A Case of Persistent and Recurrent Ventricular Fibrillation with Successful Resuscitation and Good Neurological Outcome

A 49-year-old man suffering from chest pain collapsed on arrival at an emergency department. Ventricular fibrillation was confirmed and he survived neurologically normal after 22 defibrillation shocks. This case attests that persistent and recurrent ventricular fibrillation is still compatible with good neurological outcome. Energetic and persistent efforts should be continued in such cases. Amiodarone should be considered early in the course of refractory ventricular fibrillation.

An Analysis of Unscheduled Return Visits to the Accident and Emergency Department of a General Public Hospital

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.

Go-Kart Related Injuries: A Local Scene

Objectives

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

Methods

A prospective survey of patients with go-kart 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

Forty-two patients were collected in the study. The mean age was 26 years. Ten patients (23.8%) were at or below the age of 20 years. Twenty-nine patients (69.0%) were males. Out of the 42 patients, all were riders except one who was a bystander. Thirty-three patients (78.6%) had injuries in indoor tracks. Ten (23.8%) patients were admitted and five (50%) of those admitted required operations. There was no fatality. Twenty-seven patients (64.3%) had only single injury. Most (64.2%) were minor soft tissue injuries. However, fractures or dislocations occurred in 13 patients (31.0%). Two patients (4.8%) suffered from internal organ injuries. Isolated head and facial injuries occurred in 11.9% of patients. All were simple concussion. Nine patients (21.4%) suffered from isolated lower limb injuries, with more than half sustaining fractures or dislocations. Collision with other karts (40.5%) was the most frequent mechanism of injury. Riding in outdoor track was associated significantly with increased admission when compared with indoor track (77.8% vs 9.1%, p<0.001). There was no association between rider's age, gender, previous riding or injury experience, or the presence of briefing before the race with the rate of admission.

Conclusion

Go-kart racing and working on racing track can be a recreation or occupation with potential dangers. In our study, characteristics of patients, mechanisms and types of injuries were similar to other western studies. Accidents on outdoor tracks appeared to be more serious and more likely admitted than those on indoor circuits. Special safety precautions on outdoor events may help to reduce the severity of injuries. However, drivers with more riding or injury experiences were not exempted from severe injuries. Moreover, presence of briefing before the race did not help reduce the admission rate either. Perhaps, a safe and careful attitude of the rider and a seriously conducted briefing by a qualified instructor would be more important to reduce accidents. Further proper large scale controlled epidemiological studies will definitely help to improve the understanding of go-kart related injuries.

Pancreatic Injury: An Uncommon Cause of Abdominal Pain after Blunt Trauma

Blunt pancreatic injury is an uncommon cause of traumatic abdominal pain. Early diagnosis is difficult due to its subtle initial presentation, both clinically and on imaging study. Dilemma between a watchful expectant management and thorough initial investigation may arise. The management of a 44-year-old man presenting to the emergency department because of generalised trunk pain after blunt trauma is reported.

Golf-related Injuries: Case Series and Reports

Within the year 2002, eleven patients attended the emergency department of a public district hospital because of golf-related injuries. This attested to the low but occasionally serious risk of this type of sport activity. As golf is becoming increasingly popular in Hong Kong, it is expected that emergency physicians will see more and more golf-related injuries.

Acute Ischaemic Stroke: Management, Recent Advances and Controversies

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.

A Retrospective Study of Seclusion in an Emergency Department

Objectives

To study the practice of seclusion in an emergency department (ED) and to explore high-risk elements during seclusion.

Methods

The study consisted of two parts: an in-depth analysis on all incidents associated with seclusion in a six-year period (1998–2004) and a two-year (2002–2004) retrospective analysis of secluded patient records to understand the rationale and patient outcome.

Results

Part 1: A total of 9 incident records were collected. Four patients were related to setting fire. Five patients had violence or threat of violence. The median length of stay (LOS) in seclusion at the time of incident was 129 minutes. Although 66.7% of the patients had additional restraint prior to the seclusion, incidents still occurred. Two staff sustained injuries and hospital facilities were damaged in some of the incidents. Six patients were later admitted to psychiatric hospital. Part 2: 141 patient data were collected in the study (M: 89 and F: 52). The average monthly number of patients secluded was about 6. The mean age was 45 years (SD 19) and the mean LOS was 616 minutes (SD 478). There were three incidences (2.1%) during the two-year period. A total of 82 patients (58.2%) were associated with violence or threat of violence and 38 (46.3%) of the group had psychiatric illness; and 50 patients (35.5%) were associated with alcohol or drug intoxication. Ultimately, 56 patients (39.7%) were admitted to psychiatric hospital and 64 patients (45.4%) were treated and discharged from the ED.

Conclusion

Seclusion is a high-risk practice. In our department, the most frequent indication was violence (58.2%), with nearly half of them having history of psychiatric illness. Psychiatric illness had the highest risk for incidents, especially those with violence or threat of violence. The LOS in seclusion was relatively long in the ED and might be one of the risk factors for incidents. Inadequate removal of potentially dangerous belongings from patients before seclusion may end up with catastrophic outcomes. Curiously, ED nurses are not allowed to search patients before seclusion. They are exposed to legal liability in exercising restraint and in searching for potentially dangerous items from patients. It is suggested that clear protocols and quality assurance programs should be instituted to ensure safe seclusion.

Prognostic Predictive Values of the Initial Electrocardiogram with St-Segment Elevation Acute Myocardial Infarction in Chinese Patients

Objective

To study the electrocardiogram (ECG) features that predict 30-day mortality of ST-segment elevation acute myocardial infarction (STEMI) in Chinese patients.

Method

This was a retrospective study. Patients presenting within twelve hours after the onset of chest pain with ECG features compatible with STEMI and the diagnosis confirmed after admission were included in the study. Data taken into account included age, sex and thrombolytic therapy in the emergency department. The hospital records of the patients were later retrieved from the computer. The initial ECG performed in the emergency department were reviewed.

Results

A total of 98 patients were included in the study. There was no statistically significant relationship between 30-day mortality and the type of myocardial infarction or the magnitude of the ST segment changes. Distortion of the terminal portion of the QRS complex and prior evidence of myocardial infarction (in another location different from the presenting one) showed statistically significant relationship with 30-day mortality, with odds ratio 10.364 (95% CI 1.715–62.620) and 12.731 (95% CI 2.317–69.962) respectively.

Conclusion

In newly diagnosed STEMI patients, if there is evidence of terminal distortion of the QRS complex or prior ECG changes of myocardial infarction, the 30-day mortality will be significantly higher.

A Lady with Alarming Neck Swelling after Minor Head Injury

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

Emergency Department Violence: a Local Scene

Objectives

To study the nature, frequency and magnitude of violence in a local emergency department.

Design

Prospective epidemiological study in a three-month period, during which involved staff filled in a survey form immediately after violence incidents.

Setting

Accident & Emergency Department of a public general hospital in the northeastern New Territories.

Population

Assailants and victims of violence in the emergency department.

Main outcome measures

Nature of violence, frequency, cause, morbidity, epidemiological characteristics of assailants and victims.

Results

There were 25 incidents with 26 assailants in the three-month period. The great majority was verbal abuse only (64%). No weapon was involved. Long waiting time (36%), deranged mental condition (28%) and dissatisfaction with service (20%) were the leading causes of violence. Assailants showed a predominance of male (69%) and age between 21–50 years. They were either patients (69%) or accompanying persons (31%). Nurses (59%) and to a lesser extent doctors (23%), were the main victims.

Conclusion

The incidence of emergency department violence (0.08%) was low and the majority was verbal abuse only. Nurses bore the brunt of the violence. Long waiting time, confused patients and dissatisfied patients were high risk factors.

Meeting the Media: Friend or Foe?

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.

Ciguatera fish Poisoning: a Challenge to Emergency Physicians

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.

An Intravenous Drug Addict Presenting with ‘Shortness of Breath’: Case Report

A 49-year-old male intravenous drug addict attended the emergency department complaining of ‘shortness of breath’ for one day. He was discharged after evaluation and referred to the methadone clinic. He re-attended the next day complaining of neck stiffness and twitching of limbs for one day. The final diagnosis was tetanus. Although tetanus is rare in Hong Kong, high vigilance should still be maintained for its atypical presentations, especially in high-risk groups.

Alarming Pneumomediastinum but Benign Outcome: a Case Report on Oesophageal Perforation by Foreign Body

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.

Delayed Rupture of Occult Splenic Injury: a Case Report

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.

Management of Body Packers in the Emergency Department

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.