Table of Content

15 September 2017, Volume 8 Issue 3

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Original Articles

Emergency department procedural sedation for primary electrical cardioversion — a comparison with procedural sedations for other reasons

Michael Butler, Patrick Froese, Peter Zed, George Kovacs, Robert MacKinley, Kirk Magee, Mary-Lynn Watson, Samuel G. Campbell

2017, 8(3):  165-169.  doi:10.5847/wjem.j.1920-8642.2017.03.001

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BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED), with primary electrical cardioversion (PEC) the preferred method of rhythm control. Anecdotally, patients undergoing ED procedural sedation (EDPS) for PEC differ from those requiring EDPS for other procedures: they are at higher risk of adverse events, and require fewer drugs and lower doses. We attempt to verify this using an EDPS registry at a Canadian, tertiary care teaching hospital.

METHODS: This is a retrospective review of patients that underwent EDPS for the period of June 2006 to September 2014. We compared demographics, medication use and intra-procedural adverse events between those receiving EDPS for PEC for AF compared to that for other indications. We report the asssociation between AEs and predictors using logistic regression.

RESULTS: A total of 4 867 patients were included, 714 for PEC for AF and 4 153 for other indications. PEC patients were more likely male (58.5% vs. 47.1%), older (59.5 years vs. 48.1 years), and less likely to be ASA I (46.6% vs. 69.0%). PEC patients received smaller doses of propofol and less likely to receive adjuvant analgesic therapy (11.5% vs. 78.2%). PEC patients were more likely to experience hypotension (27.6% vs. 16.5%) but respiratory AEs (apnea, hypoxia and airway intervention) were not different.

CONCLUSION: EDPS for PEC differs from that conducted for other purposes: patients tend to be less healthy, receive smaller doses of medication and more likely to suffer hypotension without an increase in respiratory AEs. These factors should be considered when performing EDPS.

The presenting and prescribing patterns of migraine in an Australian emergency department: A descriptive exploratory study

Emily Shao, James Hughes, Rob Eley

2017, 8(3):  170-176.  doi:10.5847/wjem.j.1920-8642.2017.03.002

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BACKGROUND: Migraine is a common neurological condition that frequently presents to the emergency department (ED). Many medications are available to treat migraine. This study aims to characterize the demographics of patients who present to a large metropolitan ED with migraine, and to identify the medications used in treating this condition.

METHODS: This study is a retrospective database interrogation of clinical records, used to collect quantitative data on patient demographics and medication prescriptions in the ED.

RESULTS: A total of 2 228 patients were identified as being treated for migraine over a 10-year period. The proportion of the ED population presenting with migraine steadily increased in this time. Females (71%) more commonly presented to the ED with migraine than males. The migraine population was significantly younger (M=37.05, SD=13.23) than the whole ED population (M=46.17 SD=20.50) (P<0.001). A variety of medications were used in the treatment of migraine in the ED. Simple analgesics such as paracetamol and ibuprofen, anti-emetics and intravenous (IV) fluids with phenothiazine additives were commonly used. Over 20% of patients were prescribed oral or parenteral opiates (42 of 194 initial medication prescriptions, and 64 of 292 as required medication prescriptions). Triptans were very rarely used.

CONCLUSION: Migraine is an increasingly common presentation to the ED. People presenting to the ED with migraine are more likely to be younger and female than the general ED population. Peak presentations for migraines occurred in January and February. The medications that are prescribed in the ED for migraine is varied and are not always in line with current evidence for the treatment of migraine. The excessive reliance on opiates and lack of the use of triptans denotes a significant variation from published guidelines.

Comparison of ultrasound-measured properties of the common carotid artery to tobacco smoke exposure in a cohort of Indonesian patients

Allen R. Yu, Bima Hasjim, Luke E. Yu, Christopher Gabriel, Alexander Anshus, Jonathan B. Lee, Michael J. Louthan, Esther C. Kim, Katrina Lee, Christina Tse, Thomas Keown, Shadi Lahham, Maili Alvarado, Steven Bunch, Abdulatif Gari, J. Christian Fox

2017, 8(3):  177-183.  doi:10.5847/wjem.j.1920-8642.2017.03.003

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BACKGROUND: The purpose of this study was to use point-of-care ultrasound (POCUS) to investigate the relationship between tobacco smoke exposure and the characteristics of the common carotid artery (CCA). The effect of both primary and secondary smoking on CCA properties was evaluated.

METHODS: We performed a prospective cross-sectional study across 20 primary care clinics in Bandung, West Java, Indonesia in July 2016. Point of care ultrasound was performed on a convenience sample of Indonesian patients presenting to clinic. The CCA wall stiffness and carotid intima-media thickness (CIMT) were measured during diastole and systole. These measurements were correlated with smoke exposure and cardiovascular disease.

RESULTS: We enrolled 663 patients in the study, with 426 patients enrolled in the smoking category and 237 patients enrolled in the second-hand smoke category. There was an overall positive correlation with the measured lifestyle factors and the ultrasound-measured variables in the group of individuals who smoked. For all variables, age seemed to contribute the most out of all of the lifestyle factors for the positive changes in CIMT and CCA wall stiffness.

CONCLUSION: Our data yielded correlations between CCA properties and cardiovascular risk, as well as between CIMT and arterial stiffness. We were also able to demonstrate an increase in thickness of the CIMT in patients who have been exposed by tobacco through the use of ultrasound. Further large scale studies comparing patients with multiple cardiac risk factors need to be performed to confirm the utility of ultrasound findings of cardiovascular disease and stroke.

Validating a point of care lactate meter in adult patients with sepsis presenting to the emergency department of a tertiary care hospital of a low- to middle-income country

Muhammad Akbar Baig, Hira Shahzad, Erfan Hussain, Asad Mian

2017, 8(3):  184-189.  doi:10.5847/wjem.j.1920-8642.2017.03.004

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BACKGROUND: Timely identification of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care (POC) testing is being increasingly utilized in the emergency department (ED). We examined the accuracy and time-saving effect of a handheld POC lactate device for the measurement of fingertip and whole blood lactate as compared with reference laboratory blood testing in septic ED patients.

METHODS: A convenience sample of adult ED patients receiving serum lactate testing were enrolled prospectively in the ED of a multidisciplinary tertiary care hospital serving the population of one of the major cities of Pakistan. Participants underwent fingertip POC lactate measurement with a portable device and simultaneous whole blood sampling for analysis by both the POC lactate device and standard laboratory method. Lactate measurements were compared by intraclass correlation (ICC) and Bland and Altman plots.

RESULTS: Forty-three septic patients were included in the study. The fingertip POC & whole blood POC lactate measurements each correlated tightly with the reference method (ICC=0.93 & ICC=0.92, respectively). Similarly at 6 hours, the fingertip POC & whole blood POC lactate measurements demonstrated satisfactory correlation with the reference method (ICC=0.95 & ICC=0.97, respectively).

CONCLUSION: Fingertip POC lactate measurement is an accurate method to determine lactate levels in septic ED patients.

Can patients with non-convulsive seizure be identified in the emergency department?

Gholamreza Sadeghipoor Roodsari, Geetha Chari, Bryan Mera, Shahriar Zehtabchi

2017, 8(3):  190-194.  doi:10.5847/wjem.j.1920-8642.2017.03.005

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BACKGROUND: Non-convulsive seizure (NCS) is an underdiagnosed, potentially treatable emergency with significant mortality and morbidity. The objective of this study is to examine the characteristics of patients with NCS presenting with altered mental status (AMS) and diagnosed with electroencephalography (EEG), to identify the factors that could increase the pre-test probability of NCS.

METHODS: Retrospective study using the data collected prospectively. Inclusion criteria: patients older than 13 years with AMS. Exclusion criteria: (1) immediately correctable AMS (e.g., hypoglycemia, opiod overdose); (2) inability to undergo EEG; (3) hemodynamic instability. Outcomes compared between NCS and non-NCS cases: vital signs, lactate level, gender, witnessed seizure, use of anticonvulsive in the field or in the ED, history of seizure or stroke, head injury, abnormal neurological finding and new abnormal findings on head CT. Data presented as medians and quartiles for categorical and percentages with 95%CI for continuous variables. Univariate analyses were performed with Man-Whitney U and Fisher's Exact tests. A multivariate analysis model was used to test the predictive value of clinical variables in identifying NCS.

RESULTS: From 332 patients (median age 66 years, quartiles 50-78), 16 were diagnosed with NCS (5%, 95%CI 3%-8%). Only age was significantly different between the NCS vs. non-NCS groups in both univariate (P=0.032) and multivariate analyses (P=0.016).

CONCLUSION: Other than age, no other clinically useful variable could identify patients at high risk of NCS. ED physicians should have a high suspicion for NCS and should order EEG for these patients more liberally.

Study on the development and usage of a cardiopulmonary resuscitation time point recorder

Ling Zhou, Hui Li, Hong-yan Wei, Chun-lin Hu, Xiao-li Jing, Hong Zhan, Xiao-xing Liao, Xin Li

2017, 8(3):  195-199.  doi:10.5847/wjem.j.1920-8642.2017.03.006

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BACKGROUND: To invent a novel cardiopulmonary resuscitation (CPR) time point recorder to synchronously and automatically record the time and to identify its effectiveness in humans.

METHODS: A CPR time point recorder was invented after the doctors were familiar with the traditional Utstein recovery registration mode and mastered the registration time points required. The progress of CPR was simulated. The standard and correct times were recorded, and the doctors performing the recovery collected the data about the times using our CPR time point recorder or the memory registration mode.

RESULTS: The deviation times were 21.4±24.7 seconds for the memory group and 3.57±4.58 seconds for CPR time point recorder group. The deviation of times increased significantly depending on the increase of the operation items in the memory group. A similar phenomenon was found in the timer group but with a smaller difference (P<0.01).

CONCLUSION: A CPR time point recorder could reduce the deviation of operate-time, especially after a long-time operation, and for procedures with more operating items, compared with the memory mode. It was a more advantageous and accurate method for the Utstein registration.

Out of hospital cardiac arrest resuscitation outcome in North India — CARO study

Chennappa Kalvatala Krishna, Hakim Irfan Showkat, Meenakshi Taktani, Vikram Khatri

2017, 8(3):  200-205.  doi:10.5847/wjem.j.1920-8642.2017.03.007

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BACKGROUND: To evaluate the outcome of cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrests (OHCA) in India and factors influencing the outcome.

METHODS: The outcome and related factors like demographics, aspects of the OHCA event, return of spontaneous circulation (ROSC) and survival to discharge, among the 80 adult patients presenting to emergency department experiencing OHCA considered for resuscitation between January 2014 to April 2015, were analyzed, according to the guidelines of the Utstein consensus conference.

RESULTS: The survival rate to hospital admission was 32.5%, the survival rate to hospital discharge was 8.8% and with good cerebral performance category (CPC1) neurological status was 3.8%. Majority of OHCA was seen in elderly individuals between 51 to 60 years, predominately in males. Majority of OHCA were witnessed arrests (56.5%) with 1.3% bystander CPR rate, 92.5% arrests occurred at home, 96% presented with initial non-shockable rhythm and 92.5% with presumed cardiac etiology but survival was better in those who experienced OHCA at public place, in witnessed arrests, in patients who had shockable presenting rhythm and in those where CPR duration was ≤20 minutes.

CONCLUSION: Witnessed arrests, early initiation of CPR by bystanders, CPR duration ≤20 minutes, initial presenting shockable rhythm, OHCA with non-cardiac etiology are associated with a good outcome. To improve the outcome of CPR and the low survival rates after an OHCA event in India, focused strategies should be designed to set up an emergency medical system (EMS), to boost the rates of bystander CPR and education of the lay public in basic CPR.

The Affordable Care Act: Disparities in emergency department use for mental health diagnoses in young adults

Justin Yanuck, Bryson Hicks, Craig Anderson, John Billimek, Shahram Lotfipour, Bharath Chakravarthy

2017, 8(3):  206-213.  doi:10.5847/wjem.j.1920-8642.2017.03.008

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BACKGROUND: There is little consensus as to the effects of insurance expansion on emergency department (ED) utilization for mental health purposes. We aimed to study the race specific association between the dependent coverage provision of the Affordable Care Act (ACA) and changes in young adults' usage of emergency department services for psychiatric diagnoses.

METHODS: We utilized a Quasi-Experimental analysis of ED use in California from 2009-2011 for behavioral health diagnoses of individuals aged 19 to 31 years. Analysis used a difference-in-differences approach comparing those targeted by the ACA dependent provision (19-25 years) and those who were not (27 to 31 years), evaluating changes in ED visit rates per 1 000 in California. Primary outcomes measured included the quarterly ED visit rates with any psychiatric diagnosis. Subgroups were analyzed for differences based on race and gender.

RESULTS: The ACA dependent provision was associated with 0.05 per 1 000 people fewer psychiatric ED visits among the treatment group (19-25 years) compared to the control group (27-31 years). Hispanics and Asian/Pacific Islanders were the only racial subgroups who did not see this significant reduction and were the only racial subgroups that did not see significant gains in the proportion of psychiatric ED visits covered by private insurance.

CONCLUSION: The ACA dependent provision was associated with a modest reduction in the growth rate of ED use for psychiatric reasons, however, racial disparities in the effect of this provision exist for patients of Hispanic and Asian/Pacific Islander racial groups.

Association of post-traumatic stress disorder and work performance: A survey from an emergency medical service, Karachi, Pakistan

Salima Kerai, Omrana Pasha, Uzma Khan, Muhammad Islam, Nargis Asad, Junaid Razzak

2017, 8(3):  214-222.  doi:10.5847/wjem.j.1920-8642.2017.03.009

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BACKGROUND: The purpose of the study was to explore the association between post-traumatic stress disorder (PTSD) and work performance of emergency medical services personnel in Karachi, Pakistan.

METHODS: Emergency medical service personnel were screened for potential PTSD using Impact of Event Scale-Revised (IES-R). Work performance was assessed on the basis of five variables: number of late arrivals to work, number of days absent, number of days sick, adherence to protocol, and patient satisfaction over a period of 3 months. In order to model outcomes like the number of late arrivals to work, days absent and days late, negative binomial regression was applied, whereas logistic regression was applied for adherence to protocol and linear for patient satisfaction scores.

RESULTS: Mean scores of PTSD were 24.0±12.2. No association was found between PTSD and work performance measures: number of late arrivals to work (RRadj 0.99; 0.98-1.00), days absent (RRadj 0.98; 0.96-0.99), days sick (RRadj 0.99; 0.98-1.00), adherence to protocol (ORadj 1.01; 0.99-1.04) and patient satisfaction (β 0.001%-0.03%) after adjusting for years of formal schooling, living status, coping mechanism, social support, working hours, years of experience and anxiety or depression.

CONCLUSION: No statistically significant association was found between PTSD and work performance amongst EMS personnel in Karachi, Pakistan.

Validation of different pediatric triage systems in the emergency department

Kanokwan Aeimchanbanjong, Uthen Pandee

2017, 8(3):  223-227.  doi:10.5847/wjem.j.1920-8642.2017.03.010

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BACKGROUND: Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department.

METHODS: This was a prospective observational study. This study was divided into two phases. The first phase determined the inter-rater reliability of five triage systems: Manchester Triage System (MTS), Emergency Severity Index (ESI) version 4, Pediatric Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), and Ramathibodi Triage System (RTS) by triage nurses and pediatric residents. In the second phase, to analyze the validity of each triage system, patients were categorized as two groups, i.e., high acuity patients (triage level 1, 2) and low acuity patients (triage level 3, 4, and 5). Then we compared the triage acuity with actual admission.

RESULTS: In phase I, RTS illustrated almost perfect inter-rater reliability with kappa of 1.0 (P<0.01). ESI and CTAS illustrated good inter-rater reliability with kappa of 0.8-0.9 (P<0.01). Meanwhile, ATS and MTS illustrated moderate to good inter-rater reliability with kappa of 0.5-0.7 (P<0.01). In phase II, we included 1 041 participants with average age of 4.7±4.2 years, of which 55% were male and 45% were female. In addition 32% of the participants had underlying diseases, and 123 (11.8%) patients were admitted. We found that ESI illustrated the most appropriate predicting ability for admission with sensitivity of 52%, specificity of 81%, and AUC 0.78 (95%CI 0.74-0.81).

CONCLUSION: RTS illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system.

Case Letters

A case of exercise induced rhabdomyolysis from calf raises

Jeffrey Gardecki, Henry Schuitema, James Espinosa, Alan Lucerna

2017, 8(3):  228-230.  doi:10.5847/wjem.j.1920-8642.2017.03.011

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Blunt injury to the thyroid gland: A case of delayed surgical emergency

Geraud Galvaing, Julien Brehant

2017, 8(3):  231-232.  doi:10.5847/wjem.j.1920-8642.2017.03.012

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Ocular mutilation: A case of bilateral self-evisceration in a patient with acute psychosis

Amar Pujari, Neelam Pushker, Milind Changole, Ritika Mukhija

2017, 8(3):  233-234.  doi:10.5847/wjem.j.1920-8642.2017.03.013

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Iatrogenic Horner's syndrome: A cause for diagnostic confusion in the emergency department

Kolar Vishwanath Vinod, Vanjiappan Sivabal, Mysore Venkatakrishna Vidya

2017, 8(3):  235-236.  doi:10.5847/wjem.j.1920-8642.2017.03.014

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Instructions for Authors

Instructions for Authors

2017, 8(3):  237-240. 

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