Table of Content

15 September 2015, Volume 6 Issue 3

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Meta-analyses

Albuterol in the treatment of acute respiratory distress syndrome: A meta-analysis of randomized controlled trials

Ruo Wu, Shi-yun Lin, Hui-min Zhao

2015, 6(3):  165-171.  doi:10.5847/wjem.j.1920-8642.2015.03.001

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BACKGROUND: This meta-analysis of randomized controlled trials aimed to systematically evaluate the value of albuterol in the treatment of patients with acute respiratory distress syndrome (ARDS).
DATA SOURCES: Randomized controlled trials on albuterol treatment of ARDS from its inception to October 2014 were searched systematically. The databases searched included: PubMed, Ovid EMBASE, Ovid Cochrane, CNKI, WANFANG and VIP. The trials were screened according to the pre-designed inclusion and exclusion criteria. We performed a systematic review and meta-analysis of the randomized controlled trials (RCTs) on albuterol treatment, attempting to improve outcomes, i.e. lowering the 28-day mortality and ventilator-free days.
RESULTS: Three RCTs involving 646 patients met the inclusion criteria. There was no significant decrease in the 28-day mortality (risk difference=0.09; P=0.07, P for heterogeneity=0.22, I²=33%). The ventilator-free days and organ failure-free days were significantly lower in the patients who received albuterol (mean difference=-2.20; P<0.001, Pfor heterogeneity=0.49, I²=0% and mean difference=-1.71, P<0.001, P for heterogeneity=0.60, I²=0%).
CONCLUSIONS: Current evidences indicate that treatment with albuterol in the early course of ARDS was not effective in increasing the survival, but significantly decreasing the ventilator-free days and organ failure-free days. Owing to the limited number of included trails, strong recommendations cannot be made.

Efficacy and safety of glucocorticoids in the treatment of community-acquired pneumonia: A meta-analysis of randomized controlled trials

Li-ping Chen, Jun-hui Chen, Ying Chen, Chao Wu, Xiao-hong Yang

2015, 6(3):  172-178.  doi:10.5847/wjem.j.1920-8642.2015.03.002

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BACKGROUND: Community-acquired pneumonia (CAP) is pneumonia acquired infectiously from normal social contact as opposed to being acquired during hospitalization. CAP is a leading cause of illness and death. This review aims to determine the efficacy and safety of glucocorticoids in the treatment of community-acquired pneumonia (CAP).
DATA SOURCES: We searched randomized controlled trials (RCTs) from Pubmed, EMBASE, Cochrane Library, Chinese Journal Full-text Database, and Chinese Biomedical Literature Database to obtain the information by using steroids, glucocorticoids, cortisol, corticosteroids, community-acquired pneumonia and CAP as key words. The quality of RCTs was evaluated. A Meta-analysis was made using RevMan 5.0 provided by the Cochrance Collaboration.
RESULTS: Seven RCTs involving 944 patients were included in the meta-analysis. The mean length of hospital stay in glucocorticoids treatment group was significantly shorter than that in standard treatment group (WMD=-1.70, 95%CI 2.01-1.39, Z=10.81, P<0.00001). No statistically significant differences were found in the mortality rate (RR=0.77,95%CI 0.46-1.27, Z=1.03, P=0.30), the mean length of hospital stay in ICU (WMD=1.17, 95%CI 1.68-4.02, Z=0.81, P=0.42), the incidence of super infection (RR=1.32, 95%CI 0.66-2.63, Z=0.79, P=0.43), the incidence of hyperglycemia (RR=1.84, 95%CI 0.76-4.41, Z=1.36, P=0.17), the incidence of upper gastrointestinal bleeding (RR=1.98, 95%CI 0.37-10.59, Z=0.80, P=0.42) between the standard treatment group and the glucocorticoids treatment group.
CONCLUSIONS: The use of glucocorticoids in patients with community-acquired pneumonia can significantly shorten the duration of illness and have a favorable safety profile. However, it could not reduce the overall mortality.

Original Articles

Performance of cardiopulmonary resuscitation during prolonged basic life support in military medical university students: A manikin study

Juan Wang, Chao-nan Zhuo, Lei Zhang, Yu-shun Gong, Chang-lin Yin, Yong-qin Li

2015, 6(3):  179-185.  doi:10.5847/wjem.j.1920-8642.2015.03.003

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BACKGROUND: The quality of chest compressions can be significantly improved after training of rescuers according to the latest national guidelines of China. However, rescuers may be unable to maintain adequate compression or ventilation throughout a response of average emergency medical services because of increased rescuer fatigue. In the present study, we evaluated the performance of cardiopulmonary resuscitation (CPR) in training of military medical university students during a prolonged basic life support (BLS).
METHODS: A 3-hour BLS training was given to 120 military medical university students. Six months after the training, 115 students performed single rescuer BLS on a manikin for 8 minutes. The qualities of chest compressions as well as ventilations were assessed.
RESULTS: The average compression depth and rate were 53.7±5.3 mm and 135.1±15.7 compressions per minute respectively. The proportion of chest compressions with appropriate depth was 71.7%±28.4%. The average ventilation volume was 847.2±260.4 mL and the proportion of students with adequate ventilation was 63.5%. Compared with male students, significantly lower compression depth (46.7±4.8 vs. 54.6±4.8 mm, P<0.001) and adequate compression rate (35.5%±26.5% vs. 76.1%±25.1%, P<0.001) were observed in female students.
CONCLUSIONS: CPR was found to be related to gender, body weight, and body mass index of students in this study. The quality of chest compressions was well maintained in male students during 8 minutes of conventional CPR but declined rapidly in female students after 2 minutes according to the latest national guidelines. Physical fitness and rescuer fatigue did not affect the quality of ventilation.

Peer-assisted learning to train high-school students to perform basic life-support

Hyung Soo Choi, Dong Hoon Lee, Chan Woong Kim, Sung Eun Kim, Je Hyeok Oh

2015, 6(3):  186-190.  doi:10.5847/wjem.j.1920-8642.2015.03.004

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BACKGROUND: The inclusion of cardiopulmonary resuscitation (CPR) in formal education has been a useful approach to providing basic life support (BLS) services. However, because not all students have been able to learn directly from certified instructors, we studied the educational efficacy of the use of peer-assisted learning (PAL) to train high-school students to perform BLS services.
METHODS: This study consisted of 187 high-school students: 68 participants served as a control group and received a 1-hour BLS training from a school nurse, and 119 were included in a PAL group and received a 1-hour CPR training from a PAL leader. Participants' BLS training was preceded by the completion of questionnaires regarding their background. Three months after the training, the participants were asked to respond to questionnaires about their willingness to perform CPR on bystander CPR and their retention of knowledge of BLS.
RESULTS: We found no statistically significant difference between the control and PAL groups in their willingness to perform CPR on bystanders (control: 55.2%, PAL: 64.7%, P=0.202). The PAL group was not significantly different from the control group (control: 60.78±39.77, PAL: 61.76±17.80, P=0.848) in retention of knowledge about BLS services.
CONCLUSION: In educating high school students about BLS, there was no significant difference between PAL and traditional education in increasing the willingness to provide CPR to bystanders or the ability to retain knowledge about BLS.

Feasibility study of first-year medical students identifying cardiac anatomy using ultrasound in rural Panama

Brianna Miner, Amanda Purdy, Laura Curtis, Kevin Simonson, Caleb Shumway, Jessa Baker, Jessica Vaughan, Kara Percival, Olivia Sanchez, Shadi Lahham, Linda Joseph, J Christian Fox

2015, 6(3):  191-195.  doi:10.5847/wjem.j.1920-8642.2015.03.005

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BACKGROUND: There are over 15 million children who have cardiac anomalies around the world, resulting in a significant morbidity and mortality. Early recognition and treatment can improve the outcomes and lengthen life-expectancy of these patients. The NIH and WHO have promoted guidelines for screening for congenital cardiac anomalies using ultrasound in rural environments.
METHODS: Our study took place in Bocas Del Toro, Panama where a mobile clinic was established for community healthcare screening and ultrasonographic evaluation by medical student volunteers and volunteer clinical faculty. This was a non-blinded, investigational study utilizing a convenience sample of pediatric patients presenting for voluntary evaluation. Seven first-year medical students were recruited for the study. These students underwent a training program for advanced cardiac ultrasound instruction, termed "Pediatric Echocardiography Cardiac Screening (PECS)".
RESULTS: Ten patients were enrolled in the study. Nine patients had adequate images as defined by the PECS criteria and were all classified as normal cardiac pathology by the medical students, resulting in a sensitivity and specificity of 100%. A single patient was identified by medical students as having a pathologic pulmonic stenosis. This was confirmed as correct by a blinded ultrasonographer.
CONCLUSIONS: In this pilot study, the first-year medical students were able to correctly identify pediatric cardiac anatomy and pathology in rural Panama after undergoing a 12-hour ultrasound PECS training session. We believe that with this knowledge, minimally trained practitioners can be used to screen for cardiac anomalies in rural Panama using ultrasound.

Sequential invasive-noninvasive mechanical ventilation weaning strategy for patients after tracheostomy

Xue-xue Pu, Jiong Wang, Xue-bo Yan, Xue-qin Jiang

2015, 6(3):  196-200.  doi:10.5847/wjem.j.1920-8642.2015.03.006

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BACKGROUND: Because the continuity and integrity of the trachea are likely damaged to some extent after tracheostomy, the implementation of sequential ventilation has certain difficulties, and sequential invasive-noninvasive ventilation on patients after tracheostomy is less common in practice. The present study aimed to investigate the feasibility of invasive-noninvasive sequential weaning strategy in patients after tracheostomy.
METHODS: Fifty patients including 24 patients with withdrawal of mechanical ventilation (conventional group) and 26 patients with sequential invasive-noninvasive weaning by directly plugging of tracheostomy (sequential group) were analyzed retrospectively after appearance of pulmonary infection control (PIC) window. The analysis of arterial blood gases, ventilator-associated pneumonia (VAP) incidence, the total duration of mechanical ventilation, the success rate of weaning and total cost of hospitalization were compared between the two groups.
RESULTS: Arterial blood gas analysis showed that the sequential weaning group was better than the conventional weaning group 1 and 24 hours after invasive ventilation. The VAP incidence was lowered, the duration of mechanical ventilation shortened, the success rate of weaning increased, and the total cost of hospitalization decreased.
CONCLUSION: Sequential invasive-noninvasive ventilator weaning is feasible in patients after tracheostomy.

Paraoxonase-1 gene in patients with chronic obstructive pulmonary disease investigation Q192R and L55M polymorphisms

Şükrü Gürbüz, Mustafa Yıldız, Murat Kara, Kürşat Kargün, Mehtap Gürger, Metin Ateşçelik, Ömer Doğan Alataş

2015, 6(3):  201-206.  doi:10.5847/wjem.j.1920-8642.2015.03.007

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BACKGROUND: The effect of increased oxidative stress on the development of chronic obstructive pulmonary disease (COPD) is well known. One of the antioxidative systems against oxidative stress in human body is paraoxonase (PON) enzyme that protects low density lipoproteins (LDL) against oxidation. This study aimed to explore the polymorphisms on PON1, Q192R, L55M genes of patients with COPD.
METHODS: DNAs extraction was obtained from blood samples of 50 patients diagnosed with COPD and 50 patients as a control group who were presented to emergency clinic. Genotypes were obtained with polymerase chain reaction (PCR) and AIw I and Hsp92II restriction enzymes were used for Q192R and L55M polymorphisms, respectively. Analysis of data was done with the Chi-square test and Fisher's exact test.
RESULTS: A statistically significant difference in Q192R polymorphism was found between the COPD patients and the control group (P=0.05). There was no statistically significant difference in L55M polymorphisms between the patient and control groups (P>0.05). Q192R polymorphism was significantly correlated with the PON1 gene and cigarette smoking; however other risk factors did not show any significant correlation with this polymorphism. Though L55M polymorphism was significantly correlated with family history and tuberculosis, there was no significant correlation with other risk factors.
CONCLUSION: We believe that more studies are needed to study the correlation of L55M polymorphism with other factors.

The relationship between ischemic stroke and weather conditions in Duzce, Turkey

Harun Gunes, Hayati Kandis, Ayhan Saritas, Suber Dikici, Ramazan Buyukkaya

2015, 6(3):  207-211.  doi:10.5847/wjem.j.1920-8642.2015.03.008

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BACKGROUND: Weather conditions are thought to increase the risk of stroke occurrence. But their mechanism has not yet been clarified. We investigated possible relationships between ischemic stroke and weather conditions including atmospheric pressure, temperature, relative humidity, and wind speed.
METHODS: One hundred and twenty-eight patients with ischemic stroke who had been admitted to our hospital between January 1 and December 31, 2010 were enrolled in this study. We investigated the relationship between daily cases and weather conditions the same day or 1, 2, and 3 days before stroke.
RESULTS: A negative correlation was found between maximum wind speed and daily cases 3 days before stroke. As the relationship between daily cases and changes of weather conditions in consecutive days was evaluated, a negative correlation was found between daily cases and change of atmospheric pressure in the last 24 hours.
CONCLUSIONS: The maximum wind speed 3 days before stroke and change of atmospheric pressure in the last 24 hours were found to increase the cases of ischemic stroke. We recommend that individuals at risk of ischemic stroke should pay more attention to preventive measures, especially on days with low maximum wind speed, on subsequent 3 days, and on days with low atmospheric pressure in the last 24 hours.

The mortality of patients in a pediatric emergency department at a tertiary medical center in China: An observational study

Cui-ping Zhu, Xiao-hui Wu, Yu-ting Liang, Wen-cheng Ma, Lu Ren

2015, 6(3):  212-216.  doi:10.5847/wjem.j.1920-8642.2015.03.009

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BACKGROUND: The quality of treatment for critically ill children varies widely at different hospitals. This study aimed to analyze the characteristics of mortality in a pediatric emergency department (PED) at a tertiary children's hospital in Guangzhou, China and to investigate the risk factors associated with the mortality.
METHODS: The mortality of pediatric patients at the hospital from 2011 to 2013 was retrospectively analyzed using descriptive statistics.
RESULTS: Altogether 466 919 patients visited the PED during the period and 43 925 of them were admitted for further observation. In 230 deaths, the ratio of boys to girls was 1.4:1, and their age ranged from 2 hours to 16 years (median, 5 months). The time from admission to death ranged from 0 to 216 hours (median, 1.5 hours). There were 92 (40%) patients who died within 24 hours after admission and 104 (45.2%) patients who died on arrival. The prominent causes of the deaths were respiratory diseases, neuromuscular disorders, cardiovascular diseases, and sepsis, most of which were ascribed to severe infection. Sixty-five deaths were associated with more than one concomitant problem. The top concomitant problems were congenital malformation, low gestational age, and severe birth asphyxia.
CONCLUSIONS: In our center, 40% of the patients in the PED died of fatal acute diseases, and pneumonia was the first leading cause of the deaths. Almost half of the deaths occurred on arrival and the rest were due to end-stage malignant diseases. This study emphasized the importance of prevention of birth deficits by reducing deaths in infants and children.

Terrorist attacks in the largest metropolitan city of Pakistan: Profile of soft tissue and skeletal injuries from a single trauma center

Muhammad Shahid Khan, Shahan Waheed, Arif Ali, Narjis Mumtaz, Asher Feroze, Shahryar Noordin

2015, 6(3):  217-220.  doi:10.5847/wjem.j.1920-8642.2015.03.010

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BACKGROUND: Pakistan has been hugely struck with massive bomb explosions (car and suicide bombs) resulting in multiple casualties in the past few years. The aim of this study is to present the patterns of skeletal and soft tissue injuries and to review the outcome of the victims who presented to our hospital.
METHODS: This is a retrospective chart review from January 2008 to December 2012. The medical record numbers of patients were obtained from the hospital Health Information and Management Sciences (HIMS) as per the ICD-9 coding.
RESULTS: During the study period, more than 100 suicide and implanted bomb blast attacks took place in the public proceedings, government offices, residential areas and other places of the city. Altogether 262 patients were enrolled in the study. The mean age of the patients was 31±14 years. The shrapnel inflicted wounds were present on to the upper limb in 24 patients and the lower limb in 50.
CONCLUSION: Long bone fractures were the most common skeletal injuries. The fractures were complicated by penetrating fragments and nails which result in post operative infections and prolonged hospital stay.

Characteristics of injuries caused by paragliding accidents: A cross-sectional study

Umut Canbek, Ahmet İmerci, Ulaş Akgün, Murat Yeşil, Ali Aydin, Yasemin Balci

2015, 6(3):  221-224.  doi:10.5847/wjem.j.1920-8642.2015.03.011

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BACKGROUND: This study was undertaken to analyze the characteristics and risk factors relating to fatalities and injuries caused by paragliding.
METHODS: The judicial examination reports and hospital documents of 82 patients traumatized in 64 accidents during 242 355 paragliding jumps between August 2004 and September 2011 were analyzed.
RESULTS: In these accidents, 18 of the 82 patients lost their lives. In the patients with a confirmed cause of accident, most of them were involved with multiple fractures and internal organ injuries (n=8, 44.4%).
CONCLUSION: We investigated the incidence of paragliding injuries, the types of the injuries, and the severity of affected anatomical regions. The findings are significant for the prevention of paragliding injuries and future research.

Continuing Education

A novel and inexpensive ballistic gel phantom for ultrasound training

Richard Amini, Jeffrey Z Kartchner, Lori A Stolz, David Biffar, Allan J Hamilton, Srikar Adhikari

2015, 6(3):  225-228.  doi:10.5847/wjem.j.1920-8642.2015.03.012

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BACKGROUND: Ultrasonography use is increasing in emergency departments, and ultrasound education is now recommended in resident training. Ultrasound phantoms are used in many institutions for training purposes. The purpose of this study is to describe an inexpensive and simple method to create ultrasound-imaging models for the purpose of education and practice using clear ballistic gel.
METHODS: Clear ballistic gel is used to simulate tissue for firing practice and other military evaluations.
RESULTS: The transparent and durable ultrasound phantom we produced was clear and contained four vessel lumens. The images obtained using the phantom were of high quality and compared well to normal sonographic anatomy.
CONCLUSIONS: The clear ballistic brand gel is unique because it is inexpensive, does not dry out, does not decay, is odorless, and is reusable. The ultrasound images obtained using the phantom are realistic and useful for ultrasound education.

Case Reports

Endovascular repair of giant traumatic pseudo-aneurysm of the common carotid artery

Yuk Law, Yiu Che Chan, Stephen W. Cheng

2015, 6(3):  229-232.  doi:10.5847/wjem.j.1920-8642.2015.03.013

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BACKGROUND: Delayed presentation of carotid artery pseudoaneurysm following many years after self-inflicted penetrating injury of the neck is extremely rare. Open surgical carotid repair may involve sternotomy for proximal vascular control. Endovascular treatment is evolving as a less-invasive treatment option.
METHODS: We report a 55-year-old man with a history of paranoid schizophrenia who presented with a progressively enlarging left sided neck mass many years after attempted suicide. CT scan confirmed a 6 cm pseudoaneurysm arising from the common carotid artery.
RESULTS: Through an open retrograde puncture of the distal common carotid artery, the common carotid pseudoaneurysm was successfully repaired with a BARD fluency carotid stentgraft of 8 mm×80 mm (BARD, Tempe, AZ). The patient recovered well with no neurological deficits and was discharged on postoperative day 4. Dual antiplatelet agents of aspirin and clopidogrel were given for six months and then clopidogrel was administered lifelong. The neck mass decreased in size gradually and became non pulsatile upon follow-up.
CONCLUSION: Endovascular stenting of giant carotid pseudoaneurysm is an acceptable less invasive treatment option for giant carotid pseudoaneurysm. Long-term follow-up and a greater number of cases are mandatory to establish the safety of this strategy.

A mimic of soft tissue infection: intra-arterial injection drug use producing hand swelling and digital ischemia

Sean D. Foster, Michael S. Lyons, Christopher M. Runyan, Edward J. Otten

2015, 6(3):  233-236.  doi:10.5847/wjem.j.issn.1920-8642.2015.03.014

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BACKGROUND: Inadvertent intra-arterial injection of illicit substances is a known complication of injection drug use and can lead to severe complications, including infection, ischemia and compartment syndrome. Identifying complications of intra-arterial injection can be difficult, as clinical manifestations overlap with other more common conditions such as cellulitis and soft tissue infection, and a history of injection drug use is frequently not disclosed.
METHODS: A 37-year-old male patient presented with 24 hours of right hand pain, erythema and swelling. Despite classic “track marks”, he denied a history of injection drug use, and vascular insults were not initially considered. After failing to respond to three days of aggressive treatment for suspected deep-space infection, an arteriogram demonstrated findings consistent with digital ischemia of embolic etiology.
RESULTS: As a result of the delay in diagnosis, the lesion was not amenable to reperfusion and the patient required amputation of the distal digit.
CONCLUSION: Practitioners should be alert to the possibility of intra-arterial injection and resulting complications when evaluating unusual extremity infections or unexplained ischemic symptoms, even in the absence of a definite history of injection drug use.