.7 years. Forty-four (80.0%) of them were riders and 11 (20.0%) were non-riders. Thirteen (23.6%) were grooms. Fifteen patients (27.3%) were admitted and seven (46.7%) of those admitted required operations. There was no fatality. Thirty-nine patients (70.9%) suffered from single injury while the rest (29.1%) had multiple injuries. Most injuries (60.0%) were minor but fractures or dislocations occurred in 16 patients (29.1%). Isolated head and facial injuries occurred in 14.5% of patients. Most were simple concussion. Thirteen patients (23.6%) suffered from isolated upper limb injuries, with more than half sustaining fractures or dislocations. Falling from horse (60.0%) was the most frequent mechanism of injury. Among the non-riding patients, 72.7% were kicked or trodden by horse. There was no association between rider's status, previous riding or injury experiences, or the presence of supervision at the time of riding with the rate of admission.

Conclusion

Horse riding and working with horses can be an occupation or recreation with potential dangers. In our study, characteristics of patients, mechanisms and types of injuries were similar to other western studies. However, professional riders and those with more riding experiences were not exempted from severe injuries requiring admission. Moreover, previous injury experiences and the presence of supervision did not help reduce the admission rate either. Perhaps, as suggested by other studies, the quality of horsemanship and supervision appeared to be more important to reduce accidents. Further proper large scale controlled epidemiological studies will definitely help to improve the understanding of horse-related injuries.
Smoking and Severe Acute Respiratory Syndrome
Authors: Rainer TH , Smit D , Cameron P
Published: December 2017

In April 2003, rumours spread that smoking protected patients from developing SARS (Severe Acute Respiratory Syndrome). In a case-control study of 447 patients who attended a SARS screening clinic, 63 patients were admitted with SARS. Although a higher proportion of SARS cases were non-smokers than smokers, the adjusted odds of non-smokers with SARS was 1.7 (p=0.54). There is no evidence that smoking protects patients from developing SARS.
Is There a Relationship between Asthma Severity and Abnormalities on Chest X-Ray?: A Pilot Study
Authors: Eddy E , Kelly AM
Published: December 2017

Objectives

To determine the rate of chest X-ray (CXR) ordering for patients with acute asthma in the emergency department (ED) and the rate of relevant abnormalities on CXR for each asthma severity classification.

Methods

Retrospective explicit chart review involving adult ED patients with asthma presenting between 1 July and 31 December 2001. Data collected included severity classification according to the National Asthma Guidelines (NAG) [Australia], demographic information, temperature, white cell count, CXR ordering and findings on CXR. The main outcomes were the rate of CXR ordering and the rate of relevant abnormality on CXR by severity category.

Results

Altogether, 158 presentations by 140 patients were analysed. The overall rate of CXR ordering was 68% [mild 54%, moderate 66%, severe 84%]. The overall rate of abnormalities was 8% [mild 0%, moderate 9%, severe 14%]. Ninety-one percent of patients admitted to hospital had CXR of which 13% [8/60] revealed significant abnormalities.

Conclusion

The rate of CXR ordering in acute asthma was high with a low yield of relevant positive findings in the mild and moderate severity groups. This was at odds with NAG recommendation. Our results suggest that routine CXR may be warranted in patients with severe asthma but should be guided by clinical examination in other severity classes.
A Review on the Management of Acute Gastroenteritis in Children
Authors: Shek KC , Ng P , Hung CY , Lam KK , Lau CL , Ching WM , Kam CW
Published: December 2017

Acute gastroenteritis represents a frequent cause of morbidity among children in Hong Kong. Despite the large number of potential etiologic agents, principles of management of gastroenteritis are uniform and aim to prevent the two major complications - dehydration and malnutrition. A review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendations were generated. Current evidence emphasises the use of oral rehydration and the early reintroduction of age-appropriate foods. Apart from these two, important aspects of management reviewed included laboratory investigations, role of anti-diarrhoeal agents, and use of antimicrobial agents. Criteria for admission of high-risk children are also addressed.
Sonography of Quadriceps Tendon Ruptures
Authors: Chung KL , Wong TT , Yuen MK , Kam CW
Published: December 2017

Quadriceps tendon rupture is an uncommon injury, which may benefit from early operative repair. However, clinical assessment is frequently inaccurate and delayed diagnosis is common. Ultrasound has been shown to be sensitive in detecting quadriceps tendon rupture. We report a case of bilateral quadriceps tendon ruptures diagnosed by ultrasound. Typical sonographic findings were illustrated.
An Opinion Survey on Emergency Medical Assistant Motor Cycle Service in the Hong Kong Fire Services Department
Authors: Chim PL , Lau SSF
Published: December 2017

Emergency Medical Assistant Motor Cycle (EMAMC) plays a crucial role in prehospital care in the Ambulance Service. In Hong Kong, the implementation of Ambulance Aid Motorcycle started in 1982. It provides a more rapid response to various types of patients in order to increase survival rates such as by the provision of early defibrillation. The demand of EMAMC is significant and therefore the fleet size has been expanded to 37 motorcycles in 2004. In order to review the development and operational aspects, interviews were conducted with different riders to collect their views. This article discusses issues in different categories such as training, vehicle, equipment and mobilisation. This survey revealed some common concerns of the riders.
Beware of the Anticoagulated Elderly with Minor Head Injury
Authors: Chung CH
Published: December 2017

A 69-year-old man first presented to the emergency department after a fall. He had no history of loss of consciousness or vomiting. He sustained a 3 cm long laceration over the right occipital region of the head. There was no fracture in the X-rays of the skull. He was on warfarin because of cardiac problem. He was discharged after suturing. He re-attended the next morning because of left sided weakness. Non-contrast brain computed tomogram showed acute subdural haematoma. Burr holes were performed subsequently. Special precautions should be undertaken in managing the elderly with minor head injury, with a lower threshold for computed tomography and coagulation profile studies.
Carotid-Cavernous Fistula: An Uncommon and Easily Missed Complication of Head Trauma
Authors: Lau KH , Ng CP , Chung CH
Published: December 2017

A 57-year-old woman attended the emergency department complaining of protrusion of the right eyeball for three days. The history revealed that she had head injury in a road traffic accident about five weeks ago. The accident had caused a fracture of the right angle of the mandible that was fixed internally by the maxillo-facial surgeon. Subsequent angiogram showed a right direct carotid-cavernous fistula. Endovascular therapy was successful in obliterating the fistula. She recovered well. Although carotid-cavernous fistula is an uncommon complication of head injury, emergency physicians should be aware of this condition because of its potential mortality and morbidity.
Unrecognised Human Immunodeficiency Virus Patients in an Emergency Department in Hong Kong: A Report of Four Cases
Authors: Mok KL , Kan PG
Published: December 2017

Human immunodeficiency virus (HIV) causes breakdown of the immune system and predisposes patients to various opportunistic infections and neoplasms. However, many patients may not be aware of the HIV infection before the development of their first HIV related complications. We reported four unrecognised HIV patients presenting to our accident and emergency department with common complications of HIV infection and the acquired immunodeficiency syndrome (AIDS). Although not as common as in America, emergency physicians in Hong Kong still have to take care of patients with unknown HIV status. The common presentations of HIV patients will be discussed. A high index of suspicion and knowledge of common HIV/AIDS complications are required for managing these patients.
Hypokalaemia Re-Visited: A Case Series
Authors: Chew HC
Published: December 2017

Hypokalaemia is a relatively common biochemical abnormality found at the emergency department. Sequential changes in the electrocardiogram occur as the serum potassium is lowered. Correction of hypokalaemia can be life-saving. It is essential for physicians to be able to recognise these changes and initiate prompt replacement when necessary. We present a case series of patients presenting to the emergency department with symptomatic hypokalaemia and discuss the electrocardiographic manifestations and recognition of hypokalaemic changes.
A Rare Cause of Necrotizing Fasciitis: Psoas Abscess
Authors: Siu AYC , Kwok SL , Chung CH , Lai KK
Published: December 2017

Necrotizing fasciitis always carries very high mortality and morbidity rates. It can be due to group A beta-haemolytic streptococci, which are traditionally described as the flesh-eating bacteria. More commonly, it is related to a mixed growth of bacteria that can be secondary to trauma or surgery. Secondary necrotizing fasciitis due to concomitant soft tissue infection is uncommon. We reported a fatal case of necrotizing fasciitis which was caused by a coexisting psoas abscess. A search for concomitant soft tissue infection is warranted in patients presenting with necrotizing fasciitis. This article also reviewed the clinical tools that may help to make an early diagnosis of the disease.
Emergency Physicians in Tsunami Relief: A Discussion of Tsunami-Related Health Conditions and Necessary Preparations
Authors: Chung JSH , Shek KC , Yau HH , Kam CW
Published: December 2017

The Indian Ocean tsunami on 26th December 2004 had prompted extensive humanitarian responses and many emergency physicians had offered to join the relief force. This article discusses tsunami-related health conditions including trauma, infectious diseases and mental disturbance and how emergency physicians should be prepared in terms of emotional stability and alertness, medical protection and equipments before shouldering the responsibility.
Validation of a 3-Item Screening Tool for Geriatric Depression in the Observation Unit of an Emergency Department
Authors: Lee VMS , Wong TW , Lau CC
Published: December 2017

Introduction

The purpose of this study was to validate a new 3-item Emergency Department Depression Screening Instrument (ED-DSI) in screening for depression in elderly patients presenting to the emergency department (ED).

Methods

All Cantonese-speaking ED patients 65 years or older staying in the observation ward were included. Patients with a known diagnosis of dementia or depression and those with severe hearing problems were excluded. The doctor-in-charge would administer the 3-item ED-DSI which was adapted from the Geriatric Depression Scale (GDS). The research nurse who was blind to the answers of the initial screening then administered the 15-item GDS to the same patient. The 15-item GDS, which had been validated previously in the local population, was used as the reference standard.

Results

One hundred patients of whom 70 were female, were recruited. The mean age of the group was 75 years with a range from 65 to > 96 years. Using a cut-off score of 2, the new 3-item ED-DSI was shown to be as effective as the 15-item GDS (using a cut-off score of 8) in identifying depressed subjects. The sensitivity and specificity of the instrument were 90% and 74%, respectively.

Conclusions

The new 3-item ED-DSI for depression correlated well with the 15-item Geriatric Depression Scale. It can be used for screening of depression in elderly patients in a busy emergency department.
Ultrasonography for Acute Blunt Renal Trauma: Does it Help?
Authors: Lee GPC , Chung KL , Kam CW
Published: December 2017

The role of ultrasonography in diagnosing blunt renal trauma is uncertain because it is much less sensitive in detecting parenchymal organ injuries. Indirect evidence such as perinephric haematoma may be easier to identify by ultrasonography and it is highly suggestive of underlying renal parenchymal injury. A patient with significant renal injuries diagnosed by bedside ultrasonography is reported and the role of ultrasonography in renal trauma is discussed.
Efficacy and Safety of Snake Antivenom Therapy: Experience of a Regional Hospital
Authors: Fung HT , Lam KK , Kam CW
Published: December 2017

Introduction

Snakebite is a commonly encountered envenomation emergency in the rural areas of Hong Kong. The majority of cases do not warrant antivenom therapy. We looked into those receiving antivenom to enhance the understanding of the results of antivenom therapy.

Methods

This was a retrospective review of the snakebite cases treated with antivenom in Tuen Mun Hospital from 1st January 2000 to 31st August 2005, focusing on both the therapeutic and side effects of the antivenom.

Results

Twelve patients were identified. All had local symptoms of swelling or numbness. Two of them subsequently developed skin necrosis requiring operative treatment. Thrombocytopenia was less amenable to correction than prolonged INR. No early or late allergic reactions were observed.

Conclusion

Because of the small number of cases, the apparent safety of the antivenoms in the current review warrants larger trials in future.
The Epidemiology of Patients with Dizziness in an Emergency Department
Authors: Lam JMY , Siu WS , Lam TS , Cheung NK , Graham CA , Rainer TH
Published: December 2017

Objectives

The aims of this prospective study were (1) to describe the patterns of presentation, causes and disposition of patients with dizziness in an emergency department (ED) and (2) to identify the factors that predict central vestibular disorder.

Methods

All adult patients (≥18 years) attending our ED with a chief complaint of dizziness were included. Demographic characteristics, presenting complaint, symptoms, past medical illnesses, physical findings, provisional diagnosis and disposition were recorded in a data collection sheet by the medical officers.

Results

A total of 104 consecutive dizzy patients were recruited from 12th to 19th December 2003. The incidence of adult patients with dizziness was 4.0% (104/2594). There were 34 (32.7%) male and 70 (67.3%) female patients; 64 (61.5%) patients were below 65 and 40 (38.5%) were above 65. Lightheadedness (61.5%), vertigo (31.7%) and disequilibrium (4.8%) were the most frequent complaints. Nausea and/or vomiting (32.7%) and raised blood pressure on arrival (23.1%) were the most common associated symptoms and physical finding respectively. Hypertension (38.5%) was the most common pre-existing medical illness. Of all patients, 63.5% had non-vestibular disorder, 31.7% had peripheral vestibular disorder and 4.8% had central vestibular disorder. A clinical diagnosis could be made in 52.9% of our dizzy patients and about 20 different diagnoses were made. The majority (82.7%) of the patients were discharged from the ED. A presenting complaint of lightheadedness, altered mental state, focal neurological signs, raised blood pressure and history of stroke were predictors of central vestibular disorder (p<0.05).

Conclusions

Lightheadedness and vertigo were the two commonest presentations of dizzy patients. Most dizzy patients had benign causes and could be discharged from the ED. Lightheadedness, focal neurological symptoms and signs, altered mental state, hypertension and previous stroke were factors that would help to diagnose central vestibular disorder.
Treatment and Outcome of Acute Cardiogenic Pulmonary Oedema Presenting to an Emergency Department in Hong Kong: Retrospective Cohort Study
Authors: Kwok TYT , Mak PSK , Rainer TH , Graham CA
Published: December 2017

Objectives

To explore the epidemiology, treatment and outcome of acute cardiogenic pulmonary oedema (ACPO) in a Hong Kong emergency department (ED).

Methods

This was a retrospective cohort study in a university hospital ED. Cases were identified from ED records and resuscitation room logbooks. The study extended from 1 September 2004 to 30 April 2005. Parametric tests and logistic regression were used to identify predictors of survival.

Results

A total of 140 patients were identified, with a mean age of 75 years and male:female ratio of 1:1.4. Mean values (range) on presentation were as follows: pulse rate 103 beats/minute (36–108); blood pressure (BP) 169/88 mmHg (77-274/20-162) and respiratory rate 31 breaths/minute (12–88). Past medical history included previous ACPO (12.1%), diabetes (45.7%), chronic obstructive pulmonary disease (9.3%), ischaemic heart disease (45.0%), hypertension (72.1%) and congestive heart failure (40.7%). On admission, 47.1% had pH<7.35 and 40.7% had PaCO2>5.5kPa. ED treatments included: sublingual nitrates (n=2), intravenous (IV) nitrates (n=89, median 10 mg/hr), IV frusemide (n=85, median 40 mg), IV morphine (n=25, median 3 mg). There were 21 patients on non-invasive ventilation; 27 intubations and 41 patients were admitted to the intensive care unit. Survival to discharge was 95.7%; and median length of hospital stay was 8 days. The 90-day all-cause hospital readmission rate was 30.0%. The 30-day mortality was 12.9% (n=18) and 90-day mortality was 29.3% (n=41). Logistic regression showed that past history of hypertension (p=0.0061), higher systolic BP on ED discharge (p=0.0102) and lower creatinine following treatment (p=0.035) were predictors of improved survival at 90 days.

Conclusion

ACPO commonly presents to the ED in Hong Kong and has a high 90-day mortality. Previous hypertension, higher systolic blood pressure on leaving the ED and lower creatinine following treatment predict improved survival at 90 days.
Case Report: Paracetamol Poisoning in a 2-Year-Old Child – from International Overview to the Role of the Hong Kong Poison Information Centre
Authors: Sia JYS , Chan YC
Published: December 2017

We report a 2-year-old girl suffering from acute liver failure as a result of paracetamol poisoning. The child successfully recovered after intensive care. We performed literature search for the past decade and found that the pathophysiological response in the child was different from that of the adult. Despite paracetamol poisoning being one of the most common poisonings in the world, there is still no consensus in the treatment protocol. Hence the role of the Hong Kong Poison Information Centre is briefly discussed.
Painless Benign Epidermoid Cyst of the Testis
Authors: Tan LTH , Ong KL
Published: December 2017

Benign intratesticular lesions such as epidermoid cyst are rare, but recognition is important to avoid unnecessary surgical intervention (orchiectomy). The combination of ultrasonographic findings and negative tumour markers can help differentiate benign from malignant intratesticular lesions. At surgery, the lesion can be enucleated and frozen sections obtained to confirm the diagnosis, thus avoiding the need for orchiectomy.
Exertional Heat Stroke: A Lucky Bunch of Overly Motivated Policemen!
Authors: Shafie H , Wahab M Abd , Masilamany M , Hassan AA Abu
Published: December 2017

Introduction

Exertional heat stroke is a true medical emergency resulting from thermoregulatory failure. The risk of death is related directly to the peak temperature, duration of exposure and acclimatisation period. This case report illustrates the management of multiple casualties of heat stroke in the emergency department and their outcomes.

Clinical feature

Nine policemen arrived in the emergency department in semiconscious state after being retrieved from a group of policemen who were loaded into a bus without proper ventilation during a selection program. All of them presented with hyperpyrexia, hypotension, tachycardia and altered sensorium.

Treatment

Immediate evaporative cooling with support of organ‐system dysfunction was commenced. Six patients were intubated and admitted to the intensive care unit. One patient was monitored in high dependency ward while the other two were admitted to the general medical ward.

Outcome

All patients were extubated within 48 hours. None of them had residual neurological dysfunction. One patient developed coagulopathy which required blood product transfusion. Three patients were discharged in less than one week and the rest were observed in the general ward in stable condition for liver profile monitoring.
A Case of Fatal Hydroxychloroquine Overdose
Authors: Fung HT , Lam KK , Wong OF , Lau B , Kam CW
Published: December 2017

A 28‐year‐old woman ingested 20 g of hydroxychloroquine sulphate for suicidal attempt. She developed hypotension, cardiac conduction disturbance, hypokalemia and hypoglycemia. Despite treatment with mechanical ventilation, epinephrine, sodium bicarbonate, diazepam and potassium replacement, she succumbed 10 hours post‐overdose. Previous case reports of hydroxychloroquine overdose are summarised and the therapeutic choices are discussed.
Painless Gross Haematuria
Authors: Tan LTH , Ong KL
Published: December 2017

Inflammatory pseudotumour is a benign mesenchymal lesion that has distinct pathological features. Patients often present with haematuria, abdominal pain or recurrent cystitis. There are overlapping features with bladder sarcoma in presentation, age range, and size, but the pseudotumour does not metastasise. Awareness of this unusual lesion is important to prevent its misinterpretation. Complete surgical excision of the tumour mass is the treatment of choice.
A Case of Methanol Poisoning
Authors: Chan CK , Chan YC , Lau FL
Published: December 2017

A 29‐year‐old male took about 300 ml industrial alcohol in a suicidal attempt. The industrial alcohol was later confirmed to be methanol. He presented to the emergency department 10 hours post‐ingestion with an anion gap metabolic acidosis and an osmol gap of 76.7 mOsm/kg. Ethanol infusion was started in the emergency department at 11 hours post‐ingestion before the availability of serum methanol level. The clinical diagnosis of toxic alcohol ingestion was based on the history, arterial blood gases results and the presence of a significant osmol gap. The patient was then admitted to the intensive care unit for ethanol therapy and haemodialysis. Prompt initiation of ethanol therapy and the subsequent intensive care prevented the development of life‐threatening complications of methanol poisoning in this case.
A Case of Cervical Tuberculous Spondylitis: An Uncommon Cause of Neck Pain
Authors: Li YW , Fung YW
Published: December 2017

Neck pain is a common presentation to the emergency department. We report a case of cervical tuberculous spondylitis in an old lady with neck pain. She re‐attended the emergency department because of progressive nocturnal pain and stiffness. X‐ray of the cervical spine showed blurred endplate and prevertebral soft tissue swelling. CT cervical spine showed evidence of infective discitis. Surgical intervention and anti‐tuberculosis therapy were given. The patient became bed‐ridden and died of pneumonia two months later. Alarming clinical features and serial assessment of X‐ray changes would help to look for potentially fatal differential diagnoses of neck pain.
A Case of Slow-Release Potassium Chloride Overdose
Authors: Wan CK , Tong HK
Published: December 2017

An 86-year-old gentleman was brought to the emergency department after a massive overdose of slow-release potassium chloride and indapamide. The initial serum potassium was 6.8 mmol/L. His abdominal X-ray did not reveal any radio-opaque drugs. Whole bowel irrigation was commenced shortly after presentation. There was no rebound of hyperkalaemia and his stay in the acute hospital was short. Slow-release potassium overdose is uncommonly reported in the medical literature; such poisoning in the elderly has not been reported. Previous case reports are summarised and the management of this uncommon poisoning is discussed.
A Case of Splenic Peliosis Associated with Pathologic Rupture
Authors: Lo CM
Published: December 2017

A patient walked into the accident and emergency department with spontaneous onset of left-sided abdominal pain. Physical examination suggested the presence of an acute abdominal condition. He was admitted to the surgical ward with a provisional diagnosis of perforated peptic ulcer. Emergency laparotomy revealed haemoperitoneum caused by rupture of the spleen. Pathologic examination confirmed the rare diagnosis of splenic peliosis. Emergency physicians should be aware of the possibility of atraumatic splenic rupture as a cause of spontaneous haemoperitoneum, bearing in mind that isolated splenic peliosis (also known as peliosis lienis) is one of the causes of pathologic splenic rupture.
A Fatal Case of Acute Appendicitis
Authors: Sim TB , Ooi SBS
Published: December 2017

Appendicitis continues to be the most common acute surgical emergency. We report a fatal case of acute appendicitis, illustrating that the early presentation of appendicitis is non-specific and that serial examination is the key to the diagnosis to avoid a fatal outcome. We also present an evidence-based approach to the diagnosis of acute appendicitis in the emergency department and highlight the pearls and pitfalls of diagnosing acute appendicitis.
A Case Series of Puffer Fish Poisoning
Authors: Wan CK , Tsui SH , Tong HK
Published: December 2017

Puffer fish poisoning caused by tetrodotoxin, a potent neurotoxin, is uncommon in Hong Kong. We report a total of seven cases of puffer fish poisoning with different levels of severity. Two of them developed respiratory distress and subsequently required endotracheal intubation and respiratory support while the others presented with numbness and mild weakness. Most of them experienced perioral numbness as the first symptom. The mean time of symptoms onset was approximately 94 minutes. All of our patients survived the intoxication.
Bell'S Palsy in Children: Is There Any Role of Steroid or Acyclovir?
Authors: Doshi D , Saab M
Published: December 2017

We describe a case of a seven‐year‐old child with Bell's palsy who made a full recovery without the use of steroid or acyclovir. This is followed by a review of the literature to see whether or not there is any role of steroid or acyclovir in childhood Bell's palsy.