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Table of Content

    15 December 2011, Volume 2 Issue 4
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    Special Article
    Emergency medicine in China: present and future
    Y. Veronica Pei, Feng Xiao
    2011, 2(4):  245-252.  doi:10.5847/wjem.j.1920-8642.2011.04.001
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    BACKGROUND: Emergency medicine was inaugurated, as an official specialty in China, only 25 years ago, and its growth in clinical practice and academic development since that time have been remarkable.
    METHODS: This paper is a critical and descriptive review on current situations in emergency medicine in China, based on the literature review, personal observations, interviews with many Chinese emergency medicine doctors and experts, and personal experience in both China and USA.
    RESULTS: The current practice of emergency medicine in China encompasses three areas: pre-hospital medicine, emergency medicine, and critical care medicine. Most tertiary emergency departments (EDs) are structurally and functionally divided into several clinical areas, allowing the ED itself to function as a small independent hospital. While Chinese emergency physicians receive specialty training through a number of pathways, national standards in training and certification have not yet been developed. As a result, the scope of practice for emergency physicians and the quality of clinical care vary greatly between individual hospitals. Physician recruitment, difficult working conditions, and academic promotion remain as major challenges in the development of emergency medicine in China.
    CONCLUSION: To further strengthen the specialty advancement, more government leadership is needed to standardize regional training curriculums, elucidate practice guidelines, provide funding opportunities for academic development in emergency medicine, and promote the development of a system approach to emergency care in China.

    Review Articles
    Demand for hospital emergency departments: a conceptual understanding
    Jun He, Xiang-yu Hou, Sam Toloo, Jennifer R Patrick, Gerry Fitz Gerald
    2011, 2(4):  253-261.  doi:10.5847/wjem.j.1920-8642.2011.04.002
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    BACKGROUND: Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to influence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs.
    DATA SOURCES: Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand.
    RESULTS: Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship.
    CONCLUSION: This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.

    Spinal cord stimulation for patients with inoperable chronic critical leg ischemia
    Xiao-pei Chen, Wei-min Fu, Wei Gu
    2011, 2(4):  262-266.  doi:10.5847/wjem.j.1920-8642.2011.04.003
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    BACKGROUND: Because of the prevalence of diabetes, the treatment of diabetic foot is still challenging. Even an exactly proved effective and practical method can’t be listed except vascular surgery which is not a long-term way for it. Spinal cord stimulation (SCS) is a very promising option in the treatment algorithm of inoperable chronic critical leg ischemia (CLI).
    DATA SOURCES: We searched Pubmed database with key words or terms such as “spinal cord stimulation”, “ischemic pain” and “limb ischemia” appeared in the last five years.
    RESULTS: The mechanism of SCS is unclear. Two theories have emerged to interpret the benefits of SCS. Pain relief from SCS can be confirmed by a majority of the studies, while limb salvage and other more ambitious improvements have not come to an agreement. The complications of SCS are not fatal, but most of them are lead migration, lead connection failure, and local infection.
    CONCLUSIONS: SCS is a safe, promising treatment for patients with inoperable CLI. It is effective in pain reduction compared with traditional medical treatment.

    Original Article
    Medical care delivery at the Beijing 2008 Olympic Games
    Jin-jun Zhang, Li-dong Wang, Zhi Chen, Jun Ma, Jian-ping Dai
    2011, 2(4):  267-271.  doi:10.5847/wjem.j.1920-8642.2011.04.004
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    BACKGROUND: Beijing successfully hosted the 2008 Olympic Games, and the services including medical services were widely appreciated by both participants and visitors. We retrospectively analyzed the quality of the medical services provided to athletes, spectators, VIPs, and the workforce during the Beijing 2008 Olympic Games. The information thus gathered would be useful for planning strategies for managing mass gatherings.
    METHODS: Medical encounter forms filled during the Beijing 2008 Olympic Games were retrospectively reviewed. Descriptive statistics was used to characterize the data by accreditation and diagnostic categories.
    RESULTS: A total of 22 892 medical encounters were documented during the Beijing 2008 Olympic Games. Among them, 10 549 (46.08%) involved the workforce, 3 365 (14.70%) athletes, 3 019 (13.19%) spectators, 585 (2.56%) members of the media, 1 065 (4.65%) VIPs, and 4 309 (18.82%) others. Of the 22 892 cases, physical injury accounted for 27.90% (6 386), respiratory disease 18.21% (4 169), and heat-related illnesses 2.68% (615).
    CONCLUSIONS: Preparations of the medical service for the Beijing 2008 Olympic Games were made for 7 years, and the service provided has been praised worldwide. This study provides valuable information that may be useful for planning medical services for upcoming Olympic Games, including the London 2012 Olympic Games and other mass gatherings.

    Can we predict which patients with community-acquired pneumonia are likely to have positive blood cultures?
    Samuel George Campbell, R. Andrew McIvor, Vincent Joanis, David Graydon Urquhart
    2011, 2(4):  272-278.  doi:10.5847/wjem.j.1920-8642.2011.04.005
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    BACKGROUND: Blood cultures (BC ) are commonly ordered during the initial assessment of patients with community-acquired pneumonia (CAP), yet their yield remains low. Selective use of BC would allow the opportunity to save healthcare resources and avoid patient discomfort. The study was to determine what demographic and clinical factors predict a greater likelihood of a positive blood culture result in patients diagnosed with CAP.
    METHODS: A structured retrospective systematic chart audit was performed to compare relevant demographic and clinical details of patients admitted with CAP, in whom blood culture results were positive, with those of age, sex, and date-matched control patients in whom blood culture results were negative.
    RESULTS: On univariate analysis, eight variables were associated with a positive BC result. After logistic regression analysis, however, the only variables statistically significantly associated with a positive BC were WBC less than 4.5 x 109/L [likelihood ratio (LR): 7.75, 95% CI=2.89-30.39], creatinine >106 μmol/L (LR: 3.15, 95%CI=1.71-5.80), serum glucose<6.1 mmol/L (LR: 2.46, 95%CI=1.14-5.32), and temperature > 38 °C (LR: 2.25, 95% CI =1.21-4.20). A patient with all of these variables had a LR of having a positive BC of 135.53 (95% CI=25.28-726.8) compared to patients with none of these variables.
    CONCLUSIONS: Certain clinical variables in patients with CAP admitted to hospitals do appear to be associated with a higher probability of a positive yield of BC, with combinations of these variables increasing this likelihood. We have identified a subgroup of CAP patients in whom blood cultures are more likely to be useful.

    Application of emergency severity index in pediatric emergency department
    Lei Wang, Hong Zhou, Jing-fang Zhu
    2011, 2(4):  279-282.  doi:10.5847/wjem.j.1920-8642.2011.04.006
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    BACKGROUND: The purpose of triage is to identify patients needing immediate resuscitation, to assign patients to a pre-designed patient care area, and to initiate diagnostic/therapeutic measures as appropriate. This study aimed to use emergency severity index (ESI) in a pediatric emergency room.
    METHODS: From July 2006 to August 2010, a total of 21 904 patients visited the International Department of Beijing Children's Hospital. The ESI was measured by nurses and physicians, and compared using SPSS.
    RESULTS: Nurses of the hospital took approximately 2 minutes for triage. The results of triage made by nurses were similar to those made by doctors for ESI in levels 1-3 patients. This finding indicated that the nurses are able to identify severe pediatric cases.
    CONCLUSION: In pediatric emergency rooms, ESI is a suitable tool for identifying severe cases and then immediate interventions can be performed accordingly.

    Artificial liver support system in treatment of liver failure after acute poisoning
    Li-gang Chen, Bayasi Guleng, Jian-lin Ren, Jian-min Chen, Lin Wang
    2011, 2(4):  283-286.  doi:10.5847/wjem.j.1920-8642.2011.04.007
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    BACKGROUND: Acute poisoning (AP) may cause failure of the liver and kidney, and even death. This study aimed to investigate the efficacy of artificial liver support system (ALSS) on the treatment of liver failure after acute poisoning.
    METHODS: A total of 31 patients with liver failure caused by AP were admitted to emergency ICU, central ICU, and Department of Gastroenterology from 2005 to 2009 in Zhongshan Hospital Affiliated to Xiamen University, China. Among them, 13 patients served as a treatment group, and used ALSS in addition to detoxification treatment and protective treatment of liver function, and the other 18 patients served as a control group receiving detoxification treatment and protective treatment of liver function.
    RESULTS: In the treatment group, 10 patients (76.9%) were cured or improved, 2 died, and 1 was discharged against advice. In the 18 patients in the control group, 7 (38.9%) were cured or improved, 3 died, and 8 were discharged against advice. There was a significant difference in the rates of improvement between the two groups (P<0.05).
    CONCLUSION: ALSS is a safe and effective clinical method for the treatment of acute toxic liver failure.

    Early changes of plasma angiopoietin-2 in patients with multiple trauma
    Hai-bin Weng, Sen Li
    2011, 2(4):  287-290.  doi:10.5847/wjem.j.1920-8642.2011.04.008
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    BACKGROUND: This study was undertaken to investigate the early changes of plasma levels of angiopoietin-2 (Ang-2) in patients with multiple trauma and the relations of plasma Ang-2, endothelial injury, and prognosis.
    METHODS: This study comprised 59 patients with multiple trauma who had been treated at the emergency department of Liao Cheng People′s Hospital from January 2008 to January 2010. Among them, 36 were male and 23 female. Their average age was 32.3±11.5 years. The 59 patients were divided into a severe trauma group (ISS≥16 points, 29 patients) and a slight trauma group (ISS<16 points, 30 patients) by injury severity score (ISS). Thirty healthy people aged more than 18 years with an average of 33.5±10.6 years served as controls (19 male and 11 female). Peripheral blood (10 mL) was collected within 10 minutes after the patients arrived at the emergency department, and plasma was separated from the blood. Enzyme-linked immunosorbent assay (ELISA) was applied to detect the levels of angiopoietin 2, thrombomodulin (TM), and Von willebrand factor (vWF).
    RESULTS: The level of Ang-2 in the severe trauma group (ISS score≥16 points) was significantly higher than that in the slight trauma group (ISS score<16 points) (P<0.05). The levels in the two groups were significantly higher than those in the control group (P<0.05). The levels of angiopoietin-2 in deaths were significantly higher than those in survivors (P<0.05). The levels of angiopoietin-2 were significantly correlated with the levels of vWF and TM (P<0.05).
    CONCLUSIONS: The plasma levels of Ang-2 are significantly higher after multiple trauma, and correlated with the degree of trauma severity. The levels of angiopoietin-2 are correlated with endothelial injury after multiple trauma, and are important values for the prognosis of patients with multiple trauma.

    Effect of exogenous phosphocreatine on cardiomycytic apoptosis and expression of Bcl-2 and Bax after cardiopulmonary resuscitation in rats
    Ping Yan, Shou-quan Chen, Zhang-ping Li, Jie Zhang, Ji-ke Xue, Wan-tie Wang, Wei-jia Huang, Jun-yan Cheng, Hui-ping Li
    2011, 2(4):  291-295.  doi:10.5847/wjem.j.1920-8642.2011.04.009
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    BACKGROUND: Ischemia-reperfusion injury in the myocardium after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) is an important pathologic basis of post-cardiac arrest of syndrome (PCAS), and apoptosis is one of the major mechanisms in myocardial ischemia-reperfusion injury. To lessen myocardial ischemia-reperfusion injury after cardiac arrest and CPR, it is important to reduce energy consumption and to increase energy supply in the myocardium. This study aimed to observe changes of cell apoptosis and expression of Bcl-2 and Bax protein on the myocardium after CPR in rats, and the protective effects of different doses of exogenous phosphocreatine (creatine phosphate, CP) on them.
    METHODS: A total of 32 male adult Sprague-Dawley rats were randomly divided into 4 groups: control group (group A), CPR group (group B), low-dose CP group (group C, CP 0.5 g/kg at beginning of CPR and 1.0 g/kg at 2 hours after CPR) and high-dose CP group (group D, CP 1.0 g/kg at beginning of CPR and 2.0 g/kg at 2 hours after CPR). Cardiac arrest was induced by asphyxiation and CPR started at 7 minutes after asphyxiation in groups B, C and D. Myocardium samples were taken at 24 hours after CPR. Cardiomycytic apoptosis was detected by the TdT-mediated dUTP-biotin nick end labeling (TUNEL) method. The expression of Bcl-2 and Bax protein was measured by immunohistochemistry.
    RESULTS: Cardiomyocytic apoptosis index (AI) and expression of Bcl-2 and Bax protein increased more significantly in groups B, C and D than in group A (P<0.01), but Bcl-2/Bax ratio significantly decreased (P<0.01). Cardiomyocytic AI and expression of Bcl-2 and Bax protein decreased more significantly in groups C and D than in group B (P<0.01), but Bcl-2/Bax ratio increased more significantly (P<0.01). Cardiomyocytic AI and expression of Bcl-2 and Bax protein decreased more significantly in group D than in group C (P<0.05), but Bcl-2/Bax ratio increased more significantly (P<0.05).
    CONCLUSION: Exogenous phosphocreatine, especially at a large dose, could inhibit cardiomyocytic apoptosis and alleviate myocardial injury after CPR in rats.

    Effects of pulmonary stretch reflex on lung injury in rabbits with acute respiratory distress syndrome
    Xiao-yan Wu, Ying-zi Huang, Huo-gen Liu, Dong-ya Huang, Rui Tang, Hai-bo Qiu
    2011, 2(4):  296-301.  doi:10.5847/wjem.j.1920-8642.2011.04.010
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    BACKGROUND: Pulmonary stretch reflex plays an important role in regulation of respiratory movement. This study aimed to evaluate the effect of pulmonary stretch reflex on lung injury in rabbits with acute respiratory distress syndrome (ARDS).
    METHODS: ARDS rabbits were given intratracheal infusion of hydrochloric acid and ventilated with neurally adjusted ventilatory assistance (NAVA) with a tidal volume (VT) of 6 mL/kg and the electrical activity of diaphragm (EAdi)-determined positive end expiratory pressure. After isolation of the bilateral vagus nerve trunk, the rabbits were randomized into two groups: sham operation (SHAM) group (n=5) and bilateral vagotomy (VAG) group (n=5). Gas exchange and respiratory mechanics were detected at baseline, after lung injury and 1, 2, and 3 hours after ventilation respectively. Pulmonary permeability index, pathological changes and inflammatory response were also measured.
    RESULTS: Compared with the SHAM group, PaO2/FiO2 in the VAG group decreased significantly 2 and 3 hours after ventilation (P<0.05). There was no significant difference in PaCO2 between the SHAM and VAG groups (P>0.05), and the VAG group had a high VT, peak pressure (Ppeak), and mean pressure (Pm) compared with the SHAM group 1, 2, 3 hours after ventilation (P<0.05). Compared to the SHAM group, dead space fraction (VD/VT) and respiratory system elastance (Ers) in the VAG group increased (P<0.05) and static pulmonary compliance (Cst) decreased markedly (P<0.05) after ventilation for 3 hours. Lung wet/dry weight ratio (W/D) (8.4±1.2 vs. 6.6±1.0), lung injury score (6.3±1.8 vs. 3.8±1.3), tumor necrosis factor-α (TNF-α) (779±372 pg/mL vs. 355±130 pg/mL) and interleukin-8 (IL-8) (169±21 pg/mL vs. 118±17 pg/mL) increased significantly in the VAG group compared with the SHAM group (P<0.05).
    CONCLUSION: Lung injury is aggravated after bilateral vagotomy, demonstrating that pulmonary stretch reflex may have protective effect on the lung.

    Expression of high mobility group protein B1 in the lungs of rats with sepsis
    Qiao-meng Qiu, Zhong-wang Li, Lu-ming Tang, Qi Sun, Zhong-qiu Lu, Huan Liang, Guang-liang Hong, Meng-fang Li
    2011, 2(4):  302-306.  doi:10.5847/wjem.j.1920-8642.2011.04.011
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    BACKGROUND: Vibrio vulnificus inside the body could activate the NF-κB signaling pathway and initiate the inflammatory cascade. The lung is one of the earliest organs affected by sepsis associated with acute lung injury. High mobility group protein B1 (HMGB1) is an important late-acting pro-inflammatory cytokine involving in the pathophysiology of sepsis. It is also involved in the injury process in the lung, liver and intestine. There has been no report on the involvement of HMGB1 in Vibrio vulnificus sepsis-induced lung injury.
    METHODS: Sixty rats were randomly divided into a normal control group (group A, n=10) and a Vibrio vulnificus sepsis group (group B, n=50). Sepsis was induced in the rats by subcutaneous injection of Vibrio vulnificus (concentration 6×108 cfu/mL, volume 0.1 mL/100g)) into the left lower limbs. The rats in group B were sacrificed separately 1, 6, 12, 24, and 48 hours after the infection. Their lungs were stored as specimens, lung water content was measured, and lung pathology was observed under a light microscope. The expressions of the HMGB1 gene and protein in the lungs were detected by RT-PCR and Western blot. Data were analyzed with one-way analysis of variance (ANOVA) and the LSD method for pair-wise comparison between the two groups. P<0.05 was considered statistically significant.
    RESULTS: Compared to group A (0.652±0.177), HMGB1 mRNA expression in the lungs of group B was significantly higher at 0 hour (1.161±0.358, P=0.013), 24 hours (1.679±0.235, P=0.000), and 48 hours (1.258±0.274, P=0.004) (P<0.05), and peaked at 24 hours. Compared to group A (0.594±0.190), HMGB1 protein expression at 6 hours (1.408±0.567, P=0.026) after infection was significantly increased (P<0. 05), and peaked at 24 hours (2.415±1.064, P=0.000) after infection. Compared to group A (0.699±0.054), lung water content was significantly increased at 6 hours (0.759±0.030, P=0.001),12 hours (0.767±0.023, P=0.000), 24 hours (0.771±0.043, P=0.000) and 48 hours (0.789±0.137, P=0.000) after infection (P<0.05). Compared to group A, pathological changes at 12 hours in group B indicate marked pulmonary vascular congestion, interstitial edema and inflammatory infiltration. Alveolar cavity collapse and boundaries of the alveolar septum could not be clearly identified.
    CONCLUSION: Vibrio vulnificus sepsis can lead to injury in rat lungs, and increased HMGB1 expression in lung tissue may be one of the mechanisms for injury from Vibrio vulnificus sepsis.

    Case Reports
    Is tracheostomy suitable for securing airway after facial firearm injuries?
    Derinoz Oksan, Belen F. Burcu, Yılmaz Sebahat
    2011, 2(4):  307-309.  doi:10.5847/wjem.j.1920-8642.2011.04.012
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    BACKGROUND: Head and neck region have many vital structures, and facial firearm injuries (FFIs) more likely lead to life-threatening situations than other body injuies. These injuries have high potential of airway compromise associated with significant morbidity and mortality.
    METHODS: We describe an 11-year-old boy who had received tracheostomy after a FFI complicated with pneumothorax and subcutaneous emphysema 8 hours after the procedure. The patient was treated at the Department of Emergency and Critical Care, Gazi University School of Medicine, Turkey.
    RESULTS: The patient was discharged without any complications from the Critical Care Unit after treatment for five days.
    CONCLUSIONS: Airway management is of utmost importance in resuscitation of FFI, but it is always difficult to secure via the orotracheal route due to the deformed facial structures. Tracheostomy is an option for airway management in FFI affecting head and neck region. However, tracheostomy may be associated with life-threatening complications, which should be closely monitored with early intervention.

    Oral acyclovir induced acute renal failure
    Jian-biao Meng, Xia Zheng, Gen Zhang, Qiang Fang
    2011, 2(4):  310-313.  doi:10.5847/wjem.j.1920-8642.2011.04.013
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    BACKGROUND: The study aimed to investigate the clinical characteristics of acute renal failure (ARF) caused by oral acyclovir.
    METHODS: A 45-year-old Chinese male patient with acyclovir-induced ARF suffered from abdominal pain for one day. The pain was extended to the epigastric area from the right lower quadrant. Transient oliguria was seen in addition to microscopic hematuria and proteinuria. The serum creatinine concentration was 304 μmol/L. Eight days before the occurrence of ARF, the patient took oral acyclovir for facial neuritis.
    RESULTS: His renal function was restored completely following the discontinuation of acyclovir, with continuous renal replacement therapy for 54 hours and some symptomatic treatment.
    CONCLUSION: The presentation of acute renal failure caused by acyclovir can be diverse, but the prognosis is good after active treatment.