World Journal of Emergency Medicine

Availability and quality of procedural sedation and analgesia in emergency departments without emergency physicians: A national survey in the Netherlands

Maybritt I. Kuypers, Adinda Klijn, Nieke E. Mullaart-Jansen, Frans B. Plötz

2020, 11(2): 69-73. doi:10.5847/wjem.j.1920-8642.2020.02.001

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BACKGROUND: Emergency physicians have been successful in implementing procedural sedation and analgesia (PSA) to treat emergency department (ED) patients who need to undergo painful procedures. However, 25% of the EDs in the Netherlands are not staffed by emergency physicians. The aim of this study was to investigate PSA availability and quality in EDs without emergency physicians.

METHODS: We performed an exploratory cross-sectional study amongst ED nurses and physicians in all 13 EDs without emergency physicians in the Netherlands. Data were gathered using a standardized questionnaire.

RESULTS: The response rate was 34.3% (148/432). Of the respondents, 84/148 (56.8%) provided adult PSA and 30/148 (20.3%) provided paediatric PSA. Main reasons for not providing PSA were insufficient numbers of trained staff to support PSA in the ED and insufficient training and exposure. The providers agreed significantly stronger when reflecting their PSA competencies in adults compared to paediatric patients.

CONCLUSION: The key to improve pain management in the ED-setting may lay in investing in continuous training of ED health care professionals and/or acquiring professionals who are both qualified in PSA and available in the ED.

Presenting patterns of dermatology conditions to an Australian emergency department

Emily Shao, Chantelle Judge, Erin McMeniman, Tina Bazianas, Rob Eley

2020, 11(2): 74-78. doi:10.5847/wjem.j.1920-8642.2020.02.002

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BACKGROUND: Approximately 5%-8% of emergency department (ED) presentations are due to a dermatological condition. This study aimed to identify and characterise patients with skin conditions presenting to a busy ED.

METHODS: A 5-year retrospective study on patients with dermatological conditions presenting to the Princess Alexandra Hospital ED in Brisbane, Australia was performed. Electronic medical records were used to compare demographics and admission status of the dermatology group and the total ED group presentations. A prospective survey was conducted on low priority triage (triage 4 and 5) patients identifying reasons presenting to the ED.

RESULTS: Of a total 281,718 ED presentations, 11,748 dermatology presentations were identified between January 2012 to December 2016. Of the dermatology presentations, 41.5% were female and had an average age of 47. The most common dermatology presentations were cellulitis, abscess, rash unspecified, and ulcer. Of those admitted, 36% were female, average age was 53, mean length of stay of 294 minutes and 83.1% had an infectious aetiology. Of triage 4 and 5 presentations, 66% patients we approached had been seen by a health practitioner prior to coming to the ED.

CONCLUSION: Within the population presenting with a skin related condition to the Princess Alexandra Hospital ED, characteristics associated with admission include male sex, older age, and an infectious etiology. This data may help ED clinicians decide on the discharge disposition of these patients. There may be a role for streamlined admissions for skin related infections, or improved hospital in the home services to support this group.

Effect of neutrophil CD64 for diagnosing sepsis in emergency department

Wen-peng Yin, Jia-bao Li, Xiao-fang Zheng, Le An, Huan Shao, Chun-sheng Li

2020, 11(2): 79-86. doi:10.5847/wjem.j.1920-8642.2020.02.003

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BACKGROUND: The aim of this study is to investigate the diagnostic and prognostic value of neutrophil CD64 (nCD64) as a novel biomarker in sepsis patients.

METHODS: One hundred fifty-one adult patients diagnosed with sepsis and 20 age-matched healthy controls were enrolled in the study. Patients with sepsis were further subdivided into a sepsis group and a septic shock group. nCD64 expression, serum procalcitonin (PCT) level, C-reactive protein (CRP) level, and white blood cell (WBC) count were obtained for each patient, and Sequential Organ Failure Assessment (SOFA) scores were calculated.

RESULTS: nCD64 expression was higher in the sepsis group with confirmed infection than in the control group. The receiver operating characteristic (ROC) curve of nCD64 was higher than those of SOFA score, PCT, CRP and WBC for diagnosing infection. The area under the curve (AUC) of nCD64 combined with SOFA score was the highest for all parameters. The AUC of nCD64 for predicting 28-day mortality in sepsis was significantly higher than those of PCT, CRP, and WBC, but slightly lower than that of SOFA score. The AUC of nCD64 or PCT combined with SOFA score was significantly higher than that of any single parameter for predicting 28-day mortality.

CONCLUSION: nCD64 expression and SOFA score are valuable parameters for early diagnosis of infection and prognostic evaluation of sepsis patients.

Post-dilatation improves stent apposition in patients with ST-segment elevation myocardial infarction receiving primary percutaneous intervention: A multicenter, randomized controlled trial using optical coherence tomography

Jun Jiang, Nai-liang Tian, Han-bin Cui, Chang-ling Li, Xian-bao Liu, Liang Dong, Yong Sun, Xiao-min Chen, Shao-liang Chen, Bo Xu, Jian-an Wang

2020, 11(2): 87-92. doi:10.5847/wjem.j.1920-8642.2020.02.004

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BACKGROUND: Stent failure is more likely in the lipid rich and thrombus laden culprit lesions underlying ST-segment elevation myocardial infarction (STEMI). This study assessed the effectiveness of post-dilatation in primary percutaneous coronary intervention (pPCI) for acute STEMI.

METHODS: The multi-center POST-STEMI trial enrolled 41 consecutive STEMI patients with symptom onset <12 hours undergoing manual thrombus aspiration and Promus Element stent implantation. Patients were randomly assigned to control group (n=20) or post-dilatation group (n=21) in which a non-compliant balloon was inflated to >16 atm pressure. Strut apposition and coverage were evaluated by optical coherence tomography (OCT) after intracoronary verapamil administration via thrombus aspiration catheter, post pPCI and at 7-month follow-up. The primary endpoint was rate of incomplete strut apposition (ISA) at 7 months after pPCI.

RESULTS: There were similar baseline characteristics except for stent length (21.9 [SD 6.5] mm vs. 26.0 [SD 5.8] mm, respectively, P=0.03). In post-dilatation vs. control group, ISA rate was lower (2.5% vs. 4.5%, P=0.04) immediately after pPCI without affecting final TIMI flow 3 rate (95.2% vs. 95.0%, P>0.05) or corrected TIMI frame counts (22.6±9.4 vs. 22.0±9.7, P>0.05); and at 7-month follow-up (0.7% vs. 1.8%, P<0.0001), the primary study endpoint, with similar strut coverage (98.5% vs. 98.4%, P=0.63) and 1-year rate of major adverse cardiovascular events (MACE).

CONCLUSION: In STEMI patients, post-dilatation after stent implantation and thrombus aspiration improved strut apposition up to 7 months without affecting coronary blood flow or 1-year MACE rate. Larger and longer term studies are warranted to further assess safety (ClinicalTrials.gov identifier: NCT02121223).

Predictive role of interleukin-6 and CAT score in mechanical ventilation in patients with chronic obstructive pulmonary disease at the acute exacerbation stage in the emergency department

Wei Bi, Yan Sun, Lin-qin Ma, Cai-jun Wu

2020, 11(2): 93-96. doi:10.5847/wjem.j.1920-8642.2020.02.005

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BACKGROUND: The study aimed to evaluate the predictive role of interleukin-6 (IL-6) and chronic obstructive pulmonary disease (COPD) assessment test (CAT) score in mechanical ventilation (MV) in COPD patients at the acute exacerbation stage in the emergency department (ED).

METHODS: For a one-year period, among adult patients in the ED who met the criteria of acute exacerbation of COPD, 158 who received MV within 48 hours after admission were compared to 294 who didn't require MV within the same period after admission. IL-6 level and CAT score were compared between the two groups. The predicted value of IL-6 and CAT score was assessed by logistic regression analysis and a receiver operating characteristic (ROC) curve.

RESULTS: The IL-6 and CAT scores in the 158 MV patients were much higher than those without. IL-6 and CAT scores were independent predictors of MV within 48 hours using logistic regression analysis (IL-6: odds ratio [OR] 1.053, 95% confidence interval [CI] 1.039-1.067, P<0.001; CAT score: OR 1.122, 95% CI 1.086-1.159, P<0.001). The combination of IL-6 and CAT scores (area under ROC curve [AUC] 0.826, 95% CI 0.786-0.866, P<0.001) improved the accuracy of predicting MV within 48 hours when compared with IL-6 (AUC 0.752, 95% CI 0.703-0.800, P<0.001) and CAT scores alone (AUC 0.739, 95% CI 0.692-0.786, P<0.001). The sensitivity and specificity were 69.6%, 74.1%, 75.32% and 63.6%, respectively.

CONCLUSION: The combined of IL-6 and CAT scores is useful for evaluating the risk of COPD patients at acute exacerbation in ED, and can provide a predictive value for MV or not within 48 hours.

Changes in peak inspiratory flow rate and peak airway pressure with endotracheal tube size during chest compression

Jung Wan Kim, Jin Woong Lee, Seung Ryu, Jung Soo Park, InSool Yoo, Yong Chul Cho, Hong Joon Ahn

2020, 11(2): 97-101. doi:10.5847/wjem.j.1920-8642.2020.02.006

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BACKGROUND: Adequate airway management plays an important role in high-quality cardiopulmonary resuscitation (CPR). Airway management is usually performed using an endotracheal tube (ETT) during CPR. However, no study has assessed the effect of ETT size on the flow rate and airway pressure during CPR.

METHODS: We measured changes in peak inspiratory flow rate (PIFR), peak airway pressure (P_peak), and mean airway pressure (P_mean) according to changes in ETT size (internal diameter 6.0, 7.0, and 8.0 mm) and with or without CPR. A tidal volume of 500 mL was supplied at a rate of 10 times per minute using a mechanical ventilator. Chest compressions were maintained at a constant compression depth and speed using a mechanical chest compression device (LUCAS2, mode: active continuous, chest compression rate: 102±2/minute, chest compression depth 2-2.5 inches).

RESULTS: The median of several respiratory physiological parameters during CPR was significantly different according to the diameter of each ETT (6.0 vs. 8.0 mm): PIFR (32.1 L/min [30.5-35.3] vs. 28.9 L/min [27.5-30.8], P<0.001), P_peak (48.84 cmH₂O [27.46-52.11] vs. 27.45 cmH₂O [22.53-52.57], P<0.001), and P_mean (18.34 cmH₂O [14.61-21.66] vs.13.66 cmH₂O [8.41-19.24], P<0.001).

CONCLUSION: The changes in PIFR, P_peak, and P_mean were related to the internal diameter of ETT, and these values tended to decrease with an increase in ETT size. Higher airway pressures were measured in the CPR group than in the no CPR group.

Comparison of invasive dynamic blood pressure between superior mesenteric artery and common carotid artery in rats

Rui-ning Liu, Xiao-jun Wei, Shao-ping Li, Cheng Jiang, Yan Zhao

2020, 11(2): 102-108. doi:10.5847/wjem.j.1920-8642.2020.02.007

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BACKGROUND: The purpose of this study was to identify the consistency of invasive dynamic blood pressure (BP) monitoring between the superior mesenteric artery (SMA) and the common carotid artery (CCA).

METHODS: Eight male Sprague-Dawley rats were cannulated in SMA and CCA simultaneously for BP monitoring, respectively. The abdominal aorta was prepared for the induction of BP change through clamping/de-clamping by a microvascular clip. The dynamic BP monitoring was performed by a polygraph system. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) values would be recorded during different time periods: the baseline (T1), the increasing period after clamping (T2), the platform period during clamping (T3), the decreasing period after de-clamping (T4), and the final platform period (T5). Three trials were performed on each rat with 15-minute intervals between consecutive monitoring.

RESULTS: Systolic BP showed no significant differences between SMA and CCA. However, significant difference was found in diastolic blood pressure except at T5 (P=0.534). Mean arterial pressure of two arteries were significantly different only at T1 (P=0.015). The strength of association was significantly high between BP measurements through SMA and CCA (P<0.001). The Bland-Altman analyses showed that mean bias of MAP changed no more than 5 mmHg and standard deviation less than 8 mmHg during T2 and T4, respectively.

CONCLUSION: The study indicates SMA might be an alternative site for invasive BP monitoring during abdominal aorta occlusion and release, especially in cerebrovascular-related research.

Effect of low high-density lipoprotein levels on mortality of septic patients: A systematic review and meta-analysis of cohort studies

Shao-hua Liu, Huo-yan Liang, Hong-yi Li, Xian-fei Ding, Tong-wen Sun, Jing Wang

2020, 11(2): 109-116. doi:10.5847/wjem.j.1920-8642.2020.02.008

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BACKGROUND: An increase in high-density lipoprotein (HDL) is well associated with a decreased cardiovascular risk, especially atherosclerosis. Recent studies suggest that lower levels of HDL may also be associated with an increased risk of sepsis and an increased rate of mortality in septic patients. However, this conclusion remains controversial.

METHODS: MEDLINE, EMBASE, and CENTRAL databases were searched from inception to September 30, 2019. All studies were conducted to evaluate the correlation of lipoprotein levels and the risk and outcomes of sepsis in adult patients. The primary outcomes were the risk and mortality of sepsis.

RESULTS: Seven studies comprising 791 patients were included. Lower levels of HDL had no marked relevance with the risk of sepsis (odds radio [OR] for each 1 mg/dL increase, 0.94; 95% CI 0.86-1.02; P=0.078), whereas lower HDL levels were related to an increased mortality rate in septic patients (OR for below about median HDL levels, 2.00; 95% CI 1.23-3.24; P=0.005).

CONCLUSION: This meta-analysis did not reveal a significant association between lower HDL levels and an increase in the risk of sepsis, whereas it showed that lower HDL levels are associated with a higher mortality rate in septic adult patients. These findings suggest that HDL may be considered as a promising factor for the prevention and treatment of sepsis in the future.

An unexpected electrocardiogram sign of subacute left ventricular free wall rupture: Its early awareness may be lifesaving

Hong-yi Wu, Ju-ying Qian, Qi-bing Wang, Jun-bo Ge

2020, 11(2): 117-119. doi:10.5847/wjem.j.1920-8642.2020.02.009

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BACKGROUND: Post-infarct left ventricular free wall rupture (LVFWR) is not always an immediately catastrophic complication. The rupture can be subacute, allowing time for diagnosis and intervention. Accordingly, early recognition of the entity may be lifesaving.

METHODS: We present an electrocardiogram (ECG) change pattern in two cases, which was erroneously attributed to ischemia. Two women in their 80s were admitted to our institute after experiencing the sudden onset of chest pain. They were managed as anterior ST-segment elevation myocardial infarction without reperfusion treatment. Unfortunately, they experienced a recurrence of severe chest pain with cardiogenic shock during hospitalisation. The ECG recorded at that time showed a ST-segment re-elevation in infract-related leads.

RESULTS: The two cases were regrettably received a misjudgement of reinfarction at first, and one of the patients even was administrated with tirofiban. Afterwards the diagnosis of subacute LVFWR was made through antemortem echocardiography.

CONCLUSION: New ST-segment elevation (STE) in infarct-associated leads, coupled with recurrence of chest pain and new-onset hypotension, may constitute the premonitory signs of a subacute LVFWR.

Outcome predictors for severely brain-injured patients directly admitted or transferred from emergency departments to a trauma center

Ryne Jenkins, Nicholas A. Morris, Bryce Haac, Richard Van Besien, Deborah M. Stein, Neeraj Badjatia, Amir Medic, Gaurika Mester, Quincy K. Tran

2020, 11(2): 120-121. doi:10.5847/wjem.j.1920-8642.2020.02.010

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A young lady presenting to the emergency department with blue lips: A case study with review of literature

Debkumar Chowdhury

2020, 11(2): 122-124. doi:10.5847/wjem.j.1920-8642.2020.02.011

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