Table of Content

15 September 2011, Volume 2 Issue 3

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Review Article

Mechanical cardiopulmonary resuscitation for patients with cardiac arrest

Lei Jiang, Jin-song Zhang

2011, 2(3):  165-168.  doi:10.5847/wjem.j.1920-8642.2011.03.001

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BACKGROUND: Although modern cardiopulmonary resuscitation (CPR) substantially decreases the mortality induced by cardiac arrest, cardiac arrest still accounts for over 50% of deaths caused by cardiovascular diseases. In this article, we address the current use of mechanical devices during CPR, and also compare the CPR quality between manual and mechanical chest compression.
METHODS: We compared the quality and survival rate between manual and mechanical CPR, and then reviewed the mechanical CPR in special circumstance, such as percutaneous coronary intervention, transportation, and other fields.
RESULTS: Compared with manual compression, mechanical compression can often be done correctly, and thus can compromise survival; can provide high quality chest compressions in a moving ambulance; enhance the flow of blood back to the heart via a rhythmic constriction of the veins; allow ventilation and CPR to be per formed simultaneously.
CONCLUSION: Mechanical devices will be widely used in clinical practice so as to improve the quality of CPR in patients with cardiac arrest.

Original Article

Survey of the current state of emergency care in Chennai, India

Jay Khadpe, Tausif Thangalvadi, Parivalavan Rajavelu, Richard Sinert

2011, 2(3):  169-174.  doi:10.5847/wjem.j.1920-8642.2011.03.002

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BACKGROUND: On July 21, 2009, the Medical Council of India officially recognized the specialty of emergency medicine in India. The city of Chennai with over six and a half million people is the fourth largest on the subcontinent and has already been a prominent city of interest in the specialty's development. However, there is no standardization of the resources found in the city's emergency departments. This study was to survey the equipment, training, and certification of Chennai area emergency departments and their staff.
METHODS: We conducted a cross-sectional survey of emergency department staff from 38 Chennai area hospitals. The survey instrument contained 44 questions pertaining to hospital demographics, staff training and certification, and ED equipment and supplies. The items on the survey were specifically chosen to represent only the most basic and common resources necessary to practise emergency medicine.
RESULTS: The survey found a majority of hospitals are privately operated but there is a wide range in terms of size and volume of patients. A minority of both doctors and nurses are certified in BLS, ACLS, PALS, and ATLS. While almost all departments surveyed had the basic code medications, a number of basic equipment items were lacking from a large percentage of the EDs surveyed.
CONCLUSION: The newly established EP community in Chennai will have the responsibility to establish standards for both training and resources so that the specialty may grow and provide a higher standard of emergency care moving into the future.

Comparison of Airtraq optical laryngoscope and Storz video laryngoscope in a cadaver model

Michael C. Wadman, Travis W. Dierks, Chad E. Branecki, Claudia L. Barthold, Lance H. Hoffman, Lina Lander, Carol S. Lomneth, Richard A. Walker

2011, 2(3):  175-178.  doi:10.5847/wjem.j.1920-8642.2011.03.003

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BACKGROUND: Airway management in the emergency department is a critical intervention that requires both standard techniques and rescue techniques to ensure a high rate of success. Recently, video laryngoscope (VL) systems have become increasingly common in many large urban EDs, but these systems may exceed the budgets of smaller rural EDs and EMS services and the Airtraq optical laryngoscope (OL) may provide an effective, low-cost alternative. We hypothesized that laryngeal view and time to endothracheal tube placement for OL and VL intubations would not be significantly different.
METHODS: This was a prospective, crossover trial. Setting: University-based emergency medicine residency program procedure laboratory utilizing lightly embalmed cadavers. Subjects: PGY1-3 emergency medicine residents. The study subjects performed timed endotracheal intubations alternately using the OL and VL. The subjects then rated the Cormack-Lehane laryngeal view for each device. Statistical analysis: Mean time to intubation and the mean laryngeal view score were calculated with 95% confidence intervals and statistical significance was determined by Student's t test.
RESULTS: Fourteen subjects completed the study. The average laryngeal view achieved with the OL vs. the VL was not significantly different, with Cormack-Lehane grade of 1.14 vs. 1.07, respectively. Time to endotracheal intubation, however, was significantly different (P<0.001) with the average time to intubation for the OL 25.49 seconds (95% CI: 17.95-33.03) and the VL 13.41 seconds (10.27-16.55).
CONCLUSION: The Airtraq OL and the Storz VL yielded similar laryngeal views in the lightly embalmed cadaver model. Time to endotracheal tube placement, however, was less for the VL.

Serum paraquat concentration detected by spectrophotometry in patients with paraquat poisoning

Chang-bin Li, Xin-hua Li, Zhen Wang, Cheng-hua Jiang, Ai Peng

2011, 2(3):  179-184.  doi:10.5847/wjem.j.1920-8642.2011.03.004

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BACKGROUND: Paraquat (PQ) is a world-wide used herbicide and also a type of common poison for suicide and accidental poisoning. Numerous studies have proved that the concentration of serum PQ plays an important role in prognosis. Spectrophotometry, including common spectrophotometry and second-derivative spectrophotometry, is commonly used for PQ detection in primary hospitals. So far, lack of systematic research on the reliability of the method and the correlation between clinical features of patients with PQ poisoning and the test results has restricted the clinical use of spectrophotometry. This study aimed to evaluate the reliability and value of spectrophotometry in detecting the concentration of serum PQ.
METHODS: The wavelengths for detecting the concentration of serum PQ by common and second-derivative spectrophotometry were determined. Second-derivative spectrophotometry was applied to detect the concentration of serum PQ. The linear range and precision for detection of PQ concentration by this method were confirmed. The concentration of serum PQ shown by second-derivative spectrophotometry and HPLC were compared in 8 patients with PQ poisoning. Altogether 21 patients with acute poisoning 4 hours after PQ ingestion treated in the period of October 2008 to September 2010 were retrospectively reviewed. The patients were divided into higher and lower than 1.8 µg/mL groups based on their concentrations of serum PQ measured by second-derivative spectrophotometry on admission. The severity of clinical manifestations between the two groups were analyzed with Student's t test or Fisher's exact test.
RESULTS: The absorption peak of 257 nm could not be found when common spectrophotometry was used to detect the PQ concentration in serum. The calibration curve in the 0.4-8.0 µg/mL range for PQ concentration shown by second-derivative spectrophotometry obeyed Beer's law with r=0.996. The average recovery rates of PQ were within a range of 95.0% to 99.5%, relative standard deviation (RSD) was within 1.35% to 5.41% (n=6), and the lower detection limit was 0.05 µg/mL. The PQ concentrations in serum of 8 patients with PQ poisoning shown by second-derivative spectrophotometry were consistent with the quantitative determinations by HPLC (r=0.995, P<0.0001). The survival rate was 22.2% in patients whose PQ concentration in serum was more than 1.8 µg/mL, and the incidences of acidosis, oliguria and pneumomediastinum in these patients were 55.6%, 55.6% and 77.8%, respectively. These clinical manifestations were different significantly from those of the patients whose PQ concentration in serum was less than 1.8 µg/mL (P<0.05).
CONCLUSIONS: For common spectrophotometry, the wavelength at 257 nm was not suitable for detecting serum PQ as no absorbance was shown. Second-derivative spectrophotometry was reliable for detecting serum paraquat concentration. Serum PQ concentration detected by second-derivative spectrophotometry could be used to predict the severity of clinical manifestations of patients with PQ poisoning, and PQ content higher than 1.8 µg/mL 4 hours after ingestion could be an important predictive factor for poor prognosis.

Prognostic significance of urokinase-type plasminogen activator and its receptor in patients with systemic inflammatory response syndrome

Li Yu, Ding Long, Xiao-Ling Wu, Jun-hui Yang, Yuan-chao Yang, Geng Feng

2011, 2(3):  185-189.  doi:10.5847/wjem.j.1920-8642.2011.03.005

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BACKGROUND: This study aimed to determine the plasma levels of urokinase-type plasminogen activator (uPA), urokinase-type plasminogen activator receptor (uPAR), D-dimer, IL-6 and TNF-α, and observe the relations among uPA, uPAR, D-dimer, IL-6 and TNF-α in patients with systemic inflammatory response syndrome (SIRS).
METHODS: A prospective, clinical case-control study was conducted in patients with SIRS at age of more than 55 years old treated during 2008-2010 at Wuhan Central Hospital. Venous blood samples were collected by routine venipuncture. Eighty-five patients were divided into two groups according to diagnostic criteria of SIRS: SIRS patients from intensive care units (n=50), and non-SIRS patients from medical wards (n=35). Thirty healthy blood donors who visited the General Health Check-up Division at Wuhan Central Hospital served as controls. Excluded from the study were (1) those patients with pregnancy; (2) those with cancer; (3) those died after admission into the ICU in 7 days; (4) those received cardiopulmonary resuscitation; (5) those who had previous blood system diseases; and (6) those with SIRS before admission into the ICU. The levels of uPA, uPAR, D-D, IL-6 and TNF-α in blood were detected by commercial enzyme-linked immunosorbent assay (ELISA) kit. The data were analyzed using SPSS version 17.0 and expressed as mean ± standard. Student's t test and the Mann-Whitney U test were used in the analysis. The relations of uPA, uPAR and D-dimer, IL-6 TNF-α levels were analyzed using Spearman's rank-order correlation coefficient test.
RESULTS: The plasma levels of uPA , uPAR, D-dimer,IL-6 and TNF-α in the patients with SIRS were obviously higher than those in the non-SIRS patients and controls (P<0.001). Correlation analysis showed a positive correlation between uPAR and IL-6 levels (r=0.395, P=0.004) and between uPAR and TNF-α levels (r=0.606, P<0.001), but no correlation between uPAR and D-dimer levels (r=0.069, P=0.632). No correlation was observed between uPA, D-dimer, IL-6 and TNF-α levels (P>0.05). The establishment of ROC curve was based on the levels of uPAR, D-dimer, IL-6 and TNF-α in 24 hours for the diagnosis of multiple organ dysfunction syndrome (MODS), and the ROC areas under the curve were 0.76, 0.58, 0.86 and 0.83, respectively.
CONCLUSIONS: uPA and uPAR play a major role in patients with SIRS in the process of coagulation disorder, but the mechanism of SIRS is not the same. uPAR may play a central role in the development of SIRS to MODS.

Diagnostic role of soluble triggering receptor expressed on myeloid cell-1 in patients with sepsis

Hong-xia Wang, Bing Chen

2011, 2(3):  190-194.  doi:10.5847/wjem.j.1920-8642.2011.03.006

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BACKGROUND: Biomarkers may be helpful in risk stratification and prediction of mortality in septic patients. This study aimed to investigate the diagnostic role of soluble triggering receptor expressed on myeloid cell-1(sTREM-1), procalcitonin (PCT), C-reactive protein (CRP) and other inflammatory markers in patients with sepsis.
METHODS: A total of 56 patients with systemic inflammation response syndrome (SIRS) who had been admitted to the ICU department of the Second Hospital of Tianjin Medical University between May 2009 and July 2010 were enrolled. They were divided into a sepsis group (n=32) and a SIRS group (n=24). Twenty-five non-SIRS patients served as controls. The sepsis group was sub-divided into a survival group and a death group according to 28-day prognosis. The values of sTREM-1, PCT, CRP, white blood cell (WBC), and neutrophil count percentage (N) were measured. Acute physiology and chronic health evaluation II (APACHE II) score were determined within 24 hours. The correlation between sTREM-1 and APACHE II score was analyzed. Quantitative data were analyzed by the F test or the Kruskal-Wallis test.
RESULTS: The plasma level of sTREM-1 in the sepsis group was significantly higher than that in the SIRS group and control group. The plasma level of sTREM-1 in the non-survival group was significantly higher than that in the survival group. In the sepsis group, the plasma sTREM-1 level was positively correlated with APACHE II score (r_s=0.426, P= 0.032). The area under the ROC curve of sTREM-1 was 0.935, larger than that of PCT and CRP.
CONCLUSION: Plasma sTREM-1 is useful in the diagnosis of sepsis at early stage. The increased level of sTREM-1 during the first 24 hours may be correlated with poor outcome of patients with sepsis.

Exhaled nitric oxide in neonates with or without hypoxemic respiratory failure

Li-juan Liu, Xi-rong Gao, Pan-pan Wu, Li-ling Qian, Chao Chen, Bo Sun

2011, 2(3):  195-200.  doi:10.5847/wjem.j.1920-8642.2011.03.007

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BACKGROUND: Exhaled nitric oxide (eNO) is one of the airway condensate derived markers, reflecting mainly airway inflammation in asthma and other lung diseases. The changes of eNO levels as pathophysiology of neonatal hypoxemic respiratory failure (HRF) in early postnatal life have not been thoroughly studied. The present study was to establish a method for measuring eNO concentrations in neonates with or without HRF.
METHODS: Twenty-two newborn infants with HRF and 26 non-NRF controls were included within the first 24 hours of postnatal life. Their eNO levels were detected with a rapid-response chemiluminescence analyzer daily during the first week of their postnatal life, and lung mechanics and gas exchange efficiency were monitored at the same time, such as pulse oxygen saturation (SpO₂), inspired fraction of oxygen (FiO₂) and other parameters.
RESULTS: During the first two days of postnatal life, eNO values of HRF neonates were significantly higher than those of the control neonates (day 1, 7.9±3.2 vs. 5.8±1.8 parts per billion [ppb], P<0.05; day 2, 8.8±3.2 vs. 6.0±2.4 ppb, P<0.05), but there were no significant differences in the following days. With SpO₂/FiO₂ increasing, difference of eNO values between the HRF and non-HRF neonates became narrowed, but there was still a two-fold difference of eNO/[SpO₂/(FiO₂×100)] on days 5-7.
CONCLUSION: We established a method for measuring eNO and found difference in neonates with or without HRF, which diminished with prolonged postnatal days, reflecting pathophysiological characteristics of HRF.

Lung recruitment maneuver effects on respiratory mechanics and extravascular lung water index in patients with acute respiratory distress syndrome

Jian-guo Zhang, Xiao-juan Chen, Fen Liu, Zhen-guo Zeng, Ke-jian Qian

2011, 2(3):  201-205.  doi:10.5847/wjem.j.1920-8642.2011.03.008

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BACKGROUND: Animal experiments showed that recruitment maneuver (RM) and protective ventilation strategy of the lung could improve oxygenation and reduce extravascular lung water. This study was to investigate the effects of RM on respiratory mechanics and extravascular lung water index ( EVLWI) in patients with acute respiratory distress syndrome (ARDS).
METHODS: Thirty patients with ARDS were randomized into a RM group and a non-RM group. In the RM group, after basic mechanical ventilation stabilized for 30 minutes, RM was performed and repeated once every 12 hours for 3 days. In the non-RM group, lung protective strategy was conducted without RM. Oxygenation index (PaO₂/FiO₂), peak inspiratory pressure (PIP), Plateau pressure (Pplat), static pulmonary compliance (Cst) and EVLWI of patients before treatment and at 12, 24, 48, 72 hours after the treatment were measured and compared between the groups. Hemodynamic changes were observed before and after RM. One-way ANOVA, Student's t test and Fisher's exact test were used to process the data.
RESULTS: The levels of PaO₂/FiO₂ and Cst increased after treatment in the two groups, but they were higher in the RM group than in the non-RM group (P<0.05). The PIP and Pplat decreased after treatment in the two groups, but they were lower in the RM group than in the non-RM group (P<0.05). The EVLWI in the two groups showed downward trend after treatment (P<0.05), and the differences were signifcant at all time points (P<0.01); the EVLWI in the RM group was lower than that in the non-RM group at 12, 24, 48 and 72 hours (P<0.05 or P<0.01). Compared with pre-RM, hemodynamics changes during RM were significantly different (P<0.01); compared with pre-RM, the changes were not significantly different at 120 seconds after the end of RM (P>0.05).
CONCLUSIONS: RM could reduce EVLWI, increase oxygenation and lung compliance. The effect of RM on hemodynamics was transient.

Effects of enteral immunonutrition on immune function in patients with multiple trauma

Sha-luo Li, Yong-hua Xu, Xi Wang, Xue-feng Liu, Liang Zhao

2011, 2(3):  206-209.  doi:10.5847/wjem.j.1920-8642.2011.03.009

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BACKGROUND: Enteral immunonutrition (EIN) refers to addition of some specific nutrients in enteral nutrition (EN), which can help to increase the immune function, and reduce the inflammatory reaction and septic complications. This study aimed to determine whether EIN can improve the immune function in multiple trauma patients.
METHODS: Thirty-two patients with multiple trauma who had been admitted to the general ICU of Changzheng Hospital, Shanghai, from March 2007 to May 2008, were randomly divided into two groups: an enteral immunonutrition group (EIN group, n=16) and an enteral nutrition group (EN group, n=16). EIN suspension (RuiNeng produced by Sino-Swed Co., Ltd) and ordinary nutrition liquid (RuiSu produced by Sino-Swed Co., Ltd) were given to patients of the EIN group and EN group respectively for at least for 14 days. Peripheral blood lymphocyte count (TLC), immunoglobulin (IgG, IgM, IgA), and T-lymphocyte subsets (CD3, CD4, CD8, CD4 /CD8) were detected on the 1st day after grouping, and the 7th day and 14th day after nutritional support.
RESULTS: TLC, IgG, IgM, IgA, CD4 and CD4/CD8 ratio were significantly higher in the EIN group on the 7th and 14th day than that on the 1st day (P<0.05), and continually increased with a prolonged time of EIN. The parameters of immune function in the EN group on the 7th day didn't change significantly compared with those on the 1st day after grouping; on the 14 th day, TLC, IgG, IgM, IgA, CD4 and CD4/CD8 ratio were significantly higher than those on the 1st day after grouping (P<0.05), but were significantly lower than those in the EIN group on the 14th day (P<0.05).
CONCLUSION: Compared with the general formula EN, EIN is more helpful for the recovery of humoral and cellular immune function in the early post-multitraumatic phase.

Protective effect of glutamine in critical patients with acute liver injury

Hai-bin Ni, Zheng Zhang, Hai-dong Qin

2011, 2(3):  210-215.  doi:10.5847/wjem.j.1920-8642.2011.03.010

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BACKGROUND: Glutamine (Gln) supplementation is known to decrease oxidative stress and inflammatory response, enhance resistance to infectious pathogens, shorten hospital stay, and decrease medical costs of patients. This study was undertaken to evaluate the relationship between the effect of early parenteral glutamine (Gln) supplement on acute liver injury (ALI) and heat shock protein 70 (HSP-70) expression in critical patients.
METHODS: Forty-four patients who had been admitted to the emergency intensive care unit (EICU) of Nanjing First Hospital Affiliated to Nanjing Medical University were randomly divided into a control group (n=22) and a Gln group (n=22). The patients of the two groups received enteral and parenteral nutrition. In addition, parenteral Gln 0.4 g/kg per day was given for 7 days in the Gln group. Serum HSP-70 and Gln were measured at admission and at 7 days after admission. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBiL), serum levels of HSP-70 and Gln, mechanical ventilation (MV) time, ICU stay, peripheral blood of TNF-α, IL-6, CD3, CD4 and CD4/CD8 levels were also measured in the two groups.
RESULTS: In the Gln group, the levels of serum HSP-70 and Gln were significantly higher after Gln treatment than those before the treatment (P<0.01). HSP-70 level was positively correlated with the Gln level in the Gln group after administration of parenteral Gln (P<0.01). The levels of serum ALT, AST, TBiL and TNF-α, IL-6 were lower in the Gln group than in the non-Gln group (P<0.01). MV time and ICU stay were significantly different between the two groups (P<0.05). The levels of CD3, CD4 and CD4/CD8 were significantly higher in the Gln group than in the control group after treatment (P<0.05).
CONCLUSION: Parenteral Gln significantly increases the level of serum HSP70 in critically ill patients. The enhanced expression of HSP70 is correlated with improved outcomes of Gln-treated patients with acute liver injury.

Relationship between expression of triggering receptor-1 on myeloid cells in intestinal tissue and intestinal barrier dysfunction in severe acute pancreatitis

Kai Yin, Sheng-chun Dang, Jian-xin Zhang

2011, 2(3):  216-221.  doi:10.5847/wjem.j.1920-8642.2011.03.011

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BACKGROUND: Triggering receptor expressed on myeloid cells-1 (TREM-1) in the intestine was upregulated and correlated with disease activity in inflammatory bowel diseases. Membrane-bound TREM-1 protein is increased in the pancreas, liver and kidneys of patients with severe acute pancreatitis (SAP), suggesting that TREM-1 may act as an important mediator of inflammation and subsequent extra-pancreatic organ injury. This study aimed to investigate the relationship between the expression of TREM-1 in intestinal tissue and intestinal barrier dysfunction in SAP.
METHODS: Sixty-four male Wistar rats were randomly divided into a sham operation group (SO group, n=32) and a SAP group (n=32). A SAP model was established by retrograde injection of 5% sodium deoxycholate into the bile-pancreatic duct. Specimens were taken from blood and intestinal tissue 2, 6, 12, and 48 hours after operation respectively. The levels of D-lactate, diamine oxidase (DAO) and endotoxin in serum were measured using an improved spectro-photometric method. The expression levels of TREM-1, interleukin-1β (IL-1β), and tumor necrosis factor-α (TNF-α) mRNA in terminal ileum were detected by real-time reverse transcription-polymerase chain reaction (RT-PCR). Specimens of the distal ileum were taken to determine pathological changes by a validated histology score.
RESULTS: The serum levels of D-lactate, DAO and endotoxin were significantly increased in each subgroup of SAP compared with the SO group (P<0.01, P<0.05). The expression levels of TREM-1, IL-1β and TNF-α mRNA in the terminal ileum in each subgroup of SAP were significantly higher than those in the SO group (P<0.01, P<0.05). The expression level of TREM-1mRNA was positively correlated with IL-1β and TNF-α mRNA (r=0.956, P=0.044; r=0.986, P=0.015), but the correlation was not found between IL-1β mRNA and TNF-α mRNA (P=0.133). Compared to the SO group, the pathological changes were aggravated significantly in the SAP group.
CONCLUSIONS: The expression level of TREM-1 in intestinal tissue of rats with SAP was elevated, leading to the release of inflammatory mediators and intestinal mucosal injury. This finding indicates that TREM-l might play an important role in the development of intestinal barrier dysfunction in rats with SAP.

Protective effects of edaravone on diffuse brain injury in rats

Jian-min Li, Pan Zhang, Ya-ning Zhao, Chang-xiang Chen, Shu-xing Li

2011, 2(3):  222-227.  doi:10.5847/wjem.j.1920-8642.2011.03.012

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BACKGROUND: Edaravone can alleviate brain injury and improve neurological functions and symptoms. This study aimed to investigate the effect of edaravone on the p38Mitogen-activated protein kinases/Caspase-3 (p38MAPK /Caspase-3) pathway after diffuse brain injury (DBI) in rats.
METHODS: DBI models were established according to the description of Marmarou's method. A total of 250 rats were divided (random number) into four groups: control group (CG, n=45), model group (MG, n=77), low-dose edaravone group (n=67, dosage 5 mg/kg) and high-dose edaravone group (n=61, dosage 10 mg/kg). After 1, 6, 24, 48, and 72 hours after injury, brain tissues were collected. The changes of neuron morphous in the hippocampal region were observed through Nissl staining. The expression levels of phosphorylated p38MAPK and caspase-3 were detected by immunohistochemistry and Western blotting respectively. Learning and memory function were tested with Morris water maze from the 3rd to 7th day after injury.
RESULTS: Some neurons had histopathologic changes of necrosis and apoptosis in the model group compared with the control group. The phosphorylated p38MAPK expressions increased at 1, 6, 4, and 48 hours (P<0.05), but no significant difference was observed at 72 hours (0.54±0.19 vs. 0.40±0.14, P>0.05). Caspase-3 expressions increased at 6, 24, 48, and 72 hours respectively (P<0.05), but there was no significant difference at 1 hour (0.59±0.29 vs. 0.40±0.17, P>0.05). From the 3rd to 6th day during the Morris water maze test, the latency to find the platform was significantly prolonged (P<0.05) and times of rats crossing the platform was decreased on the 7th day (2.28±1.18 vs. 8.20±1.52, P<0.05). The phosphorylated p38MAPK expressions decreased at 6, 24 and 48 hours respectively in the low dose edaravone group compared with the model group (P<0.05), whereas no significant difference was seen at 1 hour (1.66±0.80 vs. 1.85±0.86, P>0.05). Caspase-3 expression decreased at 6, 24, 48, and 72 hours (P<0.05). The latency to find the platform was significantly shortened (P<0.05), and times of rats crossing the platform increased (4.17±1.15 vs. 2.28±1.18, P<0.05). The above mentioned parameters changed more significantly in the high-dose edaravone group than in the low-dose edaravone group.
CONCLUSION: Edaravone can alleviate brain tissue damage after DBI, inhibit p38MAP signal activation after early injury, reduce the expression of caspase-3, and promote the recovery of neurological function in the late period.

Effect of transforming growth factor-β1 on monocyte Toll-like receptor 4 expression in septic rats

Yu Zhang, Jing Xing

2011, 2(3):  228-231.  doi:10.5847/wjem.j.1920-8642.2011.03.013

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BACKGROUND: Sepsis is a tough problem in critical ill patients. This study aimed to investigate the dynamic changes of monocyte Toll-like receptor (TLR) 4 expression in peripheral blood of septic rats and to determine the effects of transforming growth factor (TGF) -β₁ on TLR4 expression.
METHODS: Altogether 132 clean level SD rats were randomly divided into a control group (n=12), a sepsis model group (n=60), and a TGF-β₁ intervention group (n=60). In the sepsis model group and TGF-β₁ intervention group, the rats were subdivided into five groups (2-hour group, 6-hour group, 12-hour group, 24-hour group, and 48-hour group), with 12 rats in each group. Cecal ligation puncture (CLP) was performed in the sepsis model group and TGF-β₁ intervention group to establish models of sepsis. The rats in the sepsis model group were injected with 1 mL normal saline at the caudal vein 0.5 hour after the model establishment; the rats in the TGF-β₁ intervention group were injected with 20 ng/mL or 250 g TGF-β₁ 0.5 hour after the model establishment. Flow cytometry was used to detect the change of monocyte TLR4 in peripheral blood, and enzyme-linked immunosorbent assay (ELISA) was used to detect the change of TNF-α level in peripheral blood.
RESULTS: At 6-12 hours after CLP, the monocyte TLR4 in peripheral blood started to decrease, and reached the lowest level at 12 hours. Compared to the control group, the monocyte TLR4 expression at 6 and 12 hours was lowered significantly (P<0.05). Compared to the sepsis model group at 2, 24 and 48 hours after CLP, the monocyte TLR4 expression in the TGF-β₁ intervention group decreased dramatically (P<0.05), but there were no differences between the two groups at 6 and 12 hours respectively. Compared to the control group, the concentration of NF-κB in liver tissue increased significantly 6 hours after CLP (P<0.05). After use of TGF-β₁, the concentration of NF-κB was decreased significantly but still higher than that of the control group. Compared to the control group, the concentration of TNF-α in peripheral blood was increased significantly at 2-48 hours after CLP (P<0.05). After use of TGF-β₁, TNF-α was further increased.
CONCLUSION: During sepsis, TGF-β₁ can decrease the monocyte TLR4 expression and NF-κB in liver tissue, but facilitate the formation of proinflammatory mediator TNF-α. This finding indicates that TGF-β₁ may play a role in promoting inflammatory response during sepsis, but this regulation is not via direct regulation of monocyte TLR4 in peripheral blood.

Case Reports

Acute ethanol poisoning in a 6-year-old girl following ingestion of alcohol-based hand sanitizer at school

Madeline Matar Joseph, Cristina Zeretzke, Sara Reader, Dawn R. Sollee

2011, 2(3):  232-233.  doi:10.5847/wjem.j.1920-8642.2011.03.014

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BACKGROUND: Alcohol-based hand sanitizers (ABHSs) have been widely used in homes, workplaces and schools to prevent the spread of infectious diseases. We report a young child unintentionally ingested ABHS at a school, resulting in intoxication.
METHODS: The child was a 6-year-old girl who had been brought to the emergency department (ED) for hypothermia, altered mental status (AMS), periods of hypoventilation, hypothermia and vomiting. Computed tomography of her head revealed nothing abnormal in intracranial pathology. Urine drug screening was negative. Alcohol level was 205 mg/dL on admission. Other abnormal values included potassium of 2.8 mEq/L, osmolality of 340 mOsm/kg and no hypoglycemia. Further investigation revealed that the patient had gone frequently to the class restroom for ingestion of unknown quantities of ABHSs during the day. The patient was admitted for one day for intravenous fluid hydration and close observation of her mental status.
RESULTS: The patient was discharged from the hospital the next day without any complications.
CONCLUSION: Despite the large safety margin of ABHSs, emergency physicians need to be aware of the potential risk of ingestion of a large amount of such products in children and consider it in the assessment and management of school-age children with acute AMS.

Sudden cardiac death following blunt chest trauma: commotio cordis

Robert J Douglas

2011, 2(3):  234-236.  doi:10.5847/wjem.j.1920-8642.2011.03.015

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BACKGROUND: There have been numerous reports of sudden cardiac death attributable to the condition of commotio cordis. Primarily, these are reports from the USA. Although three Australian cases have been mentioned in the published literature, the present case appears to be the first described Australian case.
METHODS: A man was brought to the Emergency Department after sudden collapse while playing cricket. His medical history was suggestive of hitting by a cricket ball while batting.
RESULTS: The epidemiology and mechanism of arrhythmia induction in commotio cordis are discussed. The emergency management of commotio cordis is outlined.
CONCLUSIONS: Commotio cordis is rare in sports (and Emergency Medicine). However it has a high mortality rate, and rapid recognition of the condition allows early defibrillation, generally with a good outcome. The improvement of participant care is recommended at community and other sport events.