Substance Abuse Patient Characteristics: A Scene from an Emergency Department near the Hong Kong – Shenzhen Border

Objective

Drug abuse is an escalating problem in Hong Kong, especially among teenagers and young adults. A study was conducted in order to obtain the characteristics of drug abusers presenting to the Accident & Emergency department of North District Hospital, which is located in the New Territories near the Hong Kong – Shenzhen border.

Design

Prospective study.

Setting

Accident and Emergency department of a public general hospital.

Patients

Drug abusers presenting to the Accident and Emergency department in a six-month period.

Main outcome measures

Epidemiological data including demographic data, types of drug taken, place of drug abuse and magnitude of cross-border drug abuse were collected and analyzed.

Results

The sex distribution was male 59 and female 13 (ratio=4.5:1). The mean age was 29.2 (range 14 to 67 years). Of interest, 29.2% abused drugs at home; 29.2% abused drugs in parties such as karaoke, rave and disco; 68% abused drugs in Hong Kong; 32% abused drugs in China and 6.9% claimed themselves first-time drug abusers. The commonest drug taken was ecstasy (40.3%) – the majority (55%) in China and the rest (45%) in Hong Kong. For organic solvent abusers, 57.1% were below 18 years of age. One patient died, resulting in a mortality rate of 1.4%.

Conclusion

Ecstasy was the commonest drug abused on both sides of the “border”. The majority of substance abusers were teenagers or young adult males. This study confirmed the significant magnitude of psychotropic substance abuse problem among the young population in the North District, indicating the urgent need for clinical and social intervention.

Massive Spontaneous Haemopneumothorax and Ecstasy Abuse

A 33-year-old man developed spontaneous haemopneumothorax after taking ecstasy in a ‘rave party’. Massive haemorrhage occurred after chest drainage and decompression. Both the adverse effects of ecstasy and risk behaviours at the party might have contributed to the development of the spontaneous haemopneumothorax.

Case Report: Thoracic Spinal Epidural Haematoma – an Unusual Cause of Chest Pain

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

A Six-Year Prospective Study of Out-of-Hospital Cardiac Arrest Managed by a Voluntary Ambulance Organisation

Objective

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

Design

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

Setting

A voluntary ambulance service in Hong Kong.

Subjects and methods

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

Main outcome measures

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

Results

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

Conclusions

Bystander CPR and ambulance response time are two areas requiring urgent improvement in our locality. As the majority of cardiac arrests occurred at home, the cost-effectiveness of public access defibrillation for Hong Kong is unclear. However, strategic placement of AED at high incidence' locations should be seriously considered.

A Retrospective Study of Patients Discharged within 24 Hours after Emergency Admission in a Public General Hospital

Objectives

To identify the epidemiological characteristics and outcome of patients who were discharged within 24 hours of emergency admission, and to explore methods to reduce inappropriate admission.

Design

Retrospective study.

Setting

Emergency admission in a public general hospital in Hong Kong.

Patients

Four hundred and ninety-one cases collected in a three-month period from 1st April 2000 to 30th June 2000, excluding those who died within 24 hours of admission.

Main outcome measures

Patients' epidemiological and clinical characteristics, specialty of admission, in-patient procedures performed, diagnosis upon discharge and destination of patients.

Results

During the study period, 8.8% of the 5,587 emergency admissions were discharged within 24 hours. Most of them were middle-aged males, triaged as category 3 and 4 non-trauma cases. The percentage of emergency Orthopaedic and Surgical admission resulting in discharge within 24 hours was 18.5% and 16.2% respectively, substantially higher than the percentage of emergency Medical and Paediatric admission (5.5% and 4.7% respectively). The most common diagnoses included orthopaedic open soft tissue injuries, orthopaedic closed fractures and dislocations, head injury, drug overdose, abdominal pain, ischaemic heart disease or chest pain and foreign body in throat. Overall, 20.8% of cases received some forms of orthopaedic procedures, 9% had computed tomography (CT) brain done, and 5.5% had OGD performed. Around 90% of cases with orthopaedic open soft tissue injuries and closed fractures or dislocations received intervention, 73% of head injury cases had CT brain done, and around 63% of patients with foreign body in throat received oesophago-gastroduodenoscopy (OGD). Overall, 14% of cases discharged themselves against medical advice or walked away after admission. Up to 9.8% were transferred to other hospitals within 24 hours. Around 54.8% were followed up in hospital after discharge, and re-admission was planned in 2.9% for elective procedures. Only 13 cases (2.6%) were re-admitted through A&E within one week with the same diagnosis into the same specialty.

Conclusions

The issue of ‘discharge within 24 hours’ should not automatically be regarded as inappropriate emergency admission. Upgrade of professional training and clinical supervision, improvement of administrative arrangement and clinical audit are possible measures to enhance the efficiency of hospital utilization.

A Fatal Case of Iatrogenic Bilateral Pneumothorax after Acupuncture

We report a case of fatal iatrogenic pneumothorax after acupuncture. A patient with motor neurone disease presented with shortness of breath after acupuncture. Bilateral pneumothoraces were detected. Bilateral chest drains were inserted. However, the patient succumbed 41 days after admission. On reviewing the literature, pneumothorax was not uncommonly seen after acupuncture, and most patients recovered uneventfully. However, fatal cases still happened.

A Case of Disseminated Intravascular Coagulopathy Developing Rapidly after a Suspected Bamboo Snakebite

We present a case of disseminated intravascular coagulopathy developing rapidly after being bitten by a snake suspected to be Trimeresurus albolabris in a 67-year-old man. The unusually fast onset of coagulation disturbances and the later renal complication should alert emergency physicians that snakebites (including Trimeresurus albolabris) can be devastating if not managed promptly.

Clinical Audit in Emergency Medicine

Clinical audit is the review of clinical performance against agreed standards, and the refining of clinical practice as a result – a cyclical process of quality improvement in clinical care. The different steps of the clinical audit cycle are discussed. Publications on clinical audit in connection with Emergency Medicine are scarce in the medical literature. Clinical audit should be made compulsory for all healthcare professionals providing clinical care, and emergency physicians are no exceptions.

Diagnosing Acute Pancreatitis: Amylase or Lipase?

Introduction

Serum amylase has all along been used to aid the diagnosis of acute pancreatitis in hospitals in Hong Kong. Another serum marker lipase, on the other hand, has been claimed to have better accuracy in other countries. The aim of this study was to evaluate serum lipase as a diagnostic tool compared to the traditional serum amylase.

Methods

This was a retrospective study in a district hospital in Hong Kong. The two serum markers were taken from 3451 patients with acute abdominal pain who presented to our emergency department over an eight-month period. Receiver operating characteristic (ROC) curve was used to assess the diagnostic accuracy of both markers. Other diagnostic efficacy modalities, including sensitivity, specificity, positive and negative predictor values were also calculated.

Results

Both amylase and lipase had high accuracy index in the area under the ROC curve (0.992 and 0.996 respectively). The sensitivity and specificity of amylase at 3-fold above normal limit were 63.6% and 99.4% while those of lipase were 95.5% and 99.2% respectively.

Conclusion

Both serum enzymes had good diagnostic accuracy in our study but lipase was slightly better than amylase.

A Pilot Study on the use of Tramadol Hydrochloride for Pain Control in an Emergency Department

Introduction

Tramadol hydrochloride is a synthetic μ,-opioid agonist. It has been used in the control of moderate to severe pain. Most of the studies on tramadol were related to post-operative pain control. Data on acute pain control in the emergency setting were limited. This study reported on the initial evaluation of tramadol for pain control in an emergency department.

Materials and methods

It was a prospective observational study. Patients aged 16 years or above attending our emergency department with moderate to severe pain were recruited. Patients with known allergy, current psychiatric medication, intake of alcohol, major systemic illness and opioid dependence were excluded. All patients received 100 mg intramuscular tramadol injection. A 10 cm Visual Analogue Scale (VAS) was used to assess the pain severity before injection, 30 minutes and 60 minutes after injection. Vital signs and side effects were also recorded.

Results

Forty patients (M: 24, F: 16) were recruited from October to December 2002. Their mean age was 53.5 years. The majority of them suffered from acute musculoskeletal pain or arthritis. Tramadol was shown to be effective in pain control. The VAS decreased by 1.90 (p<0.001) and 3.38 (p<0.001) at 30 minutes and 60 minutes respectively. Four patients reported nausea and three patients vomited.

Conclusion

Tramadol appeared to be a safe drug to be used in the emergency setting. Only a few insignificant side effects were reported. The comparison of efficacy with other analgesics requires further studies.

Case and Literature Review: Adult Acute Epiglottitis – Rising Incidence or Increasing Awareness?

Objective

The prevalence of adult acute epiglottitis is probably more common than is generally appreciated. A retrospective case review in a district hospital and a medical literature search may provide baseline information to guide future strategies.

Methods

Cases of acute epiglottitis in a period of 3 years and 4 months were traced from the hospital computer systems. Medical records were reviewed. Medical literature on “adult acute epiglottitis” was searched through Medline and EMBASE. Relevant full text articles were retrieved through hospital library network.

Results

From February 1998 to June 2001, 11 cases of acute epiglottitis were identified. The age range was 34–78 (mean 47.5, median 41). There was no paediatric case. The male to female ratio was 9:2. Eight presented with fever, sore throat and dysphagia, one presented with dyspnoea and two presented as foreign body in throat. Nine were treated successfully conservatively. Two were intubated prophylactically. There was no case fatality.

Conclusion

Adult acute epiglottitis has become much commoner than its paediatric counterpart. Acute epiglottitis should be suspected in all patients with a sore throat and dysphagia, especially if symptoms are out of proportion to the pharyngeal inflammation.

Can Tension Haemopneumothorax Have Stable Haemodynamics?

Tension pneumothorax or haemopneumothorax is a clinical diagnosis. Plain radiography is not advised to confirm the diagnosis and may delay definitive treatment. Unstable haemodynamics is one of the prerequisites for the diagnosis. We report a case in which the patient suffered from haemopneumothorax with all the typical radiological features of tension, but without any clinical sign of unstable haemodynamics. Close monitoring of patients suspected to have pneumothorax is recommended, especially in the radiology suite.

Emergency Management North of the Shenzhen River

A study was carried out in a district hospital located close to the Hong Kong - Shenzhen border, in order to get a picture of the epidemiology of diseases and injuries sustained by Hong Kong residents in China. The emergency medical treatment provided and the degree of patient satisfaction were also analysed. The majority of the patients were adult males. Trauma constituted more than 50% of the attendance, with traffic accident and common assault being the leading causes. This group of Hong Kong residents preferred to be treated in Hong Kong hospitals because of perceived better quality of care. There was a high demand on the local ambulance service and this might have financial and resource implications.

Persistent Fever and Exanthema in a Family: A Case Report of Mediterranean Spotted Fever

Mediterranean spotted fever (also called Boutonneuse fever) is a notifiable disease in Hong Kong, but its diagnosis can be difficult. We report a case of Mediterranean spotted fever in a middle-aged man who presented with persistent fever, headache, and skin rash. Three weeks ago, his daughter had similar presentations. With a history of similar clinical presentation within family members, the possibility of potential exposure to a common disease vector should be suspected. Establishing an early diagnosis may be possible if this important history is obtained. Early recognition of this disease may lead to early therapeutic intervention, resulting in decreased morbidity and shortened duration of hospital stay.