The Use of Ambulatory Electrocardiography in the Emergency Medicine Ward to Assess Patients with Symptoms Possibly Related to Cardiac Arrhythmia: A Sharing of Experience in a Local Hospital

Ambulatory electrocardiography (AECG) or Holter has a long history of use in patients with suspected symptomatic arrhythmia. In Hong Kong, patients with AECG monitoring were entirely under the care of internal medicine in the past. This report described a pioneer trial on the use of AECG in a local emergency setting under the supervision of emergency physicians. A departmental guideline for AECG use on suitable patients was drawn up and patients underwent AECG monitoring in the emergency medicine ward. The AECG results were reported preliminarily by emergency physicians and then confirmed with additional comments by cardiologists. This report presented the clinical features, AECG results and clinical outcomes of all patients recruited from the start of the protocol in May 2008 to July 2009.

Prospective Observational Study on Heart Rate Variability in Emergency Department Patients with Sepsis

Objective

To study the predictive value of heart rate variability in septic patients presented to the emergency department.

Design

Cross sectional study.

Setting

Emergency department.

Methods

Septic patients in the emergency department were recruited according to criteria. Heart rate variability data on time domain and frequency domain were generated from Holter records. Sequential Organ Failure Assessment, clinical progress and laboratory values were used to access the outcomes.

Results

Spectral power of total power (TP), low frequency (LF), very low frequency (VLF) and normalised low frequency (nLF) are shown to be significantly reduced in patients with sepsis who deteriorated (p=0.0070, 0.0032, 0.0005 and 0.0109 respectively). Cut off value 172.5 of VLF can identify all septic patients with potential deterioration.

Conclusions

Application of heart rate variability recording in emergency department is feasible and helpful in early identification of potentially deteriorating septic patients.

The Impact of Enhanced Intensive Care on Outcome of Major Trauma Patients in a Regional Hospital in Hong Kong

Objectives

To describe an updated epidemiology of major trauma cases presenting to a regional hospital in Hong Kong and to analyse the impact of enhanced intensive care on the outcome of major trauma patients.

Methods

This was a retrospective comparative study. In late 2004, we amended our trauma care system with enhancement of intensive care in the management of major trauma patients. An 18-month period was chosen before and after the amendment respectively and patients' data and crude mortality rate between the two periods were compared. Stratified analyses based on mechanism of injury, injury severity and physiological parameters were also performed. Finally, a TRISS analysis was included.

Results

Altogether 163 and 155 patients were included in our study from the two periods respectively. The majority involved blunt injury and one third of them had injury severity score (ISS) greater than 15. Road traffic accidents and fall from height remained as the two leading causes of major trauma. The median length of stay in the intensive care unit increased for one day (p<0.01) in the later period but the median total length of stay in hospital remained the same. The mortality rate decreased from 10.4% to 9.7% (p=0.82).

Conclusion

With enhanced intensive care, there is an apparent decrease in mortality of major trauma patients but its significance needs to be determined with a larger scale study.

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.

A One-Year Hospital-Based Analysis of Sports Injuries

Objectives

(1) To survey and analyse the pattern of sports injuries; (2) to make implication from the results.

Methodology

Subjects with sports injuries attending the emergency department of Princess Margaret Hospital in 2006 were retrieved via the Injury Surveillance System. The characteristics of the subjects and their injuries were evaluated.

Results

In 2006, 709 subjects had sports injuries, from which 83% were male. The median age was 19. Age below 20 accounted for 53% of the attendance. Football (35%), basketball (25%) and cycling (9%) were the three commonest sport-injury activities. All sports injuries had the maximum AIS ≤3 and 83% had MAIS of 1 only. Overall, 39% had contusion and scrape, 36% with sprain and strain, and 18% had fracture. Nearly half (47%) had lower limb injury; 30% and 24% had upper limb injury and head injury respectively. Contusion and scrape of the head, and sprain and strain of the lower limb were the two commonest injuries in football and basketball. In cycling, two-thirds suffered from contusion and scrape of any body region and 57% of those involved the head.

Conclusion

Sports injury surveillance with characterised patterns of injuries helped to devise prevention measures.

A Retrospective Epidemiological Study of the Traffic-Related Injuries Cases Admitted to a Local Hospital

Road traffic injuries (RTI) are important public health problem globally. Accurate data about RTIs and its subsequent health consequences are essential to monitor the effectiveness of current RTI prevention measures and to readdress policies.

Objective

We presented the surveillance of RTI in Kwai Tsing by integrating data from traffic accident data system (TRADS) and injury surveillance system (ISS) from Princess Margaret Hospital.

Method

Retrospective observational study to examine traffic-related injuries by integrating data from TRADS and ISS databases. A multivariate analysis was performed to identify risk factors associated with hospital admissions in RTI.

Result

A total of 725 patients were included. About 19% of the visits led to hospitalisation and six deaths (0.83%) were reported. Pedestrian elders were significantly more at risk to traffic injury mortality and hospitalisation.

Conclusion

This study demonstrates the feasibility of an integrated surveillance system for RTI based on existing local databases. Special preventive measures should be tailored for pedestrian and elderly to improve their safety by improving the quality of their walking environment.

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.

Emergency Critical Care Service in Emergency Medicine Ward: The Experience in North Lantau Hospital

With the increased demand of critical care, emergency physicians often provide a significant proportion of critical care for the critically ill patients apart from their primary roles in resuscitation and initial stabilisation. The dual training pathway of emergency medicine and intensive care medicine enables the Accident and Emergency Departments (AEDs) to be staffed with emergency intensivist to provide care of critically ill patients in the AEDs beyond the initial resuscitation. North Lantau Hospital is a community hospital located in central Tung Chung of Lantau Island. Transporting critically ill patients to the nearest tertiary hospital requires a significant amount of time which poses high risk to them. An “Emergency Critical Care Management” pilot program was created under these circumstances. In this pilot program, up to 2 beds in the Emergency Medicine Ward (EMW) are used for managing critically ill patients. The experience and preliminary outcomes of implementing critical care service in the EMW are shared in this article.

Community-associated methicillin-resistant Staphylococcus aureus skin and soft tissue infections in Hong Kong

Community-associated methicillin resistant Staphylococcus aureus is an emerging cause of skin and soft tissue infections in Hong Kong, especially among certain ethnic minorities.

Luminance-dependent visual latency for the Hess effect, the Pulfrich effect, and simple reaction time

The Hess effect, a monocular, latency-based illusion in which the more intensely illuminated of a pair of laterally-moving targets appears displaced ahead of the other, was studied with white targets on black background at scotopic and photopic levels. The magnitude of the Hess effect was about the same as that of the Pulfrich effect under similar photopic conditions. Reaction time declined more rapidly with increasing stimulus intensity than would have been predicted either by the Hess or the Pulfrich effect. Theoretical time-constants, computed for the Hess effect by assuming a first-order diffusion process followed by a more central non-linearity (temporal centroid), ranged between 0.145 and 0.165 sec for three observers.

Effects of photopic annulus luminance level on reaction time and on the latency of evoked cortical potential responses to target flashes

Correlated experiments on visual reaction time (RT) and visual evoked cortical potentials (VECP's) were performed to assess the effects of illumination level of steady annulus surrounds on the latency of response to centrally presented target flashes (1 and 3 degrees in diameter) over a wide range of retinal illuminances. The latencies of the electrophysiological (VECP) responses are more variable than those of the psychophysical RT responses. For both classes of response, the visual latency for a given target flash luminance is systematically increased (inhibited) by a spatially contiguous annulus with a retinal illuminance that equals or exceeds that of the target. The inhibitory effect of a given annulus increases progressively as the target retinal illuminance is lowered below that of the annulus. The corresponding RT and VECP curves have the same shape, thus suggesting that the motor component of the RT responses is not differentially influenced by variations in target illumination. The inhibitory effects are characteristically greater for the 3 degrees target than for the 1 degree target. Lateral neural inhibition and stray-light models for these data are considered.