Table of Content

15 December 2015, Volume 6 Issue 4

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Consensus

Expert consensus on the perioperative management of patients with sepsis

Chinese Association of Anesthesiologists

2015, 6(4):  245-260.  doi:10.5847/wjem.j.1920-8642.2015.04.001

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Editorial

Community emergency medicine: Benefits and challenges of screening for elder abuse in the emergency department of a developing country

Muhammad Akbar Baig, Asad Mian, Erfaan Hussain, Shahan Waheed

2015, 6(4):  261-264.  doi:10.5847/wjem.j.1920-8642.2015.04.002

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Original Articles

A cross-sectional study of children with acute poisoning: A three-year retrospective analysis

Tigist Bacha, Birkneh Tilahun

2015, 6(4):  265-269.  doi:10.5847/wjem.j.1920-8642.2015.04.003

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BACKGROUND: There is a lack of evidence on description of burden and cases of childhood poisoning in developing countries. This study aimed to assess the characteristics of children with acute poisoning, and factors for time of presentation to health facility and nature of poisoning.
METHODS: A cross-sectional study was conducted at three major pediatric referral hospitals in Addis Ababa, Ethiopia. Description of demographics of children with acute poisoning and factors associated with time to presentation and nature of poisoning were analyzed. Data were entered to Epi info 3.5.3 and analyzed with SPSS version 20.
RESULTS: Over three years, we retrieved records of a total of 128 children admitted for acute poisoning. The mean age of victims was 5.46 (SD, standard deviation=4.48) years. The majority (29.7%) were poisoned by prescribed drugs. Most poisoning incidents (73.5%) were unintentional in nature. The median time to health facility visit was 15.5 hours. Age less than 2 years was related to earlier presentation to health facility (P=0.010, OR=0.28, 95%CI=0.10-0.74). Children with age more than 5 years was more likely to have intentional poisoning (χ²=25.06, P<0.0001). None of the victims was provided psychosocial evaluation and counseling.
CONCLUSION: Most poisoning incidents are unintentional. Prescribed drugs are the commonest causes. Psychosocial counseling and care for the affected children is lacking. Family and community education should be given on prevention of poisoning. We recommend that caregivers take the required action in keeping prescribed drugs at home. Psychosocial support should be part of care and treatment of children with poisoning.

Impact of the 2010 resuscitation guidelines training on layperson chest compressions

Audrey L. Blewer, David G. Buckler, Jiaqi Li, Marion Leary, Lance B. Becker, Judy A. Shea, Peter W. Groeneveld, Mary E. Putt, Benjamin S. Abella

2015, 6(4):  270-276.  doi:10.5847/wjem.j.1920-8642.2015.04.004

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BACKGROUND: Survival from cardiac arrest is sensitive to the quality of delivered CPR. In 2010, updated international resuscitation guidelines emphasized deeper chest compressions and faster rates, yet it is unknown whether training laypersons using updated guidelines resulted in changed CPR performance. We hypothesized that laypersons taught CPR using the 2010 guidelines performed deeper and faster compressions than those taught using the 2005 materials.
METHODS: This work represents a secondary analysis of a study conducted at eight hospitals where family members of hospitalized cardiac patients were trained in CPR. An initial cohort was trained using the 2005 guidelines, and a subsequent cohort was trained using the 2010 guideline materials. Post training, CPR skills were quantified using a recording manikin.
RESULTS: Between May 2009 to August 2013, 338 subjects completed the assessment. Among the subjects, 176 received 2005 training and 162 underwent 2010 training. The mean compression rate in the 2005 cohort was 87 (95%CI 83-90) per minute, and in the 2010 cohort was 86 (95%CI 83-90) per minute (P=ns), while the mean compression depth was 34 (95%CI 32-35) mm in the 2005 cohort and 46 (95%CI 44-47) mm in the 2010 cohort (P<0.01).
CONCLUSIONS: Training with the 2010 CPR guidelines resulted in a statistically significant increase in trainees' compression depth but there was no change in compression rate. Nevertheless, the majority of CPR performed by trainees in both cohorts was below the guideline recommendation, highlighting an important gap between training goals and trainee performance.

Prehospital system delay in patients with ST-segment elevation myocardial infarction in Singapore

Andrew Fu Wah Ho, Pin Pin Pek, Stephanie Fook-Chong, Ting Hway Wong, Yih Yng Ng, Aaron Sung Lung Wong, Marcus Eng Hock Ong

2015, 6(4):  277-282.  doi:10.5847/wjem.j.1920-8642.2015.04.005

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BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction (STEMI) improves outcomes. System delay is that between first medical contact and reperfusion therapy, comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore.
METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services (EMS), ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique.
RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5 minutes (interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes (IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes (IQR=1.30, 22.13); between arrival-at- and departure-from-patient-location was 13.12 minutes (IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes (IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulance-dispatch and arrival-at-patient-location was shorter (5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter (10.78 vs. 14.37 minutes, P<0.01).
CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.

Utilization of the Accident & Emergency Departments by Chinese elderly in Hong Kong

Wai Lam Yip, Kit Ling Fan, Chun Tat Lui, Ling Pong Leung, Fu Ng, Kwok Leung Tsui

2015, 6(4):  283-288.  doi:10.5847/wjem.j.1920-8642.2015.04.006

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BACKGROUND: The epidemiological data on elderly patients attending Accident and Emergency Departments (AEDs) in Hong Kong is lacking. The study aimed to examine the epidemiology of geriatric patient visits to AEDs in Hong Kong, including demographic data and predictors of life-saving interventions (LSI) and admission.
METHODS: A retrospective cross-sectional study of geriatric patients older than 64 years old attending three AEDs during the year 2012, with a sample of 1 200 patient visits recruited. The data were retrieved from the medical records of the respective hospitals. Descriptive characteristics of the visits were provided. Multivariate logistic regression was performed to evaluate the predictors of LSI and hospital admission.
RESULTS: The mean age of the patients was 79.1 years. Totally 49.7% of the patients were male. "Diseases of the respiratory system" was the commonest diagnosis in AEDs as well as that required admission. The admission rate was 56.8%. Logistic regression demonstrated that dependent activity of daily living (ADL), arrival by ambulance, and the higher number of co-morbidities were predictors of LSI, while advanced age, dependent ADL, institutionalized patients, arrival by ambulance, and higher number of co-morbidities were predictors of hospital admission.
CONCLUSIONS: Ageing population is creating an imminent burden on the emergency service in Hong Kong. Previously unavailable epidemiological information about geriatric attendance to AEDs was described. This forms the basis for development of future studies concerning the medical services on this specific group of patients.

Bombings specific triage (Bost Tool) tool and its application by healthcare professionals

Jaiswal Sanjay, Verma Ankur, Kole Tamorish

2015, 6(4):  289-292.  doi:10.5847/wjem.j.1920-8642.2015.04.007

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BACKGROUND: Bombing is a unique incident which produces unique patterns, multiple and occult injuries. Death often is a result of combined blast, ballistic and thermal effect injuries. Various natures of injury, self referrals and arrival by private transportation may lead to "wrong triage" in the emergency department. In India there has been an increase in incidence of bombing in the last 15 years. There is no documented triage tool from the National Disaster Management Authority of India for Bombings. We have tried to develop an ideal bombing specific triage tool which will guide the right patients to the right place at the right time and save more lives.
METHODS: There are three methods of studying the triage tool: 1) real disaster; 2) mock drill; 3) table top exercise. In this study, a table top exercise method was selected. There are two groups, each consisting of an emergency physician, a nurse and a paramedic.
RESULTS: By using the proportion test, we found that correct triaging was significantly different (P=0.005) in proportion between the two groups: group B (80%) with triage tool performed better in triaging the bomb blast victims than group A (50%) without the bombing specific triage tool performed.
CONCLUSION: Development of bombing specific triage tool can reduce under triaging.

A feasibility study to determine if minimally trained medical students can identify markers of chronic parasitic infection using bedside ultrasound in rural Tanzania

Maria Barsky, Lauren Kushner, MeganAnsbro, Kate Bowman, Michael Sassounian, Kevin Gustafson, Shadi Lahham, Linda Joseph, John C Fox

2015, 6(4):  293-298.  doi:10.5847/wjem.j.1920-8642.2015.04.008

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BACKGROUND: Parasitic infections pose a significant health risk in developing nations and are a major cause of morbidity and mortality worldwide. In the Republic of Tanzania, the CDC estimates that 51.5% of the population is infected with one or more intestinal parasites. If diagnosed early, the consequences of chronic parasitic infection can potentially be avoided.
METHODS: Six first-year medical students were recruited to enroll patients in the study. They underwent ten hours of formal, hands-on, ultrasound which included basic cardiac, hepatobiliary, renal, pulmonary and FAST scan ultrasound. A World Health Organization protocol with published grading scales was adapted and used to assess for pathology in each patient's liver, bladder, kidneys, and spleen.
RESULTS: A total of 59 patients were enrolled in the study. Students reported a sensitivity of 96% and specificity of 100% for the presence of a dome shaped bladder, a sensitivity and specificity of 100% for bladder thickening, a sensitivity and specificity of 100% for portal hypertension and ascites. The sensitivity was 81% with a specificity of 100% for presence of portal vein distention. The sensitivity was 100% with a specificity of 90% for dilated bowel.
CONCLUSIONS: Ultrasound has shown a promise at helping to identify pathology in rural communities with limited resources such as Tanzania. Our data suggest that minimally trained first year medical students are able to perform basic ultrasound scans that can identify ultrasonographic markers of parasitic infections.

Expression of phosphatidylinositol-3 kinase and effects of inhibitor Wortmannin on expression of tumor necrosis factor-α in severe acute pancreatitis associated with acute lung injury

Ming Wei, Yan-jie Gong, Ling Tu, Jia Li, Ying-hong Liang, Yi-hua Zhang

2015, 6(4):  299-304.  doi:10.5847/wjem.j.1920-8642.2015.04.009

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BACKGROUND: Acute lung injury (ALI) is a common and serious complication of severe acute pancreatitis (SAP). The study aimed to investigate the protective effect and mechanism of phosphatidylinositol-3 kinase (PI3K) inhibitor Wortmannin in SAP associated with ALI.
METHODS: Ninety rats were randomly divided into three groups: sham operation (SO) group (n=30), SAP group (n=30), and SAP+Wortmannin (SAP+W) group (n=30). SAP model was induced by retrograde injection of 4% sodium taurocholate into the biliopancreatic duct of rats. The rate of lung water content, myeloperoxidase (MPO), matrix metalloproteinase 9 (MMP-9), protein kinase B (PKB), abdphosphorylation of protein kinase B (P-PKB) activity in the lung tissue were evaluated.
RESULTS: In the SAP group, the p-PKB expression in the lung tissue began to rise at 3 hours after modeling, and peaked at 12 hours (P<0.05); the rate of lung water content, MPO and TNF-α activity were also gradually increased, and the degree of lung lesion gradually increased (P<0.05). In the SAP+Wortmannin group, the p-PKB expression in the lung tissue began to rise at 3 hours after modeling, and peaked at 12 hours; it was higher than that in the SO group (P<0.05), but significantly lower than that in the SAP group (P<0.05). The rest indicators in the SAP+Wortmannin group were also significantly decreased as compared with the SAP group (P<0.05).
CONCLUSIONS: The expression of phosphatidylinositol-3 kinase/protein kinase B was elevated in severe pancreatitis rats with lung injury. This suggested that PI3K signal transduction pathway is involved in the control and release of proinflammatory cytokines TNF-α, which may play an important role in the pathogenesis of severe acute pancreatitis associated with lung injury. This finding indicated that Wortmannin can block the PI3K signal transduction pathway, and inhibit the release of inflammatory factor TNF-α.

Case Reports

Wooden stick penetration from the perineal region up to the thorax

Khem Pal Singh, Anil Kumar Joshi, Mohit Kumar Joshi, Chitra Joshi, Mridu Singh, Vikram Singh

2015, 6(4):  305-307.  doi:10.5847/wjem.j.1920-8642.2015.04.010

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BACKGROUND: Penetrating injuries of the perineum are rare but very dangerous. Since the genitourinary and colorectal organs may be injured, how to evaluate surgical management of the injury is very important.
METHODS: The present report presents a case of penetrating injury of the perineum by a wooden stick when the patient fell on the upright wooden stick from a tree. The three feet long stick entered the perineal region just left lateral to the anal opening. Upon reaching the thoracic cavity, it broke and only a foot stick was left in the subcutaneous plane. These injuries are potentially serious with risk of damage to multiple organs. Exploratory laprotomy was done, and bladder injury was repaired. The entry wound and the track of stick was thoroughly washed and allowed for secondary intention healing.
RESULTS: The post operative period was uneventful and the patient recovered fully.
CONCLUSION: Meticulous evaluation and surgical management of perineal injuries are the key to prevent devastating complications.

Bottle gourd (Lagenaria siceraria) juice poisoning

Ankur Verma, Sanjay Jaiswal

2015, 6(4):  308-310.  doi:10.5847/wjem.j.1920-8642.2015.04.011

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BACKGROUND: Bottle gourd (Lagenaria siceraria) is popularly known as lauki, ghia or dudhi in India. Its consumption is advocated by traditional medicine healers for controlling diabetes mellitus, hypertension, liver diseases, weight loss and other diseases. However, in last few years there have been reports of suspected toxicity due to consumption of its juice leading to severe vomiting and upper gastrointestinal bleeding. As emergency physicians we need to be aware of this very rare poisoning specially in India.
METHODS: We present a case of a 52-year-old woman who presented with multiple episodes of hematemesis and shock to the emergency department (ED) after consuming bottle gourd juice. The patient was resuscitated and stabilized with fluids, proton pump inhibitors and antiemetics and shifted to the intensive care unit (ICU) under the care of a gastroenterology team for urgent endoscopy and further management.
RESULTS: The patient received intravenous fluids, antibiotics, antiemetics, and antacids and underwent upper gastroenterologic endoscopy during the hospitalization. She was discharged in a stable condition 4 days later.
CONCLUSIONS: As a member of the Cucurbitaceae family, bottle gourd contains toxic tetracyclic triterpenoid compounds called cucurbitacins which are responsible for the bitter taste and toxicity. There is no known antidote for this toxicity, and clinicians treat such patients symptomatically only. It is important to educate the public about the harmful effects of this potentially life-threatening toxicity.

Letter to the Editor

Antidotes for patients taking novel oral anti-coagulants Letter to the Editor

Stefanie W Yip, Yiu Che Chan

2015, 6(4):  311-312.  doi:10.5847/wjem.j.1920-8642.2015.04.012

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