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Table of Content

    15 March 2013, Volume 4 Issue 1
    Original Articles
    Language affects length of stay in emergency departments in Queensland public hospitals
    Ibrahim Mahmoud, Xiang-yu Hou, Kevin Chu, Michele Clark
    2013, 4(1):  5-9.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.001
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    BACKGROUND: A long length of stay (LOS) in the emergency department (ED) associated with overcrowding has been found to adversely affect the quality of ED care. The objective of this study is to determine whether patients who speak a language other than English at home have a longer LOS in EDs compared to those whose speak only English at home.
    METHODS: A secondary data analysis of a Queensland state-wide hospital EDs dataset (Emergency Department Information System) was conducted for the period, 1 January 2008 to 31 December 2010.
    RESULTS: The interpreter requirement was the highest among Vietnamese speakers (23.1%) followed by Chinese (19.8%) and Arabic speakers (18.7%). There were significant differences in the distributions of the departure statuses among the language groups (Chi-squared=3236.88, P<0.001). Compared with English speakers, the Beta coefficient for the LOS in the EDs measured in minutes was among Vietnamese, 26.3 (95%CI: 22.1-30.5); Arabic, 10.3 (95%CI: 7.3-13.2); Spanish, 9.4 (95%CI: 7.1-11.7); Chinese, 8.6 (95%CI: 2.6-14.6); Hindi, 4.0 (95%CI: 2.2-5.7); Italian, 3.5 (95%CI: 1.6-5.4); and German, 2.7 (95%CI: 1.0-4.4). The final regression model explained 17% of the variability in LOS.
    CONCLUSION: There is a close relationship between the language spoken at home and the LOS at EDs, indicating that language could be an important predictor of prolonged LOS in EDs and improving language services might reduce LOS and ease overcrowding in EDs in Queensland's public hospitals.

    An attending physician float shift for the improvement of physician productivity in a crowded emergency department
    Muhammad Umer Nasim, Chintan Mistry, Robert Harwood, Erik Kulstad, Laura Tommaso
    2013, 4(1):  10-14.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.002
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    BACKGROUND: Patients backlogged in the emergency department (ED) waiting for an inpatient bed (boarders) continue to require the attention of ED physicians, exacerbating crowding in the ED. To address this problem, we added a "float shift" to our winter schedule solely to care for boarders. We sought to quantify the effect of this float shift, hypothesizing greater physician productivity.
    METHODS: We performed a retrospective observational study in our community hospital ED, measuring the number of new patients seen in each 10-hour shift in the presence or absence of a float shift physician. We calculated the number of new patients seen per shift for each of the 7 daily shifts, during February (float shift scheduled) and May (float shift unscheduled) of 2008. We then compared the mean number of patients seen per shift in February with May.
    RESULTS: Total monthly patient volume was 6 656 for February and 6 775 for May, with the mean daily census being 230 and 219 patients, respectively. The number of new patients seen during each shift was greater in February than in May, with a mean increase of 1.1 patients per shift (with the float shift). Surveying participants about intervention effectiveness showed 92% of residents, but only 65% of attending physicians, in favor of maintaining the float shift.
    CONCLUSION: The presence of a "float shift" physician caring only for boarding patients allows other physicians to maintain and even increase their productivity in our ED, despite the presence of longer throughput times and increased time on diversion.

    Management of polytrauma patients in emergency department: An experience of a tertiary care health institution of northern India
    Puri Payal, Goel Sonu, Gupta Anil K, Verma Prachi
    2013, 4(1):  15-19.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.003
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    BACKGROUND: In a tertiary care institute of northern India, the emergency department receives an average of 6-7 patients with poly trauma every day. Of these patients, some come directly and many are referred from other hospitals from the region. Various problems are faced in the management of patients with poly trauma. This study aimed to elicit various complaints, suggestions and possible solutions in the management of patients with poly trauma.
    METHODS: A retrospective cross sectional study was done on 210 patients in the emergency OPD for a period of 2 months. All the records of the patients with poly trauma were studied and the problems during their management were measured against 6 predetermined steps (step I to step VI).
    RESULTS: In the younger generation, males were predominantly the primary victims of poly trauma injury, and road traffic accident was the major etiological factor. Injuries involving more than 2 specialties induced many problems during the management of patients with poly trauma. Of 210 patients we studied, 32 patients had problems at various steps and maximum problems in step III , i.e. co-ordination between various specialties in the management of patients with poly trauma.
    CONCLUSION: A proper poly trauma management team and a well defined standard operative procedure are the keys to effective management of patients with poly trauma by minimizing the problems encountered.

    Effect of a triage course on quality of rating triage codes in a group of university nursing students:a before-after observational study
    Nicola Parenti, Maria Letizia Bacchi Reggiani, Diego Sangiorgi, Vito Serventi, Leopoldo Sarli
    2013, 4(1):  20-25.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.004
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    BACKGROUND: Most current triage tools have been tested among hospital nurses groups but there are not similar studies in university setting. In this study we analyzed if a course on a new four-level triage model, triage emergency method (TEM), could improve the quality of rating in a group of nursing students.
    METHODS: This observational study was conducted with paper scenarios at the University of Parma, Italy. Fifty students were assigned a triage level to 105 paper scenarios before and after a course on triage and TEM. We used weighted kappa statistics to measure the inter-rater reliability of TEM and assessed its validity by comparing the students' predictions with the triage code rating of a reference standard (a panel of five experts in the new triage method).
    RESULTS: Inter-rater reliability was K=0.42 (95%CI: 0.37-0.46) before the course on TEM, and K=0.61 (95%CI: 0.56-0.67) after. The accuracy of students' triage rating for the reference standard triage code was good: 81% (95%CI: 71-90). After the TEM course, the proportion of cases assigned to each acuity triage level was similar for the student group and the panel of experts.
    CONCLUSION: Among the group of nursing students, a brief course on triage and on a new in-hospital triage method seems to improve the quality of rating codes. The new triage method shows good inter-rater reliability for rating triage acuity and good accuracy in predicting the triage code rating of the reference standard.

    Post-traumatic stress disorder among paramedic and hospital emergency personnel in south-east Iran
    Sedigheh Iranmanesh, Batool Tirgari, Hojat Sheikh Bardsiri
    2013, 4(1):  26-31.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.005
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    BACKGROUND: Paramedic and emergency personnel may encounter directly many events that threat their own wellbeing during their daily work. This study was conducted to examine the prevalence rate of post-traumatic stress disorder (PTSD) among two groups of paramedic and emergency personnel in south-east Iran.
    METHODS: The study employed a descriptive design and was conducted in four hospital emergency wards and a pre-hospital emergency base supervised by Kerman Medical University. Using Mississippi PTSD, we assessed the prevalence rate in paramedics (n=150) and emergency personnel (n=250).
    RESULTS: The two groups had different levels of education, marital status, experience of traumatic events, work hours per month, and gender. Most (94%) of paramedic and hospital emergency personnel reported moderate PTSD. The two groups had significant different levels of PTSD in all subscale.
    CONCLUSION: The study suggests that health care managers should organize systematic and dynamic policies and procedures in dealing with PTSD to assist both groups of personnel.

    Association of ALOX5, LTA4H and LTC4S gene polymorphisms with ischemic stroke risk in a cohort of Chinese in east China
    Gan-nan Wang, Jin-song Zhang, Wei-juan Cao, Hao Sun, Jing Zhang, Yao Wang, Hang Xiao
    2013, 4(1):  32-37.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.006
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    BACKGROUND: Genetic variations of the 5-lipoxygenase activating protein and leukotriene A4 hydrolase genes that confer an increased risk of ischemic stroke have implicated the family of leukotrienes as potential mediators of ischemic stroke. This study aimed to explore the association ofALOX5, LTA4H and LTC4S gene polymorphisms with ischemic stroke risk in a cohort of Chinese in east China.
    METHODS: This case-control study consisted of 690 patients with ischemic stroke and 690 controls. Polymorphisms of ALOX5 rs2029253 A/G, LTA4Hrs6538697 T/C, and LTC4S rs730012 A/C were genotyped by the polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP) analysis. The multivariate logistic regression model was used to exclude the effects of conventional risk factors on ischemic stroke.
    RESULTS: Carriers of C allele in rs730012 were more susceptible to ischemic stroke (OR: 1.37; 95%CI: 1.08-1.73; P=0.009). The rs2029253 GG genotype showed a risk-reducing effect on ischemic stroke (OR: 0.72; 95%CI:0.55-0.93; P=0.013) while the rs6538697 CC genotype had an increased risk of ischemic stroke (OR: 1.77; 95%CI: 1.09-2.89; P=0.022). The rs730012 variant was not associated with ischemic stroke risk after adjusting confounding factors (P>0.05).
    CONCLUSION: The present study suggested that gene polymorphisms in the leukotrienes pathway may exert influences, with independent genetic effects, on ischemic stroke susceptibility in a cohort of Chinese in east China.

    Risk factors and prognosis of critically ill cancer patients with postoperative acute respiratory insufficiency
    Xue-zhong Xing, Yong Gao, Hai-jun Wang, Quan-hui Yang, Chu-lin Huang, Shi-ning Qu, Hao Zhang, Hao Wang, Qing-ling Xiao, Ke-lin Sun
    2013, 4(1):  43-47.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.008
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    BACKGROUND: This study aimed to investigate the risk factors and outcome of critically ill cancer patients with postoperative acute respiratory insufficiency.
    METHODS: The data of 190 critically ill cancer patients with postoperative acute respiratory insufficiency were retrospectively reviewed. The data of 321 patients with no acute respiratory insufficiency as controls were also collected. Clinical variables of the first 24 hours after admission to intensive care unit were collected, including age, sex, comorbid disease, type of surgery, admission type, presence of shock, presence of acute kidney injury, presence of acute lung injury/acute respiratory distress syndrome, acute physiologic and chronic health evaluation (APACHE II) score, sepsis-related organ failure assessment (SOFA), and PaO2/FiO2 ratio. Duration of mechanical ventilation, length ofintensive care unit stay, intensive care unit death, length of hospitalization, hospital death and one-year survival were calculated.
    RESULTS: The incidence of acute respiratory insufficiency was 37.2% (190/321). Multivariate logistic analysis showed a history of chronic obstructive pulmonary diseases (P=0.001), surgery-related infection (P=0.004), hypo-volemic shock (P<0.001), and emergency surgery (P=0.018), were independent risk factors of postoperative acute respiratory insufficiency. Compared with the patients without acute respiratory insufficiency, the patients with acute respiratory insufficiency had a prolonged length of intensive care unit stay (P<0.001), a prolonged length of hospitalization (P=0.006), increased intensive care unit mortality (P=0.001), and hospital mortality (P<0.001). Septic shock was shown to be the only independent prognostic factor of intensive care unit death for the patients with acute respiratory insufficiency (P=0.029, RR: 8.522, 95%CI: 1.243-58.437, B=2.143, SE=0.982, Wald=4.758). Compared with the patients without acute respiratory insufficiency, those with acute respiratory insufficiency had a shortened one-year survival rate (78.7% vs. 97.1%,P<0.001).
    CONCLUSION: A history of chronic obstructive pulmonary diseases, surgery-related infection, hypovolemic shock and emergency surgery were risk factors of critically ill cancer patients with postoperative acute respiratory insufficiency. Septic shock was the only independent prognostic factor of intensive care unit death in patients with acute respiratory insufficiency. Compared with patients without acute respiratory insufficiency, those with acute respiratory insufficiency had adverse short-term outcome and a decreased one-year survival rate.

    Effect of spironolactone on cardiac remodeling after acute myocardial infarction
    Chun-tao Wu, Zhong-hua Wang, Zhu-qin Li, Lan-feng Wang
    2013, 4(1):  48-53.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.009
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    BACKGROUND: Few studies have reported the effect of aldosterone receptor antagonist (ARA) on myocardial remodeling after acute myocardial infarction (AMI). This study was undertaken to investigate the preventive effect of ARA on myocardial remodeling after AMI.
    METHODS: A total of 616 patients who had been admitted into the CCU of the First Affiliated Hospital of Harbin Medical University from January 2008 to January 2010 were studied prospectively. Only 528 patients were observed completely, including 266 of the control group and 262 of the treatment group. There was no statistical difference in age, gender, medical history, admission situation, and treatment between the two groups (P>0.05). The preventive effects of spironolactone on cardiac remodeling, left ventricular function, renal function and blood levels of potassium were evaluated by echocardiography, serum potassium and serum creatinine at one-month and one-year follow-up.
    RESULTS: The echocardiography indicators such as LVESD, LVEDD, LVEF, LAD-ML and LAD-SI were significantly improved in the treatment group compared with the control group at one year (P<0.05). In the treatment group, LVESD, LVEDD, LVPWT, LVEF, LAD-ML and LAD-SI were more significantly improved at one year than one month (P<0.05, P=0.007 to LVEF), and in the control group LVEF was more significantly improved at one year than one month (P=0.0277). There were no significant differences in serum potassium and serum creatinine levels between the two groups.
    CONCLUSION: On the basis of conventional treatment, the early combination of low-dose spironolactone (20 mg/d) could inhibit cardiac remodeling at late stage and prevent heart failure.

    Correlations between quality indexes of chest compression
    Feng-ling Zhang, Li Yan, Su-fang Huang, Xiang-jun Bai
    2013, 4(1):  54-58.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.010
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    BACKGROUND: Cardiopulmonary resuscitation (CPR) is a kind of emergency treatment for cardiopulmonary arrest, and chest compression is the most important and necessary part of CPR. The American Heart Association published the new Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care in 2010 and demanded for better performance of chest compression practice, especially in compression depth and rate. The current study was to explore the relationship of quality indexes of chest compression and to identify the key points in chest compression training and practice.
    METHODS: Totally 219 healthcare workers accepted chest compression training by using Laerdal ACLS advanced life support resuscitation model. The quality indexes of chest compression, including compression hands placement, compression rate, compression depth, and chest wall recoil as well as self-reported fatigue time were monitored by the Laerdal Computer Skills and Reporting System.
    RESULTS: The quality of chest compression was related to the gender of the compressor. The indexes in males, including self-reported fatigue time, the accuracy of compression depth and the compression rate, the accuracy of compression rate, were higher than those in females. However, the accuracy of chest recoil was higher in females than in males. The quality indexes of chest compression were correlated with each other. The self-reported fatigue time was related to all the indexes except the compression rate.
    CONCLUSION: It is necessary to offer CPR training courses regularly. In clinical practice, it might be better to change the practitioner before fatigue, especially for females or weak practitioners. In training projects, more attention should be paid to the control of compression rate, in order to delay the fatigue, guarantee enough compression depth and improve the quality of chest compression.

    Prognosis of patients with shock receiving vasopressors
    Xue-zhong Xing, Hai-jun Wang, Chu-lin Huang, Quan-hui Yang, Shi-ning Qu, Hao Zhang, Hao Wang, Yong Gao, Qing-ling Xiao, Ke-lin Sun
    2013, 4(1):  59-62.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.011
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    BACKGROUND: Consensus guidelines suggested that both dopamine and norepinephrine may be used, but specific doses are not recommended. The aim of this study is to determine the predictive role of vasopressors in patients with shock in intensive care unit.
    METHODS: One hundred and twenty-two patients, who had received vasopressors for 1 hour or more in intensive care unit (ICU) between October 2008 and October 2011, were included.There were 85 men and 37 women, with a median age of 65 years (55-73 years). Their clinical data were retrospectively collected and analyzed.
    RESULTS: The median simplified acute physiological score 3 (SAPS 3) was 50 (42-55). Multivariate analysis showed that septic shock (P=0.018, relative risk: 4.094; 95% confidential interval: 1.274-13.156), SAPS 3 score at ICU admission (P=0.028, relative risk: 1.079; 95% confidential interval: 1.008-1.155), and norepinephrine administration (P<0.001, relative risk: 9.353; 95% confidential interval: 2.667-32.807) were independent predictors of ICU death. Receiver operating characteristic curve analysis demonstrated that administration of norepinephrine ≥0.7 μg/kg per minute resulted in a sensitivity of 75.9% and a specificity of 90.3% for the likelihood of ICU death. In patients who received norepinephrine ≥0.7 μg/kg per minute there was more ICU death (71.4% vs. 44.8%) and in-hospital death (76.2% vs. 48.3%) than in those who received norepinephrine <0.7 μg/kg per minute. These patients had also a decreased 510-day survival rate compared with those who received norepinephrine <0.7 μg/kg per minute (19.2% vs. 64.2%).
    CONCLUSION: Septic shock, SAPS 3 score at ICU admission, and norepinephrine administration were independent predictors of ICU death for patients with shock. Patients who received norepinephrine ≥0.7 μg/kg per minute had an increased ICU mortality, an increased in-hospital mortality, and a decreased 510-day survival rate.

    Effect of β-sodium aescinate on hypoxia-inducible factor-1α expression in rat brain cortex after cardiopulmonary resuscitation
    Jian Kang, Ping Gong, Yan-bo Ren, Dong-na Gao, Qiong-lei Ding
    2013, 4(1):  63-68.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.012
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    BACKGROUND: This study was undertaken to investigate the expression of hypoxia-inducible factor-1α (HIF-1α) in rat cerebral cortex and the effects of β-sodium aescinate (SA) administration after return of spontaneous circulation (ROSC).
    METHODS: Sixty rats were divided into three groups: SA group, injected intraperitoneally with SA instantly after ROSC; control group, injected intraperitoneally with normal saline; and sham-operated group, without cardiac arrest or SA. The cardiac arrest model was established using asphyxiation and intravenous potassium chloride. Blood was sampled 1, 6, 12, and 24 hours after ROSC. Protein and mRNA levels of HIF-1α, VEGF and EPO were detected in the cerebral cortex by immunohistochemistry and real-time RT-PCR; serum levels of NSE and S100β were determined by enzyme-linked immunosorbent assays.
    RESULTS: Serum S100β and NSE were significantly increased in the control group versus the sham-operated group 1, 6, 12 and 24 hours after ROSC (P<0.05). Protein and mRNA levels of HIF-1α, VEGF and EPO were significantly increased in the control rats (P<0.05). Serum NSE and S100β were significantly decreased in the SA group versus the control group 1, 6, 12 and 24 hours after ROSC (P<0.05). Protein and mRNA levels of HIF-1α, VEGF and EPO were significantly increased in the SA group (P<0.05).
    CONCLUSIONS: The expression of HIF-1α is increased in rat cerebral cortex after ROSC, and SA up-regulates the expression of HIF-1α. The up-regulation of HIF-1α improves the resistance of the cortex to ischemia and hypoxia and contributes to neuroprotection, possibly because of up-regulation of EPO and VEGF expression.

    Case Reports
    May headache be the first sign of mutation in the MTHFR gene?
    Suber Dikici, Ayhan Saritas, Fahri Halit Besir, Gokhan Celbek, Guven Arslan
    2013, 4(1):  69-72.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.013
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    BACKGROUND: Cerebral venous thrombosis (CVT) is a rare disease and it has different etiologies. Inherited or acquired prothrombotic state plays a key role in the development of CVT.
    METHODS: A 28-year-old man who presented to our emergency department with persistent headache and accompanied by complaints of nausea and vomiting over a week. Neurologic examination revealed bilateral papilledema. Brain computed tomography showed a hyperdense area on the posterior part of the occipital lobe. Brain magnetic resonance imaging and magnetic resonance venography revealed thrombosis of CVT. Homozygous mutations were found for methylenetetrahydrofolate reductase (MTHFR). MTHFR CG677T gene mutation and blood tests showed elevated homocysteine levels on the etiological screening. There was no other etiology for CVT.
    RESULTS: Headache and other complaints were improved after treatment of heparin, warfarin, and vitamin B12. No recurrence of symptoms was observed upon outpatient follow-up.
    CONCLUSION: Since CVT is an important cause of headache, we recommend etiology screening for patients who present with CVT for MTHFR gene mutations and family counseling should be provided.

    Suicidal ingestion of potassium permanganate
    Esin Korkut, Ayhan Saritas, Yusuf Aydin, Semih Korkut, Hayati Kandis, Davut Baltaci
    2013, 4(1):  73-74.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.014
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    BACKGROUND: Potassium permanganate is used clinically as an antiseptic and antifungal agent. Ingestion of potassium permanganate may result in damage to the upper gastrointestinal tract. Burns and ulceration of the mouth, esophagus and stomach occur due to its action. Emergency endoscopy is useful to assess the severity of damage and also to guide management.
    METHODS: We reported a patient presenting to the emergency department after suicidal ingestion of potassium permanganate.
    RESULTS: After treatment, the patient was discharged home on the 7th day after admission.
    CONCLUSION: Early emergency endoscopy should be considered to determine the extent of upper gastrointestinal damage in the emergency department.

    Clinical Image
    ECG after near-drowning mimicking acute coronary syndrome with left main coronary artery involvement
    Alfredo Vidal García, Javier Lacunza Ruiz, José María López Ayala, Mariano Valdés
    2013, 4(1):  75-76.  doi:10.5847/wjem.j.issn.1920-8642.2013.01.015
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    Editorial Office
    2013, 4(1):  77. 
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    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.