Mechanical Cardiopulmonary Resuscitation Device in an Accident and Emergency Department: A Case Report and Literature Review

We present a case of resuscitation of a 38-year-old lady with ventricular fibrillation using the Lund University Cardiopulmonary Assist System (LUCAS), a mechanical cardiopulmonary resuscitation (CPR) device. Return of spontaneous circulation was obtained after prolonged resuscitation but the patient eventually succumbed nine days after admission to the coronary care unit. The role of mechanical CPR devices in resuscitation in the accident and emergency department is discussed.

ST Elevation is not Always Equivalent to Acute Myocardial Infarction: a Case of Brugada Syndrome

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.

The Use of Patient Education Video in Improving Patient Satisfaction in the Accident and Emergency Department

Objective

To study the impact of patient education video in improving patient satisfaction in the accident and emergency department (AED).

Methods

This was a descriptive questionnaire study. A 20-minute patient education video in Cantonese was produced. The video was shown in the waiting hall from 9 am to 5 pm during the weekdays of a week in January 2008. All category 4 (semi-urgent) and category 5 (non-urgent) patients were invited to fill in an evaluation questionnaire after watching the video. The demographics of the patients were collected. There were two parts in the questionnaire. Part 1 contained four questions to test patients' knowledge retention after watching the video. These included questions on pharmacy location, triage system, use of patient identification slip and scope of the AED service. Part 2 contained six evaluation items (based on the 5-point Likert scale) to assess patients' opinion on the education video, understanding of the AED workflow and level of satisfaction after watching. Statistical analysis was performed to compare the knowledge retention scores and the Likert responses between different age and education level subgroups.

Results

Altogether 177 questionnaires were returned; 72 were excluded due to incomplete answers or absent patient gum label; and 105 completed questionnaires were analysed. Of the latter, 83 (79%) respondents scored 75% or more in the questions on knowledge retention, 79 (75%) respondents agreed that they understood the workflow of the AED better, 63 (60%) respondents thought that the video covered most frequently asked questions, and 69 (66%) respondents agreed that their level of satisfaction had improved after watching the video. There was no statistically significant difference on comparing the knowledge retention scores between different age and education level subgroups. Respondents more than 60 years old stated a better understanding about the location of consultation rooms after watching the video.

Conclusion

A patient education video is useful in providing information about operation and improving patient satisfaction in the accident and emergency department.

A Study on Trauma Documentation in Accident and Emergency Attendance Records

Aim

To study the adequacy of trauma documentation in accident and emergency (A&E) attendance records.

Method

We reviewed the A&E attendance records of major trauma requiring trauma-team care in the resuscitation room from January to June 1999 and July to December 2001. Thirty-eight items including the history, symptoms and signs of injury were scored with reference to the teaching of the Advanced Trauma Life Support course. The mean score and rate of documentation of each item were calculated. Additional items on biomechanics and environmental factors of injury were also examined. The performance of emergency medicine trainees and non-emergency medicine trainees was analysed.

Results

A total of 128 records were included, 46 and 82 records being from 1999 and 2001 respectively. The maximum documentation score was 38. The mean documentation score in 2001 was 23.27; and this was significantly better than 20.37 in 1999 (p < 0.05). The documentation rates of pre-hospital, biomechanics and environmental items were poor. Notably, 15 out of the 38 items were preformatted in the A&E records and 11 of these preformatted items had documentation rates of > 80%. Emergency medicine trainees had better scores in 2001 than in 1999. However, non-emergency medicine trainees did not show improvement in their documentation.

Conclusion

Trauma documentation has improved since 1999 for emergency medicine trainees. Preformatted charts may increase the rate of documentation. Information on pre-hospital care and injury mechanism was not well documented.

Over-Triage in Casevac Categorisation is Common in Hong Kong

Objective

To review the categorisation of patients who were transferred out from out-lying islands to urban hospitals utilising casualty evacuation (CASEVAC), and to search for possible patient characteristics which might have contributed to mis-categorisation during the ‘non-flying’ hours.

Methods

The medical records of 459 patients, who were transferred out in the year 2009 were reviewed. Correctness of categorisation was determined by 2 independent assessors according to the CASEVAC guidelines. The rates of mis-categorisation between ‘clinic hours’ and ‘AED hours’, and that between the ‘flying’ and ‘non-flying’ hours, were compared. The patients' demographic data and their presenting symptoms were collected and analysed using logistic regression models to identify factors contributing to mis-categorisation.

Results

The mis-categorisation rate was 60.1%. Among them, all were over-categorised. The over-categorisation rates between ‘clinic hours’ and ‘AED hours’, and between ‘flying’ and ‘non-flying’ hours, were not significantly different (p=0.07 and 0.09, respectively). Abnormal pulse rate was significantly associated with over-categorisation (p<0.01). Patients at extremes of age and psychiatric/drunk patients were significantly less likely to be over-categorised (p<0.05 and p<0.01, respectively). There was 20% disagreement between the two assessors when applying the existing CASEVACs guidelines (kappa score 0.58 or ‘moderate agreement’).

Conclusions

Over-triage in CASEVAC categorisation is common irrespective of the time of day. Revision of the current CASEVAC guidelines is recommended. (Hong Kong j.emerg.med. 2013; 20:327-336)

The Attitude of the Medical Students of the University of Hong Kong towards Emergency Medicine

Introduction

Understanding how medical students view the Specialty of Emergency Medicine is important. The knowledge helps the leaders in Emergency Medicine better plan the development of the specialty. In the medical literature, few studies primarily investigated this subject. Most were on the career choice of medical students. This study aimed at addressing this knowledge gap.

Methods

It was a cross-sectional questionnaire survey of the year 3 to 5 medical students studying at the Li Ka Shing Faculty of Medicine, the University of Hong Kong. The questionnaire measuring their attitude consisted of 16 items in 3 domains: overall merits of Emergency Medicine, the role and function of emergency physicians and the career prospect in Emergency Medicine. Descriptive statistics were used for data analysis. Their attitude was represented by an attitude score with 80 being most positive and 16 most negative.

Results

A total of 298 students participated in the survey. The response rate was 64.5%. The overall median attitude score was 59. Year 5 students had a statistically significant higher score. Emergency Medicine ranked third in their first specialty choice after qualification. There was no statistical relationship between a student's attitude score and the specialty choice.

Conclusion

The students' overall attitude towards Emergency Medicine was positive. Senior students held a more positive attitude. A student's specialty choice after qualification did not seem to relate to their attitude towards the specialty. (Hong Kong j.emerg.med. 2014;21:67-72)

A Study of Orotracheal Intubation in Emergency Departments of Five District Hospitals in Hong Kong

Objective

To study the success rates and complications of orotracheal intubation in emergency departments of five district hospitals in Hong Kong in order to identify ways for improvement.

Method

This was a prospective observational study. The emergency department doctors performing the intubation were asked to complete an intubation study form immediately after the procedure over a period of four months. Data collected included vital signs, experiences of intubators, method of intubation and complications.

Results

A total of 347 cases were collected and 93% of them were non-trauma cases. Fifty-two percent (52%) of the cases were in cardiac arrest before intubation. Rapid sequence intubation (RSI) was applied in 36% of the cases. Junior doctors first intubated about 72% of the patients. Successful intubation was achieved in 1 and 2 attempts in 70% and 89% of the cases respectively. In 10 cases (3%), secondary methods such as laryngeal mask airway, Combitube, Trachlight or cricothyroidotomy were needed. The overall complication rate was 7.8% and the complication rate in the RSI group was 15.3%. The complication rate was even higher (20%) if intubation without medication was used in non-cardiac arrest patients. Significant drop in blood pressure was the most common complication and it could be attributed to the use of midazolam as induction medication. The success rate was found to correlate with the experience of the first intubator (p<0.05) and the laryngeal view (p<0.001). The complication rate increased with repeated attempts (p<0.001) and was higher among junior doctors (p<0.05). Early use of elastic gum bougie was associated with lower complication and higher success rates.

Conclusion

Orotracheal intubation in the emergency department was associated with high complication rate. Many complications came from junior intubators. Hypotension was the most common complication. Potentially avoidable complications may be a result of failure to use RSI in non-cardiac arrest patients and failure to use bougie in cases of poor laryngeal view.

The Minimum Clinically Significant Difference in Visual Analogue Scale Pain Score in a Local Emergency Setting

Objectives

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

Methods

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

Results

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

Conclusions

The MCSD in VAS pain scores was found to be 17 mm. There was significant differences in MCSD in VAS pain score in different genders and between trauma and non-trauma cases.

A Prospective Epidemiological Study of Acute Poisoning in Hong Kong

Objective

To update our epidemiological knowledge of acute poisoning in Hong Kong.

Methods

A multi-centred prospective study was conducted for six months in six major accident and emergency departments in Hong Kong. A specially designed form was used to collect demographic data, type of poison involved, cause of poisoning, management, disposal as well as final outcome of the poisoned patients.

Results

A total of 1,467 patients (male: 588, female: 879) were included in the study. Most of them were young adults (32% were between 20 and 40 years old). Suicidal attempt (64%) was the most common cause of poisoning. Notably, 379 (26%) patients took more than one poison. Among the 2,007 counts of poison taken, sleeping pills (24%) and analgesics (18%) were the most commonly used drugs and paracetamol was the commonest single ingredient involved in poisoning. Most patients were treated with supportive measures, and about 40% and 15% of the patients were given gastrointestinal decontamination and specific antidotes respectively in their management, in which activated charcoal and N-acetylcysteine were the most common. Concerning disposal from the emergency department, 91% of the poisoned cases required in-patient management. Most patients had an uneventful recovery but 5 (0.3%) had significant disability and 21 (1.4%) died. Suicidal carbon monoxide poisoning was the leading cause of mortality in our study.

Conclusions

Most acute poisonings in Hong Kong were suicidal in nature and paracetamol was the commonest agent. Activated charcoal was the most commonly used decontamination method and most patients had an uneventful recovery.

Knowledge and Beliefs of Parents of Asthmatic Children Presenting to an Emergency Department

This is a survey on the knowledge and beliefs of 100 parents or guardians of asthmatic children presenting to the emergency department with an asthmatic attack and staying in the observation ward for treatment. The parents were asked to fill in a questionnaire on their knowledge and beliefs about asthma. Demographic data and data related to routine asthma care were also collected. The mean age of the children was 6.2± 3.2. The mean duration of asthma was 3.4 year (±2.6). In the preceding 6 months the mean attendance frequency at our accident and Energency department was 1.5±1.4. The majority of respondent (79%) agreed that asthma is caused by bronchoconstriction but only 42% understood that mucosal oedema is involved during an acute attack. Many people (82%) believed that asthma is just sensitive bronchus. Less than half (40%) believes asthma is a hereditary disease. It was a common belief that asthmatic attack can be precipitated by a change of weather (89%) and cold food/drink (77%). Over 75% agreed that carpet in the house is undesirable for an asthmatic child. The majority of parents (69%) disagreed that an asthmatic child should avoid physical exercise and only 13 would not allow the child to attend physical exercise class. Over half (54%) of the respondents believed that asthma could be cured. Only a minority (17%) believed that antibiotics are useful in shortening the attack. Thirty (30%) respondents also used alternative means of therapy for example crocodile meat. Parents' knowledge of preventive medication was inadequate. Understanding common beliefs among parents is beneficial in patient and parental education.

Validation of a 3-Item Screening Tool for Geriatric Depression in the Observation Unit of an Emergency Department

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.

Sonographic Measurement of the Epiglottis in Normal Chinese Adults

Objectives

(1) To assess the normal range of thickness of the epiglottis by means of ultrasound measurement. (2) To evaluate inter-observer agreement in measuring the thickness of the epiglottis of normal individuals by ultrasound. (3) To assess the association between biological factors and the thickness of the epiglottis.

Methods

Fifty adult volunteers working at a local accident and emergency department were recruited. The thickness of the epiglottis was measured by means of ultrasound examination, which was performed twice by two emergency physicians at different time. The study subjects' age, sex, height and body weight were recorded.

Results

The mean thickness of the epiglottis was 0.236 cm and the standard deviation was 0.020. Male subjects had thicker epiglottis. Interobserver agreement of the two emergency physicians who performed the ultrasound scan was very good. Multiple regression models showed that sex and height were useful predictors of the thickness of the epiglottis.

Conclusions

Bedside ultrasound assessment of the epiglottis is an easy, rapid and reliable method to evaluate its thickness. Further studies are needed to evaluate the thickness of the epiglottis in patients with epiglottitis before it can be put into clinical use.

Liver Allograft Provides Immunoprotection for the Cardiac Allograft in Combined Heart-Liver Transplantation

When transplanted simultaneously, the liver allograft has been thought to have an immunoprotective role on other organs; however, detailed analyses in simultaneous heart-liver transplantation (SHLT) have not been done to date. We analyzed patient outcomes and incidence of immune-mediated injury in 22 consecutive SHLT versus 223 isolated heart transplantation (IHT) recipients between January 2004 and December 2013, by reviewing 3912 protocol- and indication-specific cardiac allograft biopsy specimens. Overall survival was similar (86.4%, 86.4%, and 69.1% for SHLT and 93.3%, 84.7%, and 70.0% for IHT at 1, 5, and 10 years; p = 0.83). Despite similar immunosuppression, the incidence of T cell-mediated rejection (TCMR) was lower in SHLT (31.8%) than in IHT (84.8%) (p < 0.0001). Although more SHLT patients had preexisting donor-specific HLA antibody (22.7% versus 8.1%; p = 0.04), the incidence of antibody-mediated rejection was not different in SHLT compared with IHT (4.5% versus 14.8%, p = 0.33). While the left ventricular ejection fraction was comparable in both groups at 5 years, the incidence and severity of cardiac allograft vasculopathy were reduced in the SHLT recipients (42.9% versus 66.8%, p = 0.03). Simultaneously transplanted liver allograft was associated with reduced risk of TCMR (odds ratio [OR] 0.003, 95% confidence interval [CI] 0-0.02; p < 0.0001), antibody-mediated rejection (OR 0.04, 95% CI 0-0.46; p = 0.004), and cardiac allograft vasculopathy (OR 0.26, 95% CI 0.07-0.84; p = 0.02), after adjusting for other risk factors. These data suggest that the incidence of alloimmune injury in the heart allograft is reduced in SHLT recipients.

Quantitative characterization of chitosan in the skin by Fourier-transform infrared spectroscopic imaging and ninhydrin assay: application in transdermal sciences

The chitosan has been used as the primary excipient in transdermal particulate dosage form design. Its distribution pattern across the epidermis and dermis is not easily accessible through chemical assay and limited to radiolabelled molecules via quantitative autoradiography. This study explored Fourier-transform infrared spectroscopy imaging technique with built-in microscope as the means to examine chitosan molecular distribution over epidermis and dermis with the aid of histology operation. Fourier-transform infrared spectroscopy skin imaging was conducted using chitosan of varying molecular weights, deacetylation degrees, particle sizes and zeta potentials, obtained via microwave ligation of polymer chains at solution state. Both skin permeation and retention characteristics of chitosan increased with the use of smaller chitosan molecules with reduced acetyl content and size, and increased positive charge density. The ratio of epidermal to dermal chitosan content decreased with the use of these chitosan molecules as their accumulation in dermis (3.90% to 18.22%) was raised to a greater extent than epidermis (0.62% to 1.92%). A larger dermal chitosan accumulation nonetheless did not promote the transdermal polymer passage more than the epidermal chitosan. A small increase in epidermal chitosan content apparently could fluidize the stratum corneum and was more essential to dictate molecular permeation into dermis and systemic circulation. The histology technique aided Fourier-transform infrared spectroscopy imaging approach introduces a new dimension to the mechanistic aspect of chitosan in transdermal delivery.

A hindbrain segmental scaffold specifying neuronal location in the adult goldfish, Carassius auratus

The vertebrate hindbrain develops as a series of well-defined neuroepithelial segments or rhombomeres. While rhombomeres are visible in all vertebrate embryos, generally there is not any visible segmental anatomy in the brains of adults. Teleost fish are exceptional in retaining a rhombomeric pattern of reticulospinal neurons through embryonic, larval, and adult periods. We use this feature to map more precisely the segmental imprint in the reticular and motor basal hindbrain of adult goldfish. Analysis of serial sections cut in three planes and computer reconstructions of retrogradely labeled reticulospinal neurons yielded a segmental framework compatible with previous reports and more amenable to correlation with surrounding neuronal features. Cranial nerve motoneurons and octavolateral efferent neurons were aligned to the reticulospinal scaffold by mapping neurons immunopositive for choline acetyltransferase or retrogradely labeled from cranial nerve roots. The mapping corresponded well with the known ontogeny of these neurons and helps confirm the segmental territories defined by reticulospinal anatomy. Because both the reticulospinal and the motoneuronal segmental patterns persist in the hindbrain of adult goldfish, we hypothesize that a permanent "hindbrain framework" may be a general property that is retained in adult vertebrates. The establishment of a relationship between individual segments and neuronal phenotypes provides a convenient method for future studies that combine form, physiology, and function in adult vertebrates.

Colon-specific delivery of 5-fluorouracil from zinc pectinate pellets through in situ intracapsular ethylcellulose-pectin plug formation

Conventional fluid-bed and immersion film coating of hydrophilic zinc pectinate pellets by hydrophobic ethylcellulose is met with fast drug release. This study explored in situ intracapsular pellet coating for colon-specific delivery of 5-fluorouracil (5-FU). The solid coating powder constituted ethylcellulose and pectin in weight ratios of 11:0 to 2:9. Its weight ratio to pellets varied between 2:3 and 3:2. Pectin was used as excipient of core pellets and coating powder in view of its potential use in colon cancer treatment. Delayed 5-FU release and core pectin dissolution were attainable when the weight ratio of solid coating powder to pellets was kept at 3:2, and weight ratio of ethylcellulose and pectin in coating powder was kept at 8:3 with particle size of ethylcellulose reduced to 22 μm. In situ intracapsular wetting of pectin coat by dissolution medium resulted in the formation of ethylcellulose plug interconnecting with pellets through the binding action of pectin. Less than 25% of drug was released at the upper gastrointestinal tract. The majority of drug was released upon prolonged dissolution and in response to colonic enzyme pectinase, which digested core pellets.

Vitexin and isovitexin from the Leaves of Ficus deltoidea with in-vivo α-glucosidase inhibition

ETHNOPHARMACOLOGICAL RELEVANCE

The leaves of Ficus deltoidea are used as a traditional medicine by diabetes patients in Malaysia.

AIM OF THE STUDY

The objective of the study is to identify and evaluate bioactive constituents with in vivo α-glucosidase inhibition.

MATERIALS AND METHODS

The partitioned extracts, subfractions and pure bioactive constituents were subjected to α-glucosidase inhibition assay. The identified bioactive constituents were administered orally to sucrose loaded normoglycemic mice and induced diabetic rats. The postprandial blood glucose levels were monitored at 30 min interval. Acute toxicity was evaluated in both normoglycemic mice and induced diabetic rats.

RESULTS

Bioactivity guided fractionation led to the isolation of both vitexin (1) and isovitexin (2). Oral administration of 1mg/kg of either vitexin (1) or isovitexin (2) significantly (p<0.05) reduced the postprandial blood glucose level in sucrose loaded normoglycemic mice at 30 min. The percentage of postprandial blood glucose reduction was highest in sucrose loaded induced diabetic rats administered orally with 200mg/kg of vitexin (1) or 100mg/kg of isovitexin (2). Both vitexin (1) and isovitexin (2) did not exert any signs of toxicity at the highest dose of 2g/kg administered orally to normoglycemic mice and induced diabetic rats.

CONCLUSION

Both the C-glycosyl bioflavonoids, namely, vitexin (1) and isovitexin (2) exhibited in vivo α-glucosidase inhibition.

Serotonin syndrome following overdose of a non-prescription slimming product containing sibutramine: a case report

INTRODUCTION

Non-prescription slimming products are popular and can be easily purchased from the Internet. However, adulteration of these products with undeclared substances including prescription drugs is not uncommon. We report a case of serotonin syndrome after an overdose of a non-prescription product containing sibutramine.

CASE REPORT

A 21-year-old woman presented with somnolence, sinus tachycardia, generalised increase in tone, hyper-reflexia and clonus more prominent in the lower limbs after an intentional overdose of a non-prescription slimming product obtained from the Internet. The product was later found to contain sibutramine and other substances such as animal thyroid tissues, caffeine and phenolphthalein. Quantitative analysis of patient's serum on presentation revealed a sibutramine concentration of 112 ng/mL, which far exceeded the reported peak serum concentration after a single oral dose of 15 mg (the maximum daily recommended dose). No other culpable agent was identified. The overall clinical presentation was compatible with serotonin syndrome associated with sibutramine overdose. The patient made a full recovery after supportive management.

DISCUSSION AND CONCLUSION

This case highlighted the health threat posed by non-prescription slimming products sold over the Internet. Sibutramine overdose can result in serotonin syndrome, as in overdose of other serotonergic agents. Early recognition and timely supportive treatment are essential to ensure a good clinical outcome.