Table of Content

15 December 2014, Volume 5 Issue 4

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Review Article

Current pre-hospital traumatic brain injury management in China

Kou Kou, Xiang-yu Hou, Jian-dong Sun, Kevin Chu

2014, 5(4):  245-254.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.001

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BACKGROUND: Traumatic brain injury (TBI) is associated with most trauma-related deaths. Secondary brain injury is the leading cause of in-hospital deaths after traumatic brain injury. By early prevention and slowing of the initial pathophysiological mechanism of secondary brain injury, pre-hospital service can significantly reduce case-fatality rates of TBI. In China, the incidence of TBI is increasing and the proportion of severe TBI is much higher than that in other countries. The objective of this paper is to review the pre-hospital management of TBI in China.
DATA SOURCES: A literature search was conducted in January 2014 using the China National Knowledge Infrastructure (CNKI). Articles on the assessment and treatment of TBI in pre-hospital settings practiced by Chinese doctors were identified. The information on the assessment and treatment of hypoxemia, hypotension, and brain herniation was extracted from the identified articles.
RESULTS: Of the 471 articles identified, 65 met the selection criteria. The existing literature indicated that current practices of pre-hospital TBI management in China were sub-optimal and varied considerably across different regions.
CONCLUSION: Since pre-hospital care is the weakest part of Chinese emergency care, appropriate training programs on pre-hospital TBI management are urgently needed in China.

Original Articles

Emergency bedside ultrasound for the diagnosis of pediatric intussusception: a retrospective review

Samuel H. F. Lam, Adam Wise, Christopher Yenter

2014, 5(4):  255-258.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.002

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BACKGROUND: Ultrasound diagnosis of pediatric intussusception is feasible with limited operator training. The authors report the test characteristics of bedside ultrasound (BUS) for the diagnosis of pediatric intussusception at a single institution.
METHODS: Inclusion criteria were: 1) patients of 0-18 years old were seen in the pediatric emergency department (ED) with a clinical presentation suspicious for intussusception; 2) BUS was performed to identify intussusception and bedside impression documented in the medical record; 3) a "formal" diagnostic study (such as computed tomography, ultrasound, or barium enema) was performed by the radiology department after BUS was completed. Electronic medical record and ED BUS archive were screened for potentially eligible ED visits between January 1^st 2009 to October 3^rd2012. These records were then reviewed to identify patients for inclusion in the study. All emergency physicians who performed the BUS had undergone a minimum of 1-hour didactic training on the use of BUS to diagnose pediatric intussusception.
RESULTS: A total of 1 631 charts were reviewed, with 49 meeting inclusion criteria. Five of those were later excluded for incomplete documentation or lack of saved BUS images. The prevalence of intussusception was 23%. The mean age of the subjects was 31 months. BUS was 100% sensitive (95%CI 66%-100%) and 94% specific (95%CI 79%-99%) for detection of pediatric intussusception compared to radiology study results. Positive and negative likelihood ratios were 16.5 (95%CI 4.30%-63.21%) and 0 (95%CI 0-0) respectively.
CONCLUSIONS: BUS is an accurate means of diagnosing acute intussusception in pediatric patients. Further study might be indicated to confirm such benefits.

How to secure the connection between thoracostomy tube and drainage system?

Ka Ki Pat Li, Kit Shing John Wong, Yau Hang Henry Wong, Ka Lok Cheng, Fung Ling So, Chu Leung Lau, Chak Wah Kam

2014, 5(4):  259-263.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.003

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BACKGROUND: Thoracostomy tube insertion is one of the common bedside procedures in emergency medicine and many acute specialties. Dislodgement of thoracostomy tube from the connection tube of chest drainage system is an important problem with potential complications such as contamination, infection and pneumothorax. Besides, mere loosening can also lead to malfunction. It is a common practice to tape the connection of the system. This study aimed to evaluate the materials and methods of connection of chest drain system to minimize drainage dislodgement.
METHODS: We conducted an experimental study to assess the tightness of the connection with various taping materials and methods. We selected three commonly used adhesive materials (3M™ Transpore™ Medical tape, 3M™ Micropore™ Medical tape, 3M™ Soft Cloth Tape on Liner) and three different methods (cross method, straight method, nylon band) to secure the junction between the thoracostomy tube and the bi-conical adaptor in the drainage system. The measured outcome was the weight causing visible loosening of the junction between thoracotomy tube and the adaptor.
RESULTS: For each taping material and taping method, 10 trials were performed. The median weight required to disconnect the junction is 26.22 lb for Transpore™, 31.29 lb for Micropore™ and 32.44 lb for Soft Cloth Tape on Liner. A smaller force was required to disconnect if Transpore™ is used (P<0.001). There was no statistical significant difference between Micropore™ and Soft Cloth Tape on Liner (P=0.98). The median disconnecting force is 32.44 lb for straight taping method, 40.55 lb for cross taping method and 21.15 lb for plastic band. The cross-taping method was the more secure method (P<0.0001 when compared with plastic band) (P=0.033 when compared with straight method).
CONCLUSION: Cross-taping is the most secure method among the tested varieties in connecting the thoracostomy tube to the chest drainage system. Transpore™ is not a recommended material for thoracostomy tube taping.

Clinical probability and risk analysis of patients with suspected pulmonary embolism

Gulden Ozeren Yetgin, Sule Akkose Aydin, Ozlem Koksal, Fatma Ozdemir, Dilek Kostak Mert, Gokhan Torun

2014, 5(4):  264-269.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.004

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BACKGROUND: Pulmonary embolism (PE) is one of the most frequent diseases that could be missed in overcrowded emergency departments as in Turkey. Early and accurate diagnosis could decrease the mortality rate and this standard algorithm should be defined. This study is to find the accurate, fast, non-invasive, cost-effective, easy-to-access diagnostic tests, clinical scoring systems and the patients who should be tested for clinical diagnosis of PE in emergency department.
METHODS: One hundred and forty patients admitted to the emergency department with the final diagnosis of PE regarding to anamnesis, physical examination and risk factors, were included in this prospective, cross-sectional study. The patients with a diagnosis of pulmonary embolism, acute coronary syndrome or infection and chronic obstructive pulmonary disease (COPD) were excluded from the study. The demographics, risk factors, radiological findings, vital signs, symptoms, physical-laboratory findings, diagnostic tests and clinical scoring systems of patients (Wells and Geneva) were noted. The diagnostic criteria for pulmonary emboli were: filling defect in the pulmonary artery lumen on spiral computed tomographic angiography and perfusion defect on perfusion scintigraphy.
RESULTS: Totally, 90 (64%) of the patients had PE. Age, hypotension, having deep vein thrombosis were the risk factors, and oxygen saturation, shock index, BNP, troponin and fibrinogen levels as for the biochemical parameters were significantly different between the PE (+) and PE (-) groups (P<0.05).The Wells scoring system was more successful than the other scoring systems.
CONCLUSION: Biochemical parameters, clinical findings, and scoring systems, when used altogether, can contribute to the diagnosis of PE.

Thyroid hormone alterations in trauma patients requiring massive transfusion: An observational study

Toru Hifumi, Ichiro Okada, Nobuaki Kiriu, Eiju Hasegawa, Tomoko Ogasawara, Hiroshi Kato, Yuichi Koido, Junichi Inoue, Yuko Abe, Kenya Kawakita, Masanobu Hagiike, Yasuhiro Kuroda

2014, 5(4):  270-274.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.005

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BACKGROUND: Although non-thyroidal illness syndrome (NTIS) is considered a negative prognostic factor, the alterations in free triiodothyronine (fT3) levels in trauma patients requiring massive transfusion have not been reported.
METHODS: A prospective observational study comparing 2 groups of trauma patients was conducted. Group M comprised trauma patients requiring massive transfusions (>10 units of packed red blood cells) within 24 hours of emergency admission. Group C comprised patients with an injury severity score >9 but not requiring massive transfusions. Levels of fT3, free thyroxine (fT4), and thyroid-stimulating hormone (TSH) were evaluated on admission and on days 1, 2, and 7 after admission. The clinical backgrounds and variables measured including total transfusion amounts were compared and the inter-group prognosis was evaluated. Results are presented as mean±standard deviation.
RESULTS: Nineteen patients were enrolled in each group. In both groups, 32 were men, and the mean age was 50±24 years. In group C one patient died from respiratory failure. The initial fT3 levels in group M (1.95±0.37 pg/mL) were significantly lower than those in group C (2.49±0.72 pg/mL; P<0.01) and remained low until 1 week after admission. Initial inter-group fT4 and TSH levels were not significantly different. TSH levels at 1 week (1.99±1.64 µIU/mL) were higher than at admission (1.48±0.5 µIU/mL) in group C (P<0.05).
CONCLUSION: Typical NTIS was observed in trauma patients requiring massive transfusions. When initial resuscitation achieved circulatory stabilization, prognosis was not strongly associated with NTIS.

A single subcutaneous dose of tramadol for mild to moderate musculoskeletal trauma in the emergency department

Alejandro Cardozo, Carlos Silva, Luis Dominguez, Beatriz Botero, Paulo Zambrano, Jose Bareño

2014, 5(4):  275-278.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.006

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BACKGROUND: Mild to moderate musculoskeletal trauma is a common cause for an emergency room visit, and frequent pain is one of the cardinal symptoms of consultation. The objective of this study is to assess the perception of a single subcutaneous dose of 50 mg tramadol for pain management in patients with mild to moderate musculoskeletal trauma, likewise to appraise the perception of pain by subcutaneous injection.
METHODS: A total of 77 patients, who met inclusion criteria, received a single subcutaneous dose of tramadol. Pain control was evaluated based on the verbal numerical pain scale (0-10) at baseline, 20 and 60 minutes; similarly, pain perception was evaluated secondary to subcutaneous injection of the analgesic.
RESULTS: On admission, the average pain perceived by patients was 8; twenty minutes later, 89% of the patients reported five or less, and after sixty minutes, 94% had three or less on the verbal numerical pain scale. Of the patients, 88% reported pain perception by verbal numeric scale of 3 or less by injection of the drug, and 6.5% required a second analgesic for pain control. Two events with drug administration (soft tissue infection and mild abdominal rectus injection) were reported.
CONCLUSION: We conclude that a single subcutaneous dose of tramadol is a safe and effective option for the management of patients with mild to moderate pain and musculoskeletal disease in the emergency department.

The incidence of oxygen desaturation during rapid sequence induction and intubation

Endale Gebreegziabher Gebremedhn, Desta Mesele, Derso Aemero, Ehtemariam Alemu

2014, 5(4):  279-285.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.007

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BACKGROUND: Rapid sequence induction and intubation (RSII) is an emergency airway management technique for patients with a risk of pulmonary aspiration. It involves preoxygenation, administration of predetermined doses of induction and paralytic drugs, avoidance of mask ventilation, and laryngoscopy followed by tracheal intubation and keeping cricoid pressure applied till endotracheal tube cuff be inflated. Oxygen desaturation has been seen during RSII. We assessed the incidence of oxygen desaturation during RSII.
METHODS: An institution-based observational study was conducted from March 3 to May 4, 2014 in our hospital. All patients who were operated upon under general anesthesia with RSII during the study period were included. A checklist was prepared for data collection.
RESULTS: A total of 153 patients were included in this study with a response rate of 91.6%. Appropriate drugs for RSII, equipments for RSII, equipments for difficult intubation, suction machine with a catheter, a monitor and an oxygen backup such as ambu bag were not prepared for 41 (26.8%), 50 (32.7%), 51 (33.3%), 38 (24.8%) and 25 (16.3%) patients respectively. Cricoid pressure was not applied at all for 17 (11.1%) patients and 53 (34.6%) patients were ventilated after induction of anesthesia but before intubation and endotracheal cuff inflation. A total of 55 (35.9%) patients desaturated during RSII (SPO₂<95%). The minimum, maximum and mean oxygen desaturations were 26%, 94% and 70.9% respectively. The oxygen desaturation was in the range of <50%, 50%-64%, 65%-74%, 75%-84%, 85%-89 % and 90%-94% for 6 (3.9%), 7 (4.6%), 5 (3.3%), 10 (6.5%), 13 (8.5%) and 14 (9.2%) patients respectively.
CONCLUSION: The incidence of oxygen desaturation during RSII was high in our hospital. Preoperative patient optimization and training about the techniques of RSII should be emphasized.

Heat-related illness in Jinshan District of Shanghai:A retrospective analysis of 70 patients

Wei-chun Mo, Xia Gao, Guo-ping Liu, Wei Wang, Jun-mei Shen, Ming-jia Xu, Jie Shen

2014, 5(4):  286-290.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.008

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BACKGROUND: This study aimed to investigate the epidemiological and clinical characteristics of patients with heat-related illness, and guide the prevention, diagnosis and treatment of heat-related illness.
METHODS: From June 2013 to August 2013, seventy patients with heat-related illness were treated at Jinshan Hospital of Fudan University, and their epidemiological characteristics, laboratory results, treatment and prognosis were retrospectively analyzed.
RESULTS: In the 70 patients, 18 patients suffered from heat stroke and 52 patients from non-heat stroke. When the environmnent temperature was above 35 °C, the body temperature of the patients began to increase markedly. The patients with heat stroke were significantly older than those with non-heat stroke (P<0.05). The body temperature, heart rate, blood glucose, blood lactate dehydrogenase and blood creatine kinase in the patients with heat stroke were higher than those in the patients with non-heat stroke (P<0.05). Blood lactate dehydrogenase and blood creatine kinase were positively correlated with body temperature (r=0.801).
CONCLUSION: When the environmental temperature goes above 35 °C, heat-related illness should be prevented, especially in the elderly. The body temperature, heart rate, blood glucose, blood lactate dehydrogenase and blood creatine kinase in patients with heat stroke are higher than those in patients with non-heat stroke. Blood lactate dehydrogenase and blood creatine kinase are positively correlated with body temperature, but their relationship with heat-related illness awaits further study.

Simvastatin inhibits apoptosis of endothelial cells induced by sepsis through upregulating the expression of Bcl-2 and downregulating Bax

Hui Fu, Qiao-sheng Wang, Qiong Luo, Si Tan, Hua Su, Shi-lin Tang, Zheng-liang Zhao, Li-ping Huang

2014, 5(4):  291-297.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.009

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BACKGROUND: Many studies have showed that apoptosis of endothelial cells plays a curial role in the progress of sepsis. But the role of simvastatin in apoptosis of endothelial cells induced by sepsis is not clear. The present study aimed to investigate the role of simvastatin in apoptosis of endothelial cells induced by sepsis and its mechanism.
METHODS: Human umbilical vein endothelial cells (HUVECs) were randomly divided into three groups: control group, sepsis serum intervention group (sepsis group) and simvastatin+sepsis serum intervention group (simvastatin group). After 24-hour incubation with corresponding culture medium, the relative growth rate of HUVECS in different groups was detected by MTT assay; the apoptosis of HUVECs was detected by Hoechst33258 assay and flow cytometry; and the expression of the Bcl-2 and Bax genes of HUVECs was detected by PCR.
RESULTS: Compared with the sepsis group, HUVECs in the simvastatin group had a higher relative growth rate. Apoptotic HUVECs decreased significantly in the simvastatin group in comparison with the sepsis group. Expression of the Bcl-2 gene in HUVECs decreased obviously, but the expression of the Bax gene increased obviously after 24-hour incubation with sepsis serum; however, the expression of the Bcl-2 and Bax genes was just the opposite in the simvastatin group.
CONCLUSIONS: Our study suggests that simvastatin can inhibit apoptosis of endothelial cells induced by sepsis through upregulating the expression of Bcl-2 and downregulating Bax. It may be one of the mechanisms for simvastatin to treat sepsis.

Effects of mild hypothermia on the ROS and expression of caspase-3 mRNA and LC3 of hippocampus nerve cells in rats after cardiopulmonary resuscitation

Jian Lu, Yi Shen, Hui-yin Qian, Li-jun Liu, Bao-chun Zhou, Yan Xiao, Jin-ning Mao, Guo-yin An, Ming-zhong Rui, Tao Wang, Chang-lai Zhu

2014, 5(4):  298-305.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.010

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BACKGROUND: Cardiac arrest (CA) is a common and serious event in emergency medicine. Despite recent improvements in resuscitation techniques, the survival rate of patients with CA is unchanged. The present study was undertaken to observe the effect of mild hypothermia (MH) on the reactive oxygen species (ROS) and the effect of neurological function and related mechanisms.
METHODS: Sixty-five healthy male Sprague Dawley (SD) adult rats were randomly (random number) divided into 2 groups: blank control group (n=5) and CPR group (n=60). CA was induced by asphyxia. The surviving rats were randomly (random number) divided into two groups: normothermia CPR group (NT) and hypothermia CPR group (HT). Normothermia of 37 °C was maintained in the NT group after return of spontaneous circulation (ROSC), hypothermal intervention of 32 °C was carried out in the HT group for 4 hours immediately after ROSC. Both the NT and HT groups were then randomly divided into 2 subgroups 12 hours and 24 hours after ROSC (NT-12, NT-24, HT-12, HT-24 subgroups). During observation, the neurological deficit scores (NDSs) was recorded, then the bilateral hippocampi were obtained from rats' head, and monoplast suspension of fresh hippocampus tissue was made immediately to determine the level of intracellular ROS by flow cytometry. Transmission electron microscope was used to observe the ultramicro changes of cellular nucleus and mitochondria. Reverse transcription-polymerase chain reaction (RT-PCR) was used to determine the expression of caspase-3 mRNA, and western-blotting (WB) was used to determine the level of LC3 in frozen hippocampus tissue. Measured data were analyzed with paired sample t test and One-Way ANOVA.
RESULTS: Of 60 rats with CA, 44 (73%) were successfully resuscitated and 33 (55%) survived until the end of the experiment. The NDSs of rats in the NT and HT groups were more significantly reduced than those in the BC group (F=8.107, P<0.05), whereas the NDSs of rats in the HT-12 and HT-24 subgroups were significantly increased in comparison with those NDSs of rats in the NT-12 and NT-24 subgroups, respectively (t=9.692, P<0.001; t=14.374, P<0.001). The ROS in hippocampus nerve cells in the NT and HT groups significantly increased compared to the BC group (F=16.824, P<0.05), whereas the ROS in the HT-12 and HT-24 subgroups significantly reduced compared with that ROS in the NT-12 and NT-24 subgroups, respectively (t=9.836, P<0.001; t=7.499, P<0.001). The expression of caspase-3 mRNA in hippocampus nerve cells in the NT and HT groups were significantly increased compared to the BC group (F=24.527, P<0.05), whereas the expression of caspase-3 mRNA in rats of the HT-12 and HT-24 subgroups was significantly reduced compared to the NT-12 and NT-24 subgroups, respectively (t=6.935, P<0.001; t=4.317, P<0.001). The expression of LC3B-II/I in hippocampus nerve cells of rats in the NT and HT groups significantly increased compared to the BC group (F=6.584, P<0.05), whereas the expression of LC3B-II/I in rats of the HT-12 and HT-24 subgroups significantly reduced compared to the NT-12 and NT-24 subgroups, respectively (t=10.836, P<0.001; t=2.653, P=0.02). Ultrastructure damage of nucleus and mitochondria in the NT group was more evident than in the BC group, and eumorphism of nucleus and mitochondria were maintained in rats of the HT group compared with the NT group.
CONCLUSION: Mild hypothermia lessened the injury of nerve cells and improved the neurological function of rats that survived from cardiac arrest by reducing the ROS production of nerve cells and inhibiting the expression of caspase-3 mRNA and LC3, leading to cellular apoptosis and massive autophagy in rats that survived from cardiac arrest after CPR.

Case Reports

A man with a fracture from minor trauma

Siu Ming Yang, Chor Man Lo

2014, 5(4):  306-309.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.011

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BACKGROUND: We commonly encounter fractures secondary to trauma on and off in our daily practice. While it is not uncommon to see fractures due to underlying pathology, we need to be on the alert when patients present atypically because the treatment for pathological fractures is far different from that for simple fractures.
METHODS: We presented a case of left clavicle fracture secondary to minor trauma, in which the initial X-ray shows suspicious lesion around the fracture site and further investigation reveals multiple myeloma. The patient received treatment at the clinical oncology department upon diagnosis. Since he was relatively young and fit, he was started on the induction therapy of VTD, which was followed by high dose melphalan and autologous stem cell transplant.
RESULTS: He is currently free from symptoms and on maintenance thalidomide.
CONCLUSIONS: Though multiple myeloma is not commonly encountered in emergency practice, earlier identification of relatively subtle symptoms can allow early treatment. Missing this diagnosis will delay treatment and produce severe outcome to the patient. We should be on the alert for such important condition.

A minimally invasive multiple percutaneous drainage technique for acute necrotizing pancreatitis

Takero Terayama, Toru Hifumi, Nobuaki Kiriu, Hiroshi Kato, Yuichi Koido, Yoshiaki Ichinose, Kohei Morimoto, Kuroda Yasuhiro

2014, 5(4):  310-312.  doi:10.5847/wjem.j.issn.1920-8642.2014.04.012

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BACKGROUND: In approximately 20% of patients, necrotizing pancreatitis is complicated with severe acute pancreatitis, with high morbidity and mortality rates. Minimally invasive step-up approach is both safe and effective, but sometimes requires multiple access sites.
METHODS: A 62-year-old woman was admitted with diabetic ketoacidosis, and initial computed tomography (CT) revealed no evidence of acute pancreatitis. She was clinically improved with insulin therapy, fluid administration, and electrolyte replacement. However, on the 14^th day of admission, she developed a high-grade fever, and CT demonstrated evidence of acute necrotizing pancreatitis with a large collection of peripancreatic fluid. Percutaneous transgastric drainage was performed and a 14 French gauge (Fr) pigtail catheter was placed 1 week later, which drained copious pus. Because of persistent high-grade fever and poor clinical improvement, multiple 8 and 10 Fr pigtail catheters were placed via the initial drainage route, allowing the safe and effective drainage of the extensive necrotic tissue that was occupying the bilateral anterior pararenal space.
RESULTS: After drainage, the patient recovered well and the last catheter was removed on day 123 of admission.
CONCLUSIONS: Multiple percutaneous drainage requires both careful judgment and specialist skills. The perforation of the colon and small bowel as well as the injury of the kidney and major vessels can occur. The current technique appears to be safe and minimally invasive compared with other drainage methods in patients with extended, infected necrotic pancreatic pseudocysts.