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Ng M, Wong ZY, Ponampalam R. Extracorporeal cardio-pulmonary resuscitation in poisoning: A scoping review article. Resusc Plus 2023; 13:100367. [PMID: 36860990 PMCID: PMC9969255 DOI: 10.1016/j.resplu.2023.100367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 02/22/2023] Open
Abstract
Background Extracorporeal cardiopulmonary resuscitation (ECPR) represents last-line salvage therapy for poisoning-induced cardiac arrest but no review has focused on this specific area. Objective This scoping review sought to evaluate the survival outcomes and characteristics of published cases of ECPR for toxicological arrest, with the aim of highlighting the potential and limitations of ECPR in toxicology.Eligibility Criteria.We searched PubMed and Cochrane for eligible papers from database inception to October 1, 2022 using the keywords "toxicology", "ECLS" and "CPR". References of included publications were searched to identify additional relevant articles. Qualitative synthesis was used to summarize the evidence. Results 85 articles were chosen: 15 case series, 58 individual cases and 12 other publications that were analyzed separately due to ambiguity. ECPR may improve survival outcomes in selected poisoned patients, although the extent of benefit is unclear. As ECPR for poisoning-induced arrest may have better prognosis compared to from other aetiologies, it is likely reasonable to apply ELSO ECPR consensus guideline recommendations to toxicological arrest.Out-of-hospital cardiac arrest alone may not be sufficient grounds to deny ECPR if effective resuscitation had been promptly instituted. Poisonings involving membrane-stabilizing agents and cardio-depressive drugs, and cardiac arrests with shockable rhythms appear to have better outcomes. ECPR may permit excellent neurologically-intact recovery despite prolonged low-flow time of up to four hours. Early ECLS activation and pre-emptive catheter placement can significantly shorten time-to-ECPR and possibly improve survival. Conclusion As effects of poisoning may be reversible, ECPR can potentially support poisoned patients through the critical peri-arrest state.
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Affiliation(s)
- Mingwei Ng
- Corresponding author at: Department of Emergency Medicine, Singapore General Hospital, Outram Road, 169608, Singapore.
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2
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Lee MAB, Ng M, Yugendra P, Yao Y, Ponampalam R, Tan BKK. Hemorrhagic pancreatitis from fenofibrate and metformin toxicity: a case report. World J Emerg Med 2023; 14:495-498. [PMID: 37969214 PMCID: PMC10632758 DOI: 10.5847/wjem.j.1920-8642.2023.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/26/2023] [Indexed: 11/17/2023] Open
Affiliation(s)
- Marcus Aik Beng Lee
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
| | - Mingwei Ng
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
| | - Paul Yugendra
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
| | - Yiju Yao
- Analytical Toxicology Laboratory, Health Sciences Authority, Singapore 169078, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
| | - Boon Kiat Kenneth Tan
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
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3
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Yau CE, Chen H, Lim BPY, Ng M, Ponampalam R, Lim DYZ, Chin YH, Ho AFW. Performance of the paracetamol-aminotransferase multiplication product in risk stratification after paracetamol (acetaminophen) poisoning: a systematic review and meta-analysis. Clin Toxicol (Phila) 2023; 61:1-11. [PMID: 36444937 DOI: 10.1080/15563650.2022.2152350] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Risk stratification in paracetamol (acetaminophen) poisoning is crucial because hepatotoxicity is common and can be mitigated with treatment. However, current risk stratification tools have limitations. AIMS We evaluated the diagnostic performance of the paracetamol concentration × aminotransferase multiplication product, for predicting hepatotoxicity after paracetamol overdose. METHODS Medline, Cochrane Library and Embase were searched for eligible papers. We used random effects models to obtain pooled estimates of the likelihood ratios and diagnostic odds ratios, from which sensitivity and specificity were computed. We assessed two commonly used cut-off values of paracetamol × aminotransferase, 1500 mg/L × IU/L and 10,000 mg/L × IU/L. Using the confusion matrices of these two cut-offs, area under the summary receiver operator characteristic curve and optimal cut-off values in different clinical scenarios were established. RESULTS Six studies comprising 5036 participants were included. In 4051 patients, using the cut-off of 1500 mg/L × IU/L, a diagnostic odds ratio of 31.90 (95%CI: 9.52-106.90), sensitivity of 0.98 (95%CI: 0.94-1.00) and specificity of 0.66 (95%CI: 0.49-0.89) were obtained. In 3983 patients, using the cut-off of 10,000 mg/L × IU/L, a diagnostic odds ratio of 99.34 (95%CI: 12.26-804.87), sensitivity of 0.65 (95%CI: 0.51-0.82) and specificity of 0.97 (95%CI: 0.95-1.00) were obtained. For staggered ingestions, the 1500 mg/L × IU/L cut-off yielded a diagnostic odds ratio of 69.53 (95%CI: 4.03-1199.75), sensitivity of 1.00 (95%CI: 0.87-1.00) and specificity of 0.74 (95%CI: 0.43-1.00). Next, using the 10,000 mg/L × IU/L cut-off in this scenario yielded a diagnostic odds ratio of 254.58 (95%CI: 11.12-5827.60), sensitivity of 0.79 (95%CI: 0.59-1.00) and specificity of 0.98 (95%CI: 0.94-1.00). The overall summary receiver operator characteristic curve was 0.91 (95%CI: 0.75-0.97), and the optimal cut-off value was 3840 mg/L × IU/L. The summary receiver operator characteristic curve in patients with staggered ingestions was 0.96 (95%CI: 0.85-0.99). The summary receiver operator characteristic curve in patients with staggered ingestions and whose paracetamol concentration was below the detectable limit of 10 mg/L at presentation was 0.97 (95%CI: 0.94-0.99). CONCLUSION In this first meta-analysis, paracetamol × aminotransferase demonstrates its use in prognosticating hepatotoxicity in patients with paracetamol poisoning. It complements the Rumack-Matthew nomogram as it has shown promise in addressing two key limitations of the nomogram: it is usable after more than 24 h between overdose and acetylcysteine treatment, and it is applicable in staggered ingestions.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Haoyang Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Bryant Po-Yuen Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mingwei Ng
- SingHealth Toxicology Service; Singapore, Singapore
| | - R Ponampalam
- SingHealth Toxicology Service; Singapore, Singapore
| | - Daniel Yan Zheng Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore, Singapore
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Soo JEJ, Ng M, Chong TKL, Tan BKK, Ponampalam R. A case of persistent refractory hypoglycemia from polysubstance recreational drug use. World J Emerg Med 2023; 14:75-77. [PMID: 36713342 PMCID: PMC9842469 DOI: 10.5847/wjem.j.1920-8642.2022.088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/26/2022] [Indexed: 02/01/2023] Open
Affiliation(s)
- Jie Er Janice Soo
- Department of Emergency Medicine, Singapore General Hospital, 169608, Singapore,Corresponding Author: Jie Er Janice Soo,
| | - Mingwei Ng
- Department of Emergency Medicine, Singapore General Hospital, 169608, Singapore
| | | | | | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, 169608, Singapore
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5
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Zuhary TM, Ponampalam R. Acute kidney injury associated with consumption of starfruit juice: A case report. World J Crit Care Med 2022; 11:330-334. [PMID: 36160937 PMCID: PMC9483003 DOI: 10.5492/wjccm.v11.i5.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/06/2022] [Accepted: 07/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND This study aims to highlight the potential serious complications of acute kidney injury (AKI) resulting from the consumption of excessive amounts of starfruit, a common traditional remedy.
CASE SUMMARY A 78-year-old male with a past medical history of hypertension, diabetes mellitus and hyperlipidemia without prior nephropathy presented to the emergency department (ED) with hiccups, nausea, vomiting and generalized weakness. In the preceding 1 wk, he had consumed 3 bottles of concentrated juice self-prepared from 1 kg of small sour starfruits. His serum creatinine was noted to be 1101 μmol/L from baseline normal prior to his ED visit. He was diagnosed with AKI secondary to excessive starfruit consumption.
CONCLUSION Consumption of starfruit can cause acute renal failure, with a good outcome when promptly identified and treated.
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Affiliation(s)
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
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Thiagarajan S, Tay S, Liu Z, Ponampalam R. Assessment of the knowledge, attitude, readiness, and willingness to volunteer in disasters amongst medical students in Singapore. Singapore Med J 2022. [PMID: 35196852 DOI: 10.11622/smedj.2022027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - Zhenghong Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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7
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Hong IZ, Ponampalam R. Death related to ethyl chloride inhalation abuse: a case report. World J Emerg Med 2022; 13:422-424. [PMID: 36119769 PMCID: PMC9420668 DOI: 10.5847/wjem.j.1920-8642.2022.083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 05/26/2022] [Indexed: 08/01/2023] Open
Affiliation(s)
- Ian Zhirui Hong
- Department of Emergency Medicine, Singapore General Hospital, 169608, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, 169608, Singapore
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8
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Omar E, Wong Z, Mohamed Jamil AK, Ponampalam R. Secondary exposure to organophosphate in the emergency department: analysis of an incident. Singapore Med J 2021. [PMID: 34823333 DOI: 10.11622/smedj.2021220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Eunizar Omar
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Ziyang Wong
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | | | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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9
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Chua IS, Tan KB, Ponampalam R. Carbon monoxide poisoning in a group of restaurant workers: lessons learnt and how to prevent future occurrences. Singapore Med J 2021. [PMID: 34823325 DOI: 10.11622/smedj.2021217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ivan Sy Chua
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Kenneth Bk Tan
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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10
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Ponampalam R, Pong JZ, Wong XY. Medical students as disaster volunteers: A strategy for improving emergency department surge response in times of crisis. World J Crit Care Med 2021; 10:163-169. [PMID: 34616653 PMCID: PMC8462026 DOI: 10.5492/wjccm.v10.i5.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/25/2021] [Accepted: 08/19/2021] [Indexed: 02/06/2023] Open
Abstract
Disasters resulting in mass casualty incidents can rapidly overwhelm the Emergency Department (ED). To address critical manpower needs in the ED’s disaster response, medical student involvement has been advocated. Duke-National University of Singapore Medical School is in proximity to Singapore General Hospital and represents an untapped manpower resource. With appropriate training and integration into ED disaster workflows, medical students can be leveraged upon as qualified manpower. This review provides a snapshot of the conceptualization and setting up of the Disaster Volunteer Corps – a programme where medical students were recruited to receive regular training and assessment from emergency physicians on disaster response principles to fulfil specific roles during a crisis, while working as part of a team under supervision. We discuss overall strategy and benefits to stakeholders, emphasizing the close symbiotic relationship between academia and healthcare services.
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Affiliation(s)
- R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
| | - Jeremy Zhenwen Pong
- Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
| | - Xiang-Yi Wong
- Duke-NUS Medical School, National University of Singapore, Singapore 169857, Singapore
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Ng M, Liu Z, Tan JSL, Ponampalam R. Comparison of self-reported EDACS versus physician-reported EDACS for the triage of chest pain patients in the emergency department. J Am Coll Emerg Physicians Open 2021; 2:e12393. [PMID: 33718926 PMCID: PMC7926007 DOI: 10.1002/emp2.12393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/01/2021] [Accepted: 01/28/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Currently, there are no guidelines to help triage nurses identify high-risk emergency department chest pain patients. Patient self-reporting of Emergency Department Assessment of Chest Pain Score (EDACS) could facilitate more reliable triage compared to nursing gestalt, but this novel concept is untested. This study hypothesizes that because EDACS requires minimal clinical gestalt to derive, self-reported EDACS (S-EDACS) at triage is likely to correlate well with traditional physician-reported EDACS (P-EDACS) and have potential application as a triage tool. METHODS This single-center pilot prospective cohort study analyzed 60 patients who completed a self-reported questionnaire upon triage to determine their S-EDACS. This was matched against P-EDACS, derived from an identical questionnaire completed by the blinded treating physician. Secondary endpoint of major adverse cardiovascular events (MACE) within 30 days (all-cause mortality, myocardial infarction, coronary revascularization) was assessed by 2 blinded emergency physicians who independently reviewed the electronic medical records. S/P-EDACS also were benchmarked against nursing gestalt (based on triage to low/high-acuity areas) and emergency physician gestalt (disposition and admitting/discharge diagnoses). RESULTS There was perfect agreement between S/P-EDACS in this study (K = 1.00). Fifteen patients (25.0%) had minor discordances in their absolute S/P-EDACS that did not affect risk stratification. Of these, 11/15 (73.3%) had higher S-EDACS, suggesting S-EDACS is more likely to safely overcall MACE risk. S-EDACS outperformed nursing gestalt, triaging a greater proportion of patients (71.7% vs 35.0%) as low risk without compromising patient safety, and demonstrated similar accuracy as emergency physician gestalt. CONCLUSION S-EDACS strongly correlates with P-EDACS with perfect agreement and has potential to be used as a triage tool.
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Affiliation(s)
- Mingwei Ng
- Department of Emergency MedicineSingapore General HospitalSingapore
| | - Zhenghong Liu
- Department of Emergency MedicineSingapore General HospitalSingapore
| | - Jean Su Ling Tan
- Department of Emergency MedicineSingapore General HospitalSingapore
| | - R. Ponampalam
- Department of Emergency MedicineSingapore General HospitalSingapore
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12
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Cheng J, Chowdhury SR, Dutta A, Ponampalam R. Venous thromboembolism in a healthy young man: An unintended consequence of coronavirus disease 2019 pandemic lockdown. World J Emerg Med 2020; 11:255-257. [PMID: 33014222 DOI: 10.5847/wjem.j.1920-8642.2020.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jenshen Cheng
- SingHealth Emergency Medicine Residency Programme, Singapore Health Services, Singapore
| | | | - Aliviya Dutta
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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13
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Ng M, Tan HJG, Gao F, Tan JWC, Lim SH, Ong MEH, Ponampalam R. Comparative prospective study of the performance of chest pain scores and clinical assessment in an emergency department cohort in Singapore. J Am Coll Emerg Physicians Open 2020; 1:723-729. [PMID: 33145512 PMCID: PMC7593418 DOI: 10.1002/emp2.12242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/06/2020] [Accepted: 08/14/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Chest pain scores allow emergency department (ED) physicians to identify low-risk patients for whom discharge can be safely expedited. Although these have been extensively validated in Western cohorts, data in patients of Asian heritage are lacking. This study aimed to determine the accuracy of HEART, ED Assessment of Chest Pain Score (EDACS), and Global Registry of Acute Coronary Events (GRACE) in risk-stratifying which chest pain patients are at risk of major adverse cardiovascular events within 30 days (composite of all-cause mortality, acute myocardial infarction and coronary revascularization). METHODS This single-center prospective cohort-study that enrolled 1200 patients was conducted by a large urban tertiary center in Singapore. Chest pain scores were reported before disposition by research assistants blinded to the physician's clinical assessment. Outcomes were assessed independently by a blinded cardiologist and emergency physician, while another cardiologist adjudicated in the case of discrepancies. RESULTS Of the 1195 patients analyzed, 135 (11.3%) suffered major adverse cardiovascular events within 30 days. HEART, which ruled out major adverse cardiovascular events in 52.8% of patients with 88.1% sensitivity, and EDACS, which ruled out major adverse cardiovascular events in 57.5% of patients with 83.7% sensitivity, proved comparable to clinical judgment that ruled out major adverse cardiovascular events in 73.0% of patients with 85.5% sensitivity. GRACE was weaker-ruling out major adverse cardiovascular events in 79.2% of patients with a dismal sensitivity of 45.0%. The correlation-statistic for HEART (79.4%) was superior to EDACS (69.9%) and GRACE (69.2%). CONCLUSIONS HEART more accurately identified low-risk chest pain patients in an Asian ED, demonstrating comparable performance characteristics to clinical judgment. This has major implications on the use of chest pain scores to safely expedite disposition decisions for low-risk chest pain patients.
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Affiliation(s)
- Mingwei Ng
- Department of Emergency MedicineSingapore General HospitalSingapore
| | | | - Fei Gao
- Department of CardiologyNational Heart Centre SingaporeSingapore
| | | | - Swee Han Lim
- Department of Emergency MedicineSingapore General HospitalSingapore
| | | | - R Ponampalam
- Department of Emergency MedicineSingapore General HospitalSingapore
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14
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Gunasekeran DV, Liu Z, Tan WJ, Koh J, Cheong CP, Tan LH, Lau CS, Phuah GK, Manuel NDA, Chia CC, Seng GS, Tong N, Huin MH, Dulce SV, Yap S, Ponampalam K, Ying H, Ong MEH, Ponampalam R. Evaluating Safety and Efficacy of Follow-up for Patients With Abdominal Pain Using Video Consultation (SAVED Study): Randomized Controlled Trial. J Med Internet Res 2020; 22:e17417. [PMID: 32459637 PMCID: PMC7324993 DOI: 10.2196/17417] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/20/2020] [Accepted: 02/29/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The benefits of telemedicine include cost savings and decentralized care. Video consultation is one form that enables early detection of deteriorating patients and promotion of self-efficacy in patients who are well but anxious. Abdominal pain is a common symptom presented by patients in emergency departments. These patients could benefit from video consultation, as it enables remote follow-up of patients who do not require admission and facilitates early discharge of patients from overcrowded hospitals. OBJECTIVE The study aimed to evaluate the safety and efficacy of the use of digital telereview in patients presenting with undifferentiated acute abdominal pain. METHODS The SAVED study was a prospective randomized controlled trial in which follow-up using existing telephone-based telereview (control) was compared with digital telereview (intervention). Patients with undifferentiated acute abdominal pain discharged from the emergency department observation ward were studied based on intention-to-treat. The control arm received routine, provider-scheduled telereview with missed reviews actively coordinated and rescheduled by emergency department staff. The intervention arm received access to a platform for digital telereview (asynchronous and synchronous format) that enabled patient-led appointment rescheduling. Patients were followed-up for 2 weeks for outcomes of service utilization, efficacy (compliance with their disposition plan), and safety (re-presentation for the same condition). RESULTS A total of 70 patients participated, with patients randomly assigned to each arm (1:1 ratio). Patients were a mean age of 40.0 (SD 13.8; range 22-71) years, predominantly female (47/70, 67%), and predominantly of Chinese ethnicity (39/70, 56%). The telereview service was used by 32 patients in the control arm (32/35, 91%) and 18 patients in the intervention arm (18/35, 51%). Most patients in control (33/35, 94%; 95% CI 79.5%-99.0%) and intervention (34/35, 97%; 95% CI 83.4%-99.9%) arms were compliant with their final disposition. There was a low rate of re-presentation at 72 hours and 2 weeks for both control (72 hours: 2/35, 6%; 95% CI 1.0%-20.5%; 2 weeks: 2/35, 6%, 95% CI 1.0%-20.5%) and intervention (72 hours: 2/35, 6%; 95% CI 1.0%-20.5%; 2 weeks: 3/35, 9%, 95% CI 2.2%-24.2%) arms. There were no significant differences in safety (P>.99) and efficacy (P>.99) between the two groups. CONCLUSIONS The application of digital telereview for the follow-up of patients with abdominal pain may be safe and effective. Future studies are needed to evaluate its cost-effectiveness and usefulness for broader clinical application. TRIAL REGISTRATION ISRCTN Registry ISRCTN28468556; http://www.isrctn.com/ISRCTN28468556.
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Affiliation(s)
- Dinesh Visva Gunasekeran
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Zhenghong Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Win Jim Tan
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Joshua Koh
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Chiu Peng Cheong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Lay Hong Tan
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Chee Siang Lau
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Gaik Kheng Phuah
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Che Chong Chia
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Gek Siang Seng
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Nancy Tong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - May Hang Huin
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Susan Yap
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Kishanti Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Hao Ying
- Health Services Research Center, Singhealth Services, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
- Health Services Research Center, Singhealth Services, Singapore, Singapore
- Health Services and Systems Research, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
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15
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Lau HK, Chua ISY, Ponampalam R. Penetrating Thoracic Injury and Fatal Aortic Transection From the Barb of a Stingray. Wilderness Environ Med 2020; 31:78-81. [PMID: 31983600 DOI: 10.1016/j.wem.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/26/2019] [Accepted: 09/04/2019] [Indexed: 01/22/2023]
Abstract
Stingrays are found in open waters and are also kept in exhibits in many aquariums throughout the world. They are generally nonaggressive creatures by nature, but they can inflict injuries with their spines if provoked. We present a case of a 62-y-old diver who was pierced in the chest by the barb of a stingray while transferring the animal to another tank as part of his work in a public aquarium. He was rescued immediately from the tank but was found to be in cardiac arrest. Bystander cardiopulmonary resuscitation was promptly initiated by his colleagues. He was rapidly evacuated to the nearest emergency department, where he was noted to be in pulseless electrical activity. A single puncture wound was noted over the right second intercostal space, with the spine of the stingray still impaled in the chest. Trauma surgeons were activated promptly, and resuscitation was continued based on advanced cardiac and trauma life support guidelines, which included ongoing cardiopulmonary resuscitation, securing the airway, and emergency blood transfusion. An emergency department thoracotomy was performed, but despite aggressive resuscitation the thoracic injury was fatal. An autopsy revealed transection of the aorta by an impaled barb. We present a review of stingray injuries and suggest a general approach to management.
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Affiliation(s)
- Hong Khai Lau
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.
| | - Ivan Si Yong Chua
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
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16
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Liu Z, Ng M, Gunasekeran DV, Li H, Ponampalam K, Ponampalam R. Mobile technology: Usage and perspective of patients and caregivers presenting to a tertiary care emergency department. World J Emerg Med 2020; 11:5-11. [PMID: 31892997 DOI: 10.5847/wjem.j.1920-8642.2020.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Developments in information technology (IT) have driven a push in healthcare innovation in the emergency department (ED). Many of these applications rely on mobile technology (MT) such as smartphones but not everyone is comfortable with MT usage. Our study aims to characterize the technology usage behavior of users in the ED so as to guide the implementation of IT interventions in the ED. METHODS A cross-sectional survey was conducted in the emergency department of a tertiary hospital. Patients and their caregivers aged 21 and above were recruited. The survey collected demographic information, technology usage patterns, and participant reported comfort level in the usage of MT. We performed descriptive statistics and multivariate logistic regression to identify factors differentially associated with comfort in usage of MT. RESULTS A total of 498 participants were recruited, and 299 (60%) were patients. English was the most commonly written and read language (66.9%) and 64.2% reported a comfort level of 3/5 or more in using MT. Factors that were associated with being comfortable in using MT include having a tertiary education, being able to read and write English, as well as being a frequent user of IT. Caregivers were more likely to display these characteristics. CONCLUSION A large proportion of ED patients are not comfortable in the usage of MT. Factors that predicted comfort level in the usage of MT were common amongst caregivers. Future interventions should take this into consideration in the design of MT interventions.
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Affiliation(s)
- Zhenghong Liu
- SingHealth Emergency Medicine Residency Programme, Singapore Health Services, Singapore
| | - Mingwei Ng
- SingHealth Emergency Medicine Residency Programme, Singapore Health Services, Singapore
| | | | - Huihua Li
- Health Services Research Unit, Singapore General Hospital, Singapore
| | | | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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Ponampalam R, Loh CS. Cost Benefits of the Drug and Poison Information Centre in Preventing Unnecessary Hospitalisation: The Singapore Experience. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791001700108] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background The Drug and Poison Information Centre (DPIC) in Singapore was piloted as a new service in April 2004. This study evaluated the cost benefits of its interventions in the first two years of its operation. Method A two-year retrospective review of DPIC call records was performed and the following outcome measures were noted: (A) proportion of patients who were managed onsite and hence did not need to attend the emergency department (ED); and (B) proportion of patients who were managed in the ED without the need for admission. Cost savings were calculated based on admission costs for patients with poisoning, including other out-of-hospital costs. This amounted to savings of S$1390 and S$1170 for patients who fulfilled outcome measures A and B respectively. Savings for the hospital was S$1477 per case. The cost of operating the DPIC over the same period was S$507,922. Results There were 831 calls on acute toxic exposures over the study period. Of these, 115 and 405 patients fulfilled outcome measure A and B respectively with consequent cost savings of S$159,850 (115 x S$1390 per patient), and S$473,850 (405 x S$1170 per patient). The hospitals saved S$768,040 (520 x S$1477) from prevented admissions. Excluding operating cost, this gave net savings of S$893,818 over the two years from DPIC interventions. Conclusion The cost savings from DPIC services is evident from this study. This translates to more effective use of limited healthcare resources.
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Affiliation(s)
| | - CS Loh
- AstraZeneca Singapore Pte. Ltd., 8 Wilkie Road #06-01, Wilkie Edge, Singapore 228095
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Kang H, Seth P, Ponampalam R, Somanesan S. Case Report: Unusual Radiation Risks in the Emergency Department –125I beads. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791602300504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The use of radioactive substances in medicine accounts for the largest radiation exposure to the population from non-natural sources worldwide. The use in healthcare confers many benefits, but inappropriate or unskilled use can result in health hazards and safety issues for both patients and healthcare workers. We present two cases of radiation safety issues related to patients presenting to our emergency department after receiving non-conventional brachytherapy in the form of radiation seeds being implanted in the abdominal wall. These were done for presumed treatment of metastatic cancer in another Asian country. We share our cases to all emergency department staff to heighten their alertness for potential exposure to radiation from patients with radionuclides.
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Affiliation(s)
| | | | | | - S Somanesan
- Singapore General Hospital, Department of Nuclear Medicine and PET Imaging, Outram Road, Singapore 169608
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Oh JJ, Yong R, Ponampalam R, Anantharman V, Lim SH. Mass Casualty Incident Involving Pepper Spray Exposure: Impact on the Emergency Department and Management of Casualties. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791001700407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Exposure to pepper spray in an urban shopping complex resulted in 13 casualties being treated at a tertiary public hospital emergency department (ED). This report describes the ED's organisation in response to the disaster, and clinical management of those affected. Results Thirteen casualties – 11 acute, 2 delayed – presented with symptoms ranging from ocular, respiratory and skin irritation to nausea, vomiting and giddiness. The culprit agent was determined basing on the index patient's history and physical findings. All cases were decontaminated at the ED's on-site Hospital Decontamination Station. Nine adults were monitored overnight in the Emergency Observation Ward under the Toxic Inhalation Protocol and discharged well. The index case was treated symptomatically with improvement, but discharged against medical advice three hours later. No ED re-attendances were recorded. Conclusions The effects of pepper spray exposure are brief and self-limiting, but ED management can pose challenges in a mass casualty situation.
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Abstract
A 29-year-old, 65 kg, Chinese man presented to hospital 10 hours after ingesting 30 g of paracetamol (462 mg/kg body weight). The blood paracetamol level was 145 µg/ml at 10 hours post-ingestion. He had no known risk factors for hepatotoxicity and was treated with intravenous N-acetylcysteine (NAC). Serum creatinine level rose to a maximum of 455 µmol/L on day 8; it gradually declined without the need for dialysis. Little is known of the risk factors for nephrotoxicity, which may occur with or without concurrent liver damage, suggesting possible primary toxic effects on the kidney. The use of NAC in this case may have prevented the progression to liver failure and reduced the severity of the nephrotoxic effects.
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Affiliation(s)
| | - R Ponampalam
- Singapore General Hospital, Department of Emergency Medicine, Outram Road, Singapore 169608 R Ponampalam
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Chan JSE, Wee JC, Ponampalam R, Wong E. Pulmonary Contusion and Traumatic Pneumatoceles in a Platform Diver with Hemoptysis. J Emerg Med 2016; 52:205-207. [PMID: 27692838 DOI: 10.1016/j.jemermed.2016.07.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 07/19/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Injuries in divers resulting purely from impact with the water are uncommon in the published literature. We present a case report of pulmonary contusion in a young diver. CASE REPORT A young, healthy competitive platform diver landed flat on his back in the water from a dive of 10 meters. He complained of upper back pain and had an episode of hemoptysis after the dive. He was initially observed for 15 hours postinjury, and was discharged when three chest radiographs (CXRs) taken at 1, 7, and 11 hours postinjury did not show significant abnormalities. Thirty-six hours postinjury, the patient experienced repeat hemoptysis and returned to the emergency department, where a fourth CXR performed 43 hours postinjury was normal. A computed tomography (CT) scan revealed pulmonary contusion and traumatic subpleural pneumatoceles. The patient was admitted to the cardiothoracic ward for observation. He recovered well with conservative treatment and was discharged on the fifth day after injury with clearance for air travel. In this patient with a high-energy mechanism of rapid deceleration and hemoptysis at the scene, there may be grounds for performing a CT scan of the thorax at the time of the first presentation, although the CT findings did not change conservative management of this patient. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should recognize that a dive into water may generate sufficient impact to produce a pulmonary contusion. If the patient is clinically well and the CXR results are normal, the decision to initiate a CT scan and subsequent disposition may be based on clinical judgement and institutional practice.
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Affiliation(s)
| | - Jeremy C Wee
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Evelyn Wong
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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Ponampalam R. Effectiveness of multiple-dose activated charcoal in digoxin overdose: A case report. Toxicol Lett 2015. [DOI: 10.1016/j.toxlet.2015.08.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Koh SH, Ponampalam R, Lim SH, Gunasekeran DV. Cutaneous exposure to cobra venom: an uncommon presentation. Wilderness Environ Med 2015; 26:267-9. [PMID: 25682342 DOI: 10.1016/j.wem.2014.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 10/14/2014] [Accepted: 10/16/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Shao Hui Koh
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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Ponampalam R. Poisonings in Singapore: A poison center perspective. Toxicol Lett 2014. [DOI: 10.1016/j.toxlet.2014.06.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Radiation injuries are closer to home than expected as radioactive sources are common in daily life. Our case study illustrates a case of radiation burns to the hand which presented about two weeks later to the emergency department after accidental exposure to an industrial radiation source. A 45-year old Chinese man presented 17 days later after being exposed accidentally to iridium-192 source at 43 curies. He subsequently suffered burns that required multiple operations to treat. The diagnosis of patients who present early after exposure with no clinical signs will likely pose a challenge for the emergency medicine clinician as radiation burns take time to manifest and may present days to weeks after radiation exposure.
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Affiliation(s)
| | - Jean Mui Hua Lee
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Yih Ying Ng
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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Ponampalam R, Fook Chong SMC, Tan SC. Comparison of Full Blood Count Parameters Using Capillary and Venous Samples in Patients Presenting to the Emergency Department. ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/508649] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Full blood count (FBC) analysis is a common investigation done in the emergency department (ED). The aim of this study was to determine the accuracy of bedside FBC analysis using capillary blood samples from a finger stab at point of care (POC) compared to a conventional venous blood sample analysis. A total of 314 consecutive patients presenting to the ED were recruited. After consenting, a sample of the patient’s venous (V) blood was obtained via venepuncture and sent to the haematology laboratory for analysis as standard practice. This was followed immediately by collection of a capillary (C) blood sample from a finger stab which was analysed at site using an automated FBC analyser at POC. Agreement between the paired samples for blood parameters including the total white cell count, hemoglobin, and platelet count was assessed by the statistical method of Bland and Altman using V sample as the gold standard. The results showed a statistically significant deviation between capillary and venous samples only for platelet counts (P<0.001) and haemoglobin (P<0.001). However, the magnitudes of this difference 7.3 × 109/L and 0.5 g/dL respectively, were not clinically significant. The study suggest that the analysis of capillary samples for FBC parameters is a reliable and acceptable alternative to conventional methods with the benefits of being a rapid, convenient, and minimally invasive technique.
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Affiliation(s)
- R. Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608
| | | | - Sau Chew Tan
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608
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Abstract
Tramadol, a commonly prescribed opioid analgesic, is considered to have a low abuse potential and devoid of side effects like drug dependence. Very few fatalities due to isolated tramadol overdose, either intentional or accidental, have been reported so far. We report a case of a 27-year-old female with isolated tramadol overdose, having a peripheral blood tramadol concentration of 4mg/L, which is exceeding the lethal blood concentration of 2mg/L. This is the first report of a patient in Singapore who survived tramadol overdose despite having a lethal blood concentration. Physicians should be aware that patients with tramadol overdose may only present with signs related to isolated Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) properties and not always associated with the features of classical opioid overdose. Some patients might exhibit a certain degree of tolerance to the drug after prolonged prior exposure to the medication, and this tolerance could extend beyond the therapeutic range. It also emphasises the need for physicians to be more cautious while prescribing tramadol to their patients.
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Affiliation(s)
- Sohil Pothiawala
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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Phipps C, Chan K, Teo F, Ponampalam R. Fatal Chloroquine Poisoning: A Rare Cause of Sudden Cardiac Arrest. Ann Acad Med Singap 2011. [DOI: 10.47102/annals-acadmedsg.v40n6p296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Phipps C, Chan K, Teo F, Ponampalam R. Fatal chloroquine poisoning: a rare cause of sudden cardiac arrest. Ann Acad Med Singap 2011; 40:296-297. [PMID: 21779619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Ngo SY, Ong SH, Ponampalam R. Stonefish envenomation presenting to a Singapore hospital. Singapore Med J 2009; 50:506-509. [PMID: 19495521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Stonefish, belonging to the genus Synanceia and classified under the Synanceiidae family, are commonly found in the shallow waters of the Indo-Pacific region and are considered the most dangerous and venomous of this family. The aim of the study was to describe the presenting features, clinical course and current management of this series of patients with stonefish envenomation presenting to a tertiary general hospital in Singapore. METHODS Data involving stonefish stings was retrospectively retrieved from the Singapore General Hospital Accident & Emergency Emerge Version 3.7.6 database from October 2004 to September 2006. Information, such as the patients' demographics, date and location of the incident, identity of the fish, local or systemic effects, pain score (upon arrival and after treatment), investigations and treatment as well as the outcome of the patients, were evaluated. RESULTS 30 cases were identified. The median age of the patients was 28 years. The majority of patients were male (80 percent) and 47 percent of cases were foreign nationals. Most incidences occurred on weekends/public holidays (77 percent), with November having the highest number of cases (seven cases). The majority of cases (80 percent) arrived at the hospital within two hours of envenomation. Symptoms included extreme pain, swelling and redness of the affected limbs. 24 (80 percent) patients received hot water soak treatment and 27 (90 percent) patients received either intramuscular pethidine or diclofenac for analgesia, where nine patients (33 percent) required additional analgesics after a period of observation. 17 patients (58 percent) were treated and discharged, eight (26 percent) were referred to a specialist for follow-up and five (16 percent) were admitted for an average of three days. 13 out of 25 patients (52 percent) were discharged with antibiotics. One case complained of persistent pain and hyperalgesia five months post-envenomation. One patient required surgical intervention. No deaths and systemic symptoms were reported. CONCLUSION Cases of stonefish envenomation that presented to our hospital showed that the majority of patients were young male adults. Stonefish envenomation, though it rarely kills, can cause extreme pain, swelling and erythema, which can be managed with symptomatic treatment.
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Affiliation(s)
- S Y Ngo
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore.
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Ponampalam R, Tan HH, Ng KC, Lee WY, Tan SC. Demographics of toxic exposures presenting to three public hospital emergency departments in Singapore 2001-2003. Int J Emerg Med 2009; 2:25-31. [PMID: 19390914 PMCID: PMC2672975 DOI: 10.1007/s12245-008-0080-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 12/27/2008] [Indexed: 01/21/2023] Open
Abstract
Background The demographics of poisoned patients and the circumstances of toxic exposure have not been evaluated in Singapore for the last 10 years. Aim This study aims to give an estimate of the burden of poisoning in Singapore from the emergency department’s (ED) perspective. Method A retrospective study of toxic exposure was conducted over a period of 3 years from 2001 to 2003 at the ED of three public hospitals, one being a paediatric hospital. Results There were 9,212 cases of toxic exposures during the study period, which constituted 0.94% of total ED attendances. The poison exposure rate was 1.7 per 1,000 population and the estimated case fatality rate was 0.8 per 1,000 ED attendances for poisoning. The mean age of patients was 29 years and the majority were male (63.3%). Non-accidental injuries constituted 60% of the cohort. Alcohol was the commonest toxin involved (26%), but paracetamol (acetaminophen) was the most common pharmaceutical agent (33%). The mean time of exposure to ED presentation was 3.3 h. About one third of the patients were admitted of whom 157 patients (4.7% of admitted cases) required intensive care management. Conclusion The patients were predominantly young adults. This may suggest a need for poison prevention and chemical safety education to reduce the impact on this high-risk group. Although poisoning accounts for only 1% of the total ED attendance, a sizable proportion of them required inpatient care (36.1%) with a significant proportion requiring intensive care management. However, it was also noted that a third of those who were admitted stayed for less than 24 h, and hence a short-stay ward in the ED might be a cost-effective strategy to consider.
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Affiliation(s)
- R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore. Singapore.
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Oh J, Anantharaman V, Ponampalam R, Leong M, Chiong A. 43: Singapore General Hospital’s Semi-Automated Hospital Decontamination Station. Ann Emerg Med 2007. [DOI: 10.1016/j.annemergmed.2007.06.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
INTRODUCTION An incident involving the release of chlorine gas from the pump room at a local swimming pool resulted in 54 patients seeking treatment in the emergency departments (EDs) of two local, tertiary-level hospitals in Singapore. The hospital hazardous materials (HAZMAT) disaster plan was activated. This report describes how one of the EDs organized in response to the disaster. EVENT Of the 54 people seeking treatment, 36 were treated in the ED at the Singapore General Hospital. The patients were decontaminated at shower facilities prior to entering the ED. The ED was reorganized to cope with existing patients, as well as the large influx of patients from the event site. A protocol was established in coordination with the local drug and poison information center to manage the patients who suffered from chlorine inhalation. Most patients were observed in the ED and subsequently discharged. Outpatient review appointments were scheduled. INJURIES Acute respiratory symptoms were the most common symptoms., Four children and four adults were admitted to the hospital, and the other patients were discharged from the ED after observation. All of the chest x-rays were normal on the day of the chlorine inhalation. There were no mortalities or significant morbidities, even up to six months after the incident. CONCLUSIONS Although this chlorine HAZMAT incident did not cause severe injuries, and only a limited number of persons required admission to the hospital, some valuable lessons were learned.
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Affiliation(s)
- Adeline Ngo
- Department of Emergency Medicine, Singapore General Hospital, Singhealth, Singapore.
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Ngo ASY, Anthony CR, Samuel M, Wong E, Ponampalam R. Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department? Resuscitation 2007; 74:27-37. [PMID: 17306436 DOI: 10.1016/j.resuscitation.2006.11.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 11/01/2006] [Accepted: 11/08/2006] [Indexed: 11/16/2022]
Abstract
UNLABELLED Patients in coma with suspected drug poisoning are commonly encountered in the emergency department. Benzodiazepines are one of the most commonly used drugs in self-poisoning. Flumazenil, a benzodiazepine antagonist has been suggested as a diagnostic and treatment tool in suspected poisoning of unclear cause, but caution is required due to potential side effects. No systemic review of this literature has been done on this topic. OBJECTIVES The aim of this study is to examine if flumazenil should be used in patients with coma from suspected drug poisoning. SEARCH STRATEGY Randomised controlled trials were identified from the Cochrane Library, Pubmed and EMBASE. Bibliographies from included studies, known reviews and texts were searched. Content experts were contacted. SELECTION CRITERIA Randomised controlled trials were eligible for inclusion. Studies were included if patients who presented with altered mental state from suspected drug poisoning were treated with intravenous flumazenil as compared to placebo. DATA COLLECTION AND ANALYSIS Data were extracted and methodological quality was assessed independently by two reviewers. MAIN RESULTS Seven randomised controlled trials were included. A total of 466 patients were involved. Flumazenil was found to reverse coma from suspected drug poisoning with a relative benefit of 4.45 (95% CI 2.65, 7.45). In terms of major side effects, there was no statistical difference between flumazenil and placebo (RR 2.86, 95% CI 0.12-69.32). However, in terms of minor side effects, flumazenil was associated with a higher incidence of anxiety (RR 2.84, 95% CI 1.28-6.30) and other side effects (RR 3.73, 95% CI 2.078-6.73). There was no difference in the incidence of vomiting (RR 4.28, 95% CI 0.95-19.35). CONCLUSION Current evidence shows that flumazenil may be effective in the reversal of coma in patients presenting to the emergency department with coma from suspected drug poisoning.
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Affiliation(s)
- Adeline Su-Yin Ngo
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, Singapore.
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Ngo A, Charles R, Samuel M, Wong E, Ponampalam R. Should Benzodiazepine Antagonists Be Used in the Unconscious Emergency Department Patient? A Meta-Analysis. Acad Emerg Med 2007. [DOI: 10.1197/j.aem.2006.10.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
The spine, pelvic bones and long bones of the lower extremities are common sites for insufficiency fractures. Cases of sternum insufficiency fractures have been rarely reported in an elderly patient. Insufficiency fracture tends to occur in bones with decreased mechanical strength. It tends to occur in elderly patients, especially in postmenopausal women, with underlying diseases. We describe a case of sternum insufficiency fracture in a patient with rheumatoid arthritis and systemic lupus erythematosus on long-term corticosteroid therapy diagnosed in an emergency setting. Sternum insufficiency fracture is a rare cause of chest pain. This case serves to remind the emergency physician to remain vigilant for other noncardiac and nontraumatic causes of chest pain. If diagnosed accurately, these patients can be discharged and treated as outpatients.
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Affiliation(s)
- Kuo Hung Lin
- Singapore General Hospital, Singapore General Hospital, Singapore, Singapore.
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Affiliation(s)
- Huck Chin Chew
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore.
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Ngo A, Rabind C, Samuel M, Wong E, Ponampalam R. Use of Flumazenil in Comatose Patients Presenting to the Emergency Department. Ann Emerg Med 2005. [DOI: 10.1016/j.annemergmed.2005.06.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ponampalam R, Anantharaman V. The need for drug and poison information--the Singapore physicians' perspective. Singapore Med J 2003; 44:231-42. [PMID: 13677359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
INTRODUCTION There appears to be a significant prevalence of poisoning and adverse drug reactions in Singapore. However, the resources needed by physicians to assist them in the management of such cases are limited. This study examines the information resources currently utilised by medical professionals in assisting them in the management of poisonings and adverse drug reactions. The preferred features of an ideal Drug and Poison Information Centre in the local setting were also explored. METHOD A questionnaire survey involving all practicing physicians in Singapore to find out the current information resources utilised for Drug and Poison Information and the need for enhanced resources and its preferred form was looked at. RESULTS A total of 1,071 practicing physicians responded forming 24% of all physicians in Singapore as of December 1997. Of these, 636 (61.3%) were general practitioners and the rest specialists. The main sources of poison information were Drug Index of Malaysia and Singapore or DIMS (73.7%), standard textbooks (70.1%), fellow colleagues (44.6%) and pharmacists (41.0%). In the opinion of most (82.4%), one well run and efficient Drug and Poison Information Centre was adequate for the whole island. The majority (58.9%) preferred that experienced individuals who could be consulted upon in times of need man such a service. CONCLUSION The study shows the need for enhanced drug and poison information resources. The local physician community also expects guidance and expert advice from a specialist. With this in mind, it is worthwhile examining in depth the issues surrounding poison and adverse drug reaction management and the need for readily accessible Drug and Poison Information resources in Singapore.
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Affiliation(s)
- R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608.
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Abstract
A 31 year old tourist presented with paralytic ileus after jellyfish sting. This unusual presentation after jellyfish envenomation is reported and the literature reviewed for jellyfish envenomation syndromes.
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Affiliation(s)
- R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore.
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Ponampalam R, Otten EJ. In vitro adsorption of lithium by bentonite. Singapore Med J 2002; 43:086-9. [PMID: 11993895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Lithium poisoning is currently managed using a combination of supportive care and urgent haemodialysis in severe cases. Activated charcoal as a gut decontaminant has been found to be ineffective. The use of Sodium Polystyrene Sulphonate (SPS) as an adsorbent has been found to be effective in some studies. However, there have been case reports of gut necrosis and perforation occurring when SPS was used for the treatment of hyperkalaemia in post operative patients or patients with renal failure. Bentonite is a known adsorbent that has been used in the management of paraquat poisonings. The purpose of this study was to determine the ability of bentonite to adsorb lithium. METHOD 4.5 g of lithium carbonate was dissolved in 1.5 L of deionised water to form the stock solution. 50 mL aliquots of this stock solution were added to 50 mL of either distilled deionised water (pH 7) or simulated gastric fluid (pH 1.2). Bentonite of either 0.75, 1.5 or 4.5 g was then added to simulate 5:1, 10:1 and 30:1 ratio of adsorbent-to-drug. Controls were made with no bentonite added. The resulting mixture was placed on a shaker for five minutes before being filtered. The filtrate was diluted and batch analysed for lithium using atomic absorption spectrophotometry. RESULTS Bentonite decreased the concentration of lithium recovered from the filtrate by 20.55% in deionised water compared to 48.09% in simulated gastric fluid at a bentonite:lithium ratio of 30:1 (p value 0.005). CONCLUSION This study shows that bentonite is an effective adsorbent for lithium. The effect is enhanced in simulated gastric fluid. In vivo studies are being planned for clinical correlation.
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Affiliation(s)
- R Ponampalam
- Department of Emergency Medicine, Singapore General Hospital, Singapore.
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