Table of Content

15 March 2014, Volume 5 Issue 1

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Review Articles

Wilderness medicine

Douglas G. Sward, Brad L. Bennett

2014, 5(1):  5-15.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.001

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BACKGROUND: Human activity in wilderness areas has increased globally in recent decades, leading to increased risk of injury and illness. Wilderness medicine has developed in response to both need and interest.
METHODS: The field of wilderness medicine encompasses many areas of interest. Some focus on special circumstances (such as avalanches) while others have a broader scope (such as trauma care). Several core areas of key interest within wilderness medicine are discussed in this study.
RESULTS: Wilderness medicine is characterized by remote and improvised care of patients with routine or exotic illnesses or trauma, limited resources and manpower, and delayed evacuation to definitive care. Wilderness medicine is developing rapidly and draws from the breadth of medical and surgical subspecialties as well as the technical fields of mountaineering, climbing, and diving. Research, epidemiology, and evidence-based guidelines are evolving. A hallmark of this field is injury prevention and risk mitigation. The range of topics encompasses high-altitude cerebral edema, decompression sickness, snake envenomation, lightning injury, extremity trauma, and gastroenteritis. Several professional societies, academic fellowships, and training organizations offer education and resources for laypeople and health care professionals.
CONCLUSIONS: The future of wilderness medicine is unfolding on multiple fronts: education, research, training, technology, communications, and environment. Although wilderness medicine research is technically difficult to perform, it is essential to deepening our understanding of the contribution of specific techniques in achieving improvements in clinical outcomes.

Presepsin as a novel sepsis biomarker

Qi Zou, Wei Wen, Xin-chao Zhang

2014, 5(1):  16-19.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.002

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BACKGROUND: In 2004, a new biomarker sCD14-subtypes (presepsin) was found and its value was shown in the diagnosis and evaluation of sepsis. This article is a brief overview of the new biomarker.
DATA SOURCES: A literature search using multiple databases was performed for articles, especially meta-analyses, systematic reviews, and randomized controlled trials.
RESULTS: Compared with other markers, presepsin seems to have a better sensitivity and specificity in the diagnosis of sepsis. Presepsin as a biom1arker is not only suitable for the early diagnosis of sepsis, but also for the assessment of its severity and prognosis.
CONCLUSIONS: Presepsin has a higher sensitivity and specificity in the diagnosis of sepsis as a new biomarker, and is a predictor for the prognosis of sepsis. More importantly, preseptin seems to play a crucial role as a supplemental method in the early diagnosis of sepsis. Since there is no multicenter study on the relationship between presepsin and sepsis, further studies on the clinical values of presepsin are needed.

Original Articles

Blue code: Is it a real emergency?

Serkan E. Eroglu, Ozge Onur, Oğuz Urgan, Arzu Denizbasi, Haldun Akoglu

2014, 5(1):  20-23.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.003

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BACKGROUND: Cardiac arrests in hospital areas are common, and hospitals have rapid response teams or "blue code teams" to reduce preventable in-hospital deaths. Education about the rapid response team has been provided in all hospitals in Turkey, but true "blue code" activation is rare, and it is abused by medical personnel in practice. This study aimed to determine the cases of wrong blue codes and reasons of misuse.
METHODS: This retrospective study analyzed the blue code reports issued by our hospital between January 1 and June 1 2012. A total of 89 "blue code" activations were recorded in 5 months. A "blue code" was defined as any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital alert. Adherence to this definition, each physician classified their collected activation forms as either a true or a wrong code. Then, patient data entered a database (Microsoft Excel 2007 software) which was pooled for analysis. The data were analyzed by using frequencies and the Chi-square test on SPSSv16.0.
RESULTS: The patients were diagnosed with cardiopulmonary arrest (8), change in mental status (18), presyncope (11), chest pain (12), conversive disorder (18), and worry of the staff for the patient (22). Code activation was done by physicians in 76% of the patients; the most common reason for blue code was concern of staff for the patient.
CONCLUSION: The findings of this study show that more research is needed to establish the overall effectiveness and optimal implementation of blue code teams.

Lean techniques for the improvement of patients' flow in emergency department

HY Chan, SM Lo, LLY Lee, WYL Lo, WC Yu, YF Wu, ST Ho, RSD Yeung, JTS Chan

2014, 5(1):  24-28.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.004

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BACKGROUND: Emergency departments (EDs) face problems with overcrowding, access block, cost containment, and increasing demand from patients. In order to resolve these problems, there is rising interest to an approach called "lean" management. This study aims to (1) evaluate the current patient flow in ED, (2) to identify and eliminate the non-valued added process, and (3) to modify the existing process.
METHODS: It was a quantitative, pre- and post-lean design study with a series of lean management work implemented to improve the admission and blood result waiting time. These included structured re-design process, priority admission triage (PAT) program, enhanced communication with medical department, and use of new high sensitivity troponin-T (hsTnT) blood test. Triage waiting time, consultation waiting time, blood result time, admission waiting time, total processing time and ED length of stay were compared.
RESULTS: Among all the processes carried out in ED, the most time consuming processes were to wait for an admission bed (38.24 minutes; SD 66.35) and blood testing result (mean 52.73 minutes, SD 24.03). The triage waiting time and end waiting time for consultation were significantly decreased. The admission waiting time of emergency medical ward (EMW) was significantly decreased from 54.76 minutes to 24.45 minutes after implementation of PAT program (P<0.05).
CONCLUSION: The application of lean management can improve the patient flow in ED. Acquiesce-nce to the principle of lean is crucial to enhance high quality emergency care and patient satisfaction.

The knowledge level of final year undergraduate health science students and medical interns about cardiopulmonary resuscitation at a university teaching hospital of Northwest Ethiopia

Endale G. Gebremedhn, Gebremedhn B. Gebregergs, Bernard B. Anderson

2014, 5(1):  29-34.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.005

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BACKGROUND: Cardiopulmonary resuscitation (CPR) is a life-saving technique which is used after cardiopulmonary arrest. Chance of survival after arrest will increase if it is coupled with sufficient knowledge. Final year undergraduate health science students and interns manage many trauma and critically ill patients in our hospital. Even though all students took CPR training in undergraduate course, we sometimes saw difficulties in the resuscitation of patients after cardiopulmonary arrest by undergraduate health professionals. This study was to assess the level of knowledge of undergraduate health science students and medical interns about cardiopulmonary resuscitation.
METHODS: Hospital based cross-sectional study was conducted from February 1 to March 30, 2013. All undergraduate health professionals were included. The mean score of knowledge was compared for sex, original residence and department of the participants by using Student's t test and ANOVA with Scheffe's test. P values <0.05 were considered statistically significant.
RESULTS: Four hundred sixty-one out of 506 students were included in this study with a response rate of 91.1%. The overall mean knowledge score of final year undergraduate health science students and interns was 11.1 (SD=0.2). The mean knowledge scores of nurses, interns, health officer, midwifery, anesthesia and psychiatry nursing students were 9.84 (SD=2.5), 13.34 (SD=2.8), 9.81 (SD=3.0), 8.77 (SD=2.6), 13.31 (SD=2.7) and 8.43 (SD=2.4) respectively.
CONCLUSIONS: The knowledge level of undergraduate health professionals about cardiopulmonary resuscitation was insufficient. Training about CPR for undergraduate health professionals should be emphasized.

Strategic planning and designing of a hospital disaster manual in a tertiary care, teaching, research and referral institute in India

Shweta Talati, Prateek Bhatia, Ashok Kumar, A. K. Gupta, Col. D Ojha

2014, 5(1):  35-41.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.006

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BACKGROUND: As per the "Disaster Management Act, 2005" of India, it is mandatory for government hospitals in India to prepare a disaster plan. This study aimed to prepare a disaster manual of a 1 900 bed tertiary care hospital, in consultation and involvement of all concerned stakeholders.
METHODS: A committee of members from hospital administration, clinical, diagnostic and supportive departments worked on an initial document prepared according to the Act and gave their inputs to frame a final disaster manual.
RESULTS: The prepared departmental standard operating procedures involved 116 people (doctors and paramedical staff), and were then synchronized, in 12 committee meetings, to produce the final hospital disaster manual.
CONCLUSIONS: The present disaster manual is one of the few comprehensive plans prepared by the stakeholders of a government hospital in India, who themselves form a part of the disaster response team. It also helped in co-ordinated conduction of mock drills.

Significance of blood pressure variability in patients with sepsis

Nishant Raj Pandey, Yu-yao Bian, Song-tao Shou

2014, 5(1):  42-47.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.007

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BACKGROUND: This study was undertaken to observe the characteristics of blood pressure variability (BPV) and sepsis and to investigate changes in blood pressure and its value on the severity of illness in patients with sepsis.
METHODS: Blood parameters, APACHE II score, and 24-hour ambulatory BP were analyzed in 89 patients with sepsis.
RESULTS: In patients with APACHE II score>19, the values of systolic blood pressure (SBPV), diasystolic blood pressure (DBPV), non-dipper percentage, cortisol (COR), lactate (LAC), platelet count (PLT) and glucose (GLU) were significantly higher than in those with APACHE II score ≤19 (P<0.05 ), whereas the values of procalcitonin (PCT), white blood cell (WBC), creatinine (Cr), PaO₂, C-reactive protein (CRP), adrenocorticotropic hormone (ACTH) and tumor necrosis factor α (TNF-α) were not statistically significant (P>0.05). Correlation analysis showed that APACHE II scores correlated significantly with SBPV and DBPV (P<0.01, r=0.732 and P<0.01, r=0.762). SBPV and DBPV were correlated with COR (P=0.018 and r=0.318; P=0.008 and r=0.353 respectively). However, SBPV and DBPV were not correlated with TNF-α, IL-10, and PCT (P>0.05). Logistic regression analysis of SBPV, DBPV, APACHE II score, and LAC was used to predict prognosis in terms of survival and non-survival rates. Receiver operating characteristics curve (ROC) showed that DBPV was a better predictor of survival rate with an AUC value of 0.890. However, AUC of SBPV, APACHE II score, and LAC was 0.746, 0.831 and 0.915, respectively.
CONCLUSIONS: The values of SBPV, DBPV and non-dipper percentage are higher in patients with sepsis. DBPV and SBPV can be used to predict the survival rate of patients with sepsis.

Effects of early rehabilitation therapy on patients with mechanical ventilation

Ze-hua Dong, Bang-xu Yu, Yun-bo Sun, Wei Fang, Lei Li

2014, 5(1):  48-52.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.008

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BACKGROUND: For patients in intensive care unit (ICU), mechanical ventilation is an effective treatment to survive from acute illness and improve survival rates. However, long periods of bed rest and restricted physical activity can result in side effects. This study aimed to investigate the feasibility of early rehabilitation therapy in patients with mechanical ventilation.
METHODS: A randomized controlled trial was carried out. Sixty patients, with tracheal intubation or tracheostomy more than 48 hours and less than 72 hours, were admitted to the ICU of the Affiliated Hospital of Medical College, Qingdao University, from May 2010 to May 2012. These patients were randomly divided into a rehabilitation group and a control group. In the rehabilitation group, rehabilitation therapy was performed twice daily, and the training time and intensity were adjusted according to the condition of the patients. Early rehabilitation therapy included heading up actively, transferring from the supine position to sitting position, sitting at the edge of the bed, sitting in chair, transferring from sitting to standing, and ambulating bedside. The patient's body mass index, days to first out of bed, duration of mechanical ventilation, length of ICU stay, APACHE II score, highest FiO₂, lowest PaO₂/FiO₂ and hospital mortality of patients were all compared between the rehabilitation group and the control group. The differences between the two groups were compared using Student's t test.
RESULTS: There was no significant difference in body mass index, APACHE II score, highest FiO₂, lowest PaO₂/FiO₂ and hospital mortality between the rehabilitation group and the control group (P>0.05). Patients in the rehabilitation group had shorter days to first out of bed (3.8±1.2 d vs. 7.3±2.8 d; P=0.00), duration of mechanical ventilation (5.6±2.1 d vs. 12.7±4.1 d; P=0.005) and length of ICU stay (12.7±4.1 d vs. 15.2±4.5 d; P=0.01) compared with the control group.
CONCLUSION: Early rehabilitation therapy was feasible and effective in improving the outcomes of patients with mechanical ventilation.

Bispectral index in predicting the prognosis of patients with coma in intensive care unit

Lin Dou, Hong-mei Gao, Ling Lu, Wen-xiu Chang

2014, 5(1):  53-56.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.009

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BACKGROUND: The bispectral (BIS) index is a processed electroencephalogram (EEG) parameter with extensive validation and demonstrated clinical utility. The study aimed to investigate the correlation between the BIS index and the prognosis of patients with coma in the ICU.
METHODS: A total of 208 patients with coma in the ICU were enrolled in this study. According to the BIS value, the patients were divided into four groups: group I, BIS value 0 to 20; group II, BIS value 21 to 40; group III, BIS value 41 to 60; and group IV, BIS value greater than 60. The difference in BIS values with the differences in prognosis of patients with coma was compared between the four groups, and the prognosis of patients with coma was stratified into consciousness, coma, vegetative state, and brain death. Subsequently, the best cut-off score of BIS values calculated for determining the correlation between BIS value and mental state was proposed.
RESULTS: There are no significant differences in the age and APACHE II scores between the four groups (P>0.05). An inverse correlation was observed between BIS value and mental state (r= -0.749, P=0.00). According to the ROC curve, as BIS value was greater than 42.5, there were higher sensitivity and specificity in conscious-coma patients.
CONCLUSION: BIS value is correlated with the prognosis of patients with coma in ICU, and BIS value can be a useful marker for estimating the prognosis of comatose patients.

Effect of SP-A/B in lipoic acid on acute paraquat poisoning

Shou-peng Li, Ji-yuan Han, Peng Sun, Guo-yan Wu, Xiang-yan Bai

2014, 5(1):  57-62.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.010

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BACKGROUND: This study was undertaken to observe the concentration of SP-A/B and the pulmonary surfactant in the lung tissue of rats with acute lung injury/acute respiratory distress syndrome caused by paraquat poisoning after the treatment of metabolic antioxidant-lipoic acid and whether its influence was related to TNF-α.
METHODS: Sixty-six male Sprage-Dawley rats were randomly divided into three groups: normal control group (NS group), 6 rats; paraquat poisoning group (PQ group), 30 rats; and paraquat+lipoic acid treatment group (LA group), 30 rats. The rats in the PQ and LA groups were subdivided into 3-, 6-, 12-, 24-, 48-hour subgroups, with 6 rats in each group. After the rats were sacrificed, lung tissue from the same part was taken from the rats. After HE staining, histological changes were observed in the tissue under a light microscope. Lung tissue was also taken to test the levels of superoxide dismutase (SOD) and malondialdehyde (MDA). Whole blood (0.8 mL) without anticoagulant was drawn from the tail vein of rats for the determination of the TNF-α level. The total RNA of the lung tissue was collected, and the Rt-PCR method was used to measure the levels of SP-A and SP-B mRNA.
RESULTS: HE staining showed that histopathological changes were milder in the LA group than in the PQ group. There were significant differences in MDA and SOD levels between different intervals both in intergroups and intragroups except the 3-hour subgroup (P<0.01). Likewise, the significant differences in the levels of TNF-α were also present between the three groups and between different intervals (P<0.01). The significant differences in SP-A mRNA and SP-B mRNA amplification ratio were seen between the three groups at the same intervals (P<0.01), but the differences between different intervals in the PQ group were statistically significant (P<0.05). The differences between different intervals in the LA group were statistically significant (P<0.01).
CONCLUSION: Lipoic acid in acute paraquat poisoning could diminish lung tissue damage by regulating directly tumor necrosis factor and indirectly the content of pulmonary surfactant so as to reduce pulmonary edema, improve lung compliance, and finally protect lung tissues.

Case Reports

Flashback phenomenon and residual neurological deficits after the use of "bath salt" 3, 4- methylenedioxypyrovalerone

Aaron R. Mangold, Thomas P Bravo, Stephen J. Traub, Steven A. Maher, Christopher A. Lipinski

2014, 5(1):  63-66.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.011

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BACKGROUND: The use and abuse of designer drugs has been recognized for decades; however there are many derivatives of compounds that make their way into the community. Abuse of compound(s) known on the street as "bath salt" is on the rise.
METHODS: We report the case of a 33-year-old man who complained of "flashbacks" and right arm shaking that followed a night of "bath salt" snorting. The active compound methylenedioxypyrovalerone methamphetamine (MDPV) was confirmed; however, analysis of three different "bath salt" products showed difference in their active components.
RESULTS: The patient's symptoms remained stable and he was discharged home after observation in the emergency department with instructions to return for any symptom progression.
CONCLUSION: Practitioners should be aware of the abuse of the compounds and that not all "bath salt" products contain MDPV.

Bilateral stones as a cause of acute renal failure in the emergency department

Joaquín V. Alonso, Pedro L. cachinero, Fran R. Ubeda, Daniel J. L. Ruiz, Alfredo Blanco

2014, 5(1):  67-71.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.012

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BACKGROUND: Acute renal failure (ARF) due to obstructive uropathy is a urological emergency. The standard radiological investigations in the emergency setting include X-ray, ultrasonography and computed tomography. But occasionally the cause of obstruction may be elusive.
METHODS: We present a case of obstructive uropathy due to bilateral stones presenting as acute renal failure. The patient underwent successful shock wave lithotripsy (SWL) for dissolution of calculi.
RESULTS: The patient was successfully treated, and reported asymptomatic in a follow-up.
CONCLUSION: Close collaboration between nephrological, urological, and radiological services is required.

Acute temporal lobe infarction in a young patient associated with marijuana abuse: An unusual cause of stroke

Taylan Inal, Ataman Köse, Özlem Köksal, Erol Armagan, Sule A. Aydın, Fatma Ozdemir

2014, 5(1):  72-74.  doi:10.5847/wjem.j.issn.1920-8642.2014.01.013

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BACKGROUND: Cardiovascular or cerebrovascular events associated with drug abuse have been frequently reported, particularly in young patients. The drugs include generally cocaine, heroin, and amphetamines. Although marijuana is among the widely used narcotics in the world, stroke associated with the marijuana use is infrequently reported.
METHODS: Stroke caused by the use of marijuana was investigated in a 23-year-old man and the importance of inquiry of drug abuse in case of stroke was emphasized.
RESULTS: The patient was treated for 7 days in a follow-up, but he was not recovered. The patient was discharged in his existing condition and was directed for physiotherapy and rehabilitation.
CONCLUSION: Ischemic stroke is associated with drug abuse and/or substance use, mainly cannabinoids and amphetamines, particularly in young patients.

Letter to the Editor

Prehospital difficult airway management:old things still work

Ruggero M. Corso, Salvatore Zampone, Marcello Baccanelli, Massimiliano Sorbello, Giorgio Gambale

2014, 5(1):  75-76. 

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Instructions for Authors

Instructions for Authors

Editorial Office

2014, 5(1):  77-80. 

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Overview

World Journal of Emergency Medicine (WJEM), a peerreviewed quarterly journal based at the Second Affiliated Hospital of Zhejiang University School of Medicine, China, publishes articles of interest to both clinicians and researchers involving emergency medicine around the world. It focuses on content relevant to clinical practice and research, laboratory studies, continuing education about emergency medicine.