Table of Content

15 March 2017, Volume 8 Issue 1

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Original Articles

Comparison of extracorporeal and conventional cardiopulmonary resuscitation: A meta-analysis of 2 260 patients with cardiac arrest

Gan-nan Wang, Xu-feng Chen, Li Qiao, Yong Mei, Jin-ru Lv, Xi-hua Huang, Bin Shen, Jin-song Zhang

2017, 8(1):  5-11.  doi:10.5847/wjem.j.1920-8642.2017.01.001

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BACKGROUND: This meta-analysis aimed to determine whether extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), improves outcomes in adult patients with cardiac arrest (CA).

DATA RESOURCES: PubMed, EMBASE, Web of Science, and China Biological Medicine Database were searched for relevant articles. The baseline information and outcome data (survival, good neurological outcome at discharge, at 3-6 months, and at 1 year after CA) were collected and extracted by two authors. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using Review Manager 5.3.

RESULTS: In six studies 2 260 patients were enrolled to study the survival rate to discharge and long-term neurological outcome published since 2000. A significant effect of ECPR was observed on survival rate to discharge compared to CCPR in CA patients (RR 2.37, 95%CI 1.63-3.45, P<0.001), and patients who underwent ECPR had a better long-term neurological outcome than those who received CCPR (RR 2.79, 95%CI 1.96-3.97, P<0.001). In subgroup analysis, there was a significant difference in survival to discharge favoring ECPR over CCPR group in OHCA patients (RR 2.69, 95%CI 1.48-4.91, P=0.001). However, no significant difference was found in IHCA patients (RR 1.84, 95%CI 0.91-3.73, P=0.09).

CONCLUSION: ECPR showed a beneficial effect on survival rate to discharge and long-term neurological outcome over CCPR in adult patients with CA.

The association of layperson characteristics with the quality of simulated cardiopulmonary resuscitation performance

Marion Leary, David G. Buckler, Daniel J. Ikeda, Daiane A. Saraiva, Robert A. Berg, Vinay M. Nadkarni, Audrey L. Blewer, Benjamin S. Abella

2017, 8(1):  12-18.  doi:10.5847/wjem.j.1920-8642.2017.01.002

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BACKGROUND: Few studies have examined the association of layperson characteristics with cardiopulmonary resuscitation (CPR) provision. Previous studies suggested provider characteristics, including age and gender, were associated with CPR quality, particularly chest compression (CC) depth. We sought to determine the association of subject characteristics, including age and gender with layperson CPR quality during an unannounced simulated CPR event. We hypothesized shallower CC depth in females, and older-aged subjects.

METHODS: As part of a larger multicenter randomized controlled trial of CPR training for cardiac patients' caregivers, CPR skills were assessed 6 months after training. We analyzed associations between subject characteristics and CC rate, CC depth and no-flow time. Each variable was analyzed independently; significant predictors determined via univariate analysis were assessed in a multivariate regression model.

RESULTS: A total of 521 laypersons completed a 6-month CPR skills assessment and were included in the analysis. Mean age was 51.8±13.7 years, 75% were female, 57% were Caucasian. Overall, mean CC rate was 88.5±25.0 per minute, CC depth was 50.9±2.0 mm, and mean no-flow time was 15.9±2.7 sec/min. CC depth decreased significantly in subjects >62 years (P<0.001). Male subjects performed deeper CCs than female subjects (47.5±1.7 vs. 41.9±0.6, P<0.001).

CONCLUSION: We found that layperson age >62 years and female gender are associated with shallower CC depth.

Cardiopulmonary resuscitation knowledge and attitude among general dentists in Kuwait

Sarah A. Alkandari, Lolwa Alyahya, Mohammed Abdulwahab

2017, 8(1):  19-24.  doi:10.5847/wjem.j.1920-8642.2017.01.003

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BACKGROUND: Dentists as health care providers should maintain a competence in resuscitation. This cannot be overemphasized by the fact that the population in our country is living longer with an increasing proportion of medically compromised persons in the general population. This preliminary study aimed to assess the knowledge and attitude of general dentists towards cardiopulmonary resuscitation (CPR).

METHODS: A cross-sectional study was carried out among 250 licensed general dental practitioners working in ministry of health. Data were obtained through electronic self-administered questionnaire consisting of demographic data of general dentists, and their experience, attitude and knowledge about CPR based on the 2010 American Heart Association guidelines update for CPR.

RESULTS: Totally 208 general dentists took part in the present study giving a response rate of 83.2%. Only 36% of the participants demonstrated high knowledge on CPR, while 64% demonstrated low knowledge. Participants' age, gender, nationality, years of experience, career hierarchy, and formal CPR training were associated significantly with CPR knowledge. Almost all the participants (99%) felt that dentists needed to be competent in basic resuscitation skills and showed a positive attitude towards attending continuing dental educational programs on CPR.

CONCLUSION: This study showed that majority of general dental practitioners in Kuwait had inadequate knowledge on CPR. It was also found that CPR training significantly influenced the CPR knowledge of the participants. Therefore, training courses on CPR should be regularly provided to general dentists in the country.

Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study

Sean P. Wilson, Samer Assaf, Shadi Lahham, Mohammad Subeh, Alan Chiem, Craig Anderson, Samantha Shwe, Ryan Nguyen, John C. Fox

2017, 8(1):  25-28.  doi:10.5847/wjem.j.1920-8642.2017.01.004

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BACKGROUND: The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation.

METHODS: We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC.

RESULTS: Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95%CI 77.1%-93.5%) and specificity of 100% (95%CI 15.8%-100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10-29) and 32 minutes (IQR 19-45), respectively.

CONCLUSION: Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a confirmatory CXR.

Clinical and historical features of emergency department patients with pericardial effusions

Lori Stolz, Josephine Valenzuela, Elaine Situ-LaCasse, Uwe Stolz, Nicolas Hawbaker, Matthew Thompson, Srikar Adhikari

2017, 8(1):  29-33.  doi:10.5847/wjem.j.1920-8642.2017.01.005

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BACKGROUND: Diagnosing pericardial effusion is critical for optimal patient care. Typically, clinicians use physical examination findings and historical features suggesting pericardial effusion to determine which patients require echocardiography. The diagnostic characteristics of these tools are not well described. The objective of this study is to determine the prevalence of historical features and sensitivity of clinical signs to inform clinicians when to proceed with echocardiogram.

METHODS: A retrospective review of point-of-care echocardiograms performed over a two and a half year period in two emergency departments were reviewed for the presence of a pericardial effusion. Patient charts were reviewed and abstracted for presenting symptoms, historical features and clinical findings. The prevalence of presenting symptoms and historical features and the sensitivity of classic physical examination findings associated with pericardial effusion and tamponade were determined.

RESULTS: One hundred and fifty-three patients with pericardial effusion were identified. Of these patients, the most common presenting complaint was chest pain and shortness of breath. Patients had no historical features that would suggest pericardial effusion in 37.5% of cases. None of the patients with pericardial effusion or pericardial tamponade had all of the elements of Beck's triad. The sensitivity of Beck's triad was found to be 0 (0%-19.4%). The sensitivity for one finding of Beck's triad to diagnose pericardial tamponade was 50% (28.0%-72.0%).

CONCLUSION: History and physical examination findings perform poorly as tests for the diagnosis of pericardial effusion or pericardial tamponade. Clinicians must liberally evaluate patients suspected of having a pericardial effusion with echocardiography.

Comparison of neurological clinical manifestation in patients with hemorrhagic and ischemic stroke

Seyedhossein Ojaghihaghighi, Samad Shams Vahdati, Akram Mikaeilpour, Ali Ramouz

2017, 8(1):  34-38.  doi:10.5847/wjem.j.1920-8642.2017.01.006

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BACKGROUND: Cerebrovascular accident (CVA) is the third leading cause of death and disability in developed countries. Anyone suspected of having a stroke should be taken immediately to a medical facility for diagnosis and treatment. The symptoms that follow a stroke aren't significant and depend on the area of the brain that has been affected and the amount of tissue damaged. Parameters for predicting long-term outcome in such patients have not been clearly delineated, therefore the aim of this study was to investigate this possibility and to test a system that might practicably be used routinely to aid management and predict outcomes of individual stroke patients.

METHODS: A descriptive hospital-based study of the neurological symptoms and signs of 503 patients with ischemic stroke, including severe headache, seizure, eye movement disorder, pupil size, Glasgow Coma Scale (GCS), agitation were analyzed in this study.

RESULTS: In the current study, dilated pupils, agitation, acute onset headache, lower GCS score, seizure, and eye gaze impairment had significantly higher prevalence in hemorrhagic stroke patients (P<0.001). However, the rate of gradual progressive headache is significantly higher in ischemic stroke patients (P<0.001).

CONCLUSION: Although this result provides reliable indicators for discrimination of stroke types, imaging studies are still the gold standard modality for diagnosis.

A comparison of perspectives on costs in emergency care among emergency department patients and residents

Stefanie K. Gilbert, Leana S. Wen, Jesse M. Pines

2017, 8(1):  39-42.  doi:10.5847/wjem.j.1920-8642.2017.01.007

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BACKGROUND: Costs of care are increasingly important in healthcare policy and, more recently, in clinical care in the emergency department (ED). We compare ED resident and patient perspectives surrounding costs in emergency care.

METHODS: We conducted a mixed methods study using surveys and qualitative interviews at a single, academic ED in the United States. The two study populations were a convenience sample of adult ED patients (>17 years of age) and ED residents training at the same institution. Participants answered open- and closed-ended questions on costs, medical decision making, cost-related compliance, and communication about costs. Closed-ended data were tabulated and described using standard statistics while open-ended responses were analyzed using grounded theory.

RESULTS: Thirty ED patients and 24 ED residents participated in the study. Both patients and residents generally did not have knowledge of medical costs. Patients were comfortable discussing costs while residents were less comfortable. Residents agreed that doctors should consider costs when making medical decisions whereas patients somewhat disagreed. Additionally, residents generally took costs into consideration during clinical decision-making, yet nearly all residents agreed that they had too little education on costs.

CONCLUSION: There were several notable differences in ED patient and resident perspectives on costs in this U.S. sample. While patients somewhat disagree that cost should factor into decision making, generally they are comfortable discussing costs yet report having insufficient knowledge of what care costs. Conversely, ED residents view costs as important and agree that cost should factor into decision making but lack education on what emergency care costs.

Patterns of Ketorolac dosing by emergency physicians

Emil Soleyman-Zomalan, Sergey Motov, Antonios Likourezos, Victor Cohen, Illya Pushkar, Christian Fromm

2017, 8(1):  43-46.  doi:10.5847/wjem.j.1920-8642.2017.01.008

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BACKGROUND: Ketorolac tromethamine is a non-steroidal anti-inflammatory drug (NSAIDs) that is widely used in the emergency department (ED) for the treatment of moderate-to-severe pain. Ketorolac, like other NSAIDs, exhibits an analgesic ceiling effect and previous research suggests that 10 mg is possibly the ceiling dose. Do the patterns of ketorolac dosing by emergency physicians follow its analgesic ceiling dose?

METHODS: This was a single center retrospective, descriptive study to characterize patterns of ketorolac administration in ED patients. Data for all patients who received ketorolac during the ten year study period from January 1, 2003 to January 1, 2013 were collected from the electronic medical record of an urban community ED with an annual volume of 116 935 patients.

RESULTS: There were 49 605 ketorolac administrations during the study period; 38 687 (78%) were given intravenously, 9 916 (20%) intramuscularly, and 1 002 (2%) orally. Through the intravenous route, 5 288 (13.7%) were 15 mg, 32 715 (84.6%) were 30 mg, 15 (0.03%) were 60 mg, and 669 (1.7%) were other varying doses. Through the intramuscular route, 102 (1.0%) were 15 mg, 4 916 (49.6%) were 30 mg, 4 553 (45.9%) were 60 mg, and 345 (3.5%) were other varying doses. The most common diagnoses at discharge were renal colic (21%), low back pain (17%) and abdominal pain (11%).

CONCLUSION: The data show that ketorolac was prescribed above its ceiling dose of 10 mg in 97% of patients who received intravenous doses and in 96% of patients receiving intramuscular doses.

Prescription practice of antihistamines for acute upper respiratory tract infections in pediatric patients in a local emergency department in Hong Kong

Chun Tat Lui

2017, 8(1):  47-54.  doi:10.5847/wjem.j.1920-8642.2017.01.009

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BACKGROUND: Currently there is very limited data in the literature assessing the prevalence of antihistamine prescription, and there is no local prevalence data about the prescription of antihistamine agents among primary practitioner and emergency physicians. The objectives are 1) to report the prevalence of antihistamine prescription for children less than 6 years old with acute upper respiratory infection and 2) to explore the associated factors for the prescription practice.

METHODS: This is a cross-sectional study. All consecutive cases of paediatric patients aged 6 or below who presented to the emergency department during a study period of one week from April 1 to July 4, 2009 with diagnosis of acute upper respiratory infection were included. Totally 162 patients were included.

RESULTS: Among the 162 cases, 141 (87%) patients were prescribed one antihistamine of any group. Sixty (37%) patients were prescribed two or more antihistamines. In multivariate logistic regression model, age was found to be significantly (P<0.001) associated with multiple antihistamine prescription (OR=1.042, 95%CI=1.02 to 1.06). Years of graduation of attending physician for more than 5 years was also a strong predictor of multiple antihistamine prescription (OR=4.654, 95%CI=2.20 to 9.84, P<0.001).

CONCLUSION: In the local emergency department, patients' age and the years of graduation from medical school of the attending physician were predictors of multiple antihistamine prescription for acute upper respiratory infections for children aged less than 6.

Full Outline of Unresponsiveness score and the Glasgow Coma Scale in prediction of pediatric coma

Atahar Jamal, Naveen Sankhyan, Murlidharan Jayashree, Sunit Singhi, Pratibha Singhi

2017, 8(1):  55-60.  doi:10.5847/wjem.j.1920-8642.2017.01.010

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BACKGROUND: This study was done to compare the admission Full Outline of Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS) as predictors of outcome in children with impaired consciousness.

METHODS: In this observational study, children (5-12 years) with impaired consciousness of <7 days were included. Children with traumatic brain injury, on sedatives or neuromuscular blockade; with pre-existing cerebral palsy, mental retardation, degenerative brain disease, vision/hearing impairment; and seizure within last 1 hour were excluded. Primary outcomes: comparison of area under curve (AUC) of receiver operating characteristic (ROC) curve for in-hospital mortality. Secondary outcomes: comparison of AUC of ROC curve for mortality and poor outcome on Pediatric Overall Performance Category Scale at 3 months.

RESULTS: Of the 63 children, 20 died during hospital stay. AUC for in-hospital mortality for GCS was 0.83 (CI 0.7 to 0.9) and FOUR score was 0.8 (CI 0.7 to 0.9) [difference between areas -0.0250 (95%CI 0.0192 to 0.0692), Z statistic 1.109, P=0.2674]. AUC for mortality at 3 months for GCS was 0.78 (CI 0.67 to 0.90) and FOUR score was 0.74 (CI 0.62 to 0.87) (P=0.1102) and AUC for poor functional outcome for GCS was 0.82 (CI 0.72 to 0.93) and FOUR score was 0.79 (CI 0.68 to 0.9) (P=0.2377), which were also comparable. Inter-rater reliability for GCS was 0.96 and for FOUR score 0.98.

CONCLUSION: FOUR score was as good as GCS in prediction of in-hospital and 3-month mortality and functional outcome at 3 months. FOUR score had a good inter-rater reliability.

Intravenous injection of Xuebijing attenuates acute kidney injury in rats with paraquat intoxication

Jia-jun Xu, Jian-tao Zhen, Li Tang, Qing-ming Lin

2017, 8(1):  61-64.  doi:10.5847/wjem.j.1920-8642.2017.01.011

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BACKGROUND: The study aimed to investigate the therapeutic benefits of intravenous Xuebijing on acute kidney injury (AKI) in rats with paraquat intoxication.

METHODS: Male Sprague-Dawley rats were randomly divided equally into three groups: sham group (n=8), paraquat group (n=8) and Xuebijing-treated group (n=8) using a random number table. The rats were intraperitoneally injected with 50 mg/kg of paraquat. One hour after paraquat administration, the rats were treated intravenously with Xuebijing (8 mL/kg). At 12 hours after paraquat administration, serum was collected to evaluate kidney function, then the rats were sacrificed and kidney samples were immediately harvested. AKI scores were evaluated by renal histopathology and pro-inflammatory cytokines mRNA levels in kidney were assayed using real-time RT-PCR.

RESULTS: Serum urea nitrogen, creatinine and AKI scores were significantly higher in the paraquat group, compared with the sham group (P<0.05, respectively). Moreover, interleukin (IL)-1β, IL-6 and TNF-α mRNA levels were significantly higher in the paraquat group (P<0.01, respectively). However, intravenous Xuebijing significantly decreased serum urea nitrogen, creatinine, AKI scores and IL-1β, IL-6 and TNF-α mRNA levels, compared with the paraquat group (P<0.05, respectively).

CONCLUSION: Intravenous Xuebijing attenuates AKI following paraquat poisoning by suppressing inflammatory response.

Letter to the editors

Toxoplasma encephalitis and AIDS in a patient with seizure and altered mental status: A case report

Somayeh Valadkhani, Amir Reza Radmard, Morteza Saeedi, Sara Nikpour, Mohammad Reza Farnia

2017, 8(1):  65-67.  doi:10.5847/wjem.j.1920-8642.2017.01.012

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Vasospastic myocardial infarction: An even rarer occurrence of a rare entity

Cem Ertan, Mehmet Emre Özpelit, Önder Limon, Deniz Oray, Nihat Pekel

2017, 8(1):  68-70.  doi:10.5847/wjem.j.1920-8642.2017.01.013

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An unusual emergency department case: ruptured ectopic pregnancy presenting as chest pain

Eric Dichter, James Espinosa, James Baird, Alan Lucerna

2017, 8(1):  71-73.  doi:10.5847/wjem.j.1920-8642.2017.01.014

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An unusual cause of simultaneous bilateral spontaneous pneumothorax

Mohammed Ismail Nizami, Narendra Kumar Narahari, Goganti Kruparao Paramjyothi, Ashima Sharma

2017, 8(1):  74-76.  doi:10.5847/wjem.j.1920-8642.2017.01.015

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Instructions for Authors

Instructions for Authors

2017, 8(1):  77-80. 

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