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    15 June 2013, Volume 4 Issue 2
    Review Articles
    Epinephrine in out-of-hospital cardiac arrest:A critical review
    Peter M. Reardon, Kirk Magee
    2013, 4(2):  85-91.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.001
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    BACKGROUND: Epinephrine is recommended in advanced cardiac life support guidelines for use in adult cardiac arrest, and has been used in cardiopulmonary resuscitation since 1896. Yet, despite its long time use and incorporation into guidelines, epinephrine suffers from a paucity of evidence regarding its influence on survival. This critical review was conducted to address the knowledge deficit regarding epinephrine in out-of-hospital cardiac arrest and its effect on return of spontaneous circulation, survival to hospital discharge, and neurological performance.
    METHODS: The EMBASE and MEDLINE (through the Pubmed interface) databases, and the Cochrane library were searched with the key words "epinephrine", "cardiac arrest" and variations of these terms. Original research studies concerning epinephrine use in adult, out-of-hospital cardiac arrest were selected for further review.
    RESULTS: The search yielded nine eligible studies based on inclusion criteria. This includes five prospective cohort studies, one retrospective cohort study, one survival analysis, one case control study, and one RCT. The evidence clearly establishes an association between epinephrine and increased return of spontaneous circulation, the data were conflicting concerning survival to hospital discharge and neurological outcome.
    CONCLUSIONS: The results of this review exhibit the paucity of evidence regarding the use of epinephrine in out of hospital cardiac arrest. There is currently insufficient evidence to support or reject its administration during resuscitation. Larger sample, placebo controlled, double blind, randomized control trials need to be performed to definitively establish the effect of epinephrine on both survival to hospital discharge and the neurological outcomes of treated patients.

    The potential contributions of traditional Chinese medicine to emergency medicine
    Jun He, Xiang-yu Hou
    2013, 4(2):  92-97.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.002
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    BACKGROUND: Despite the fact that traditional Chinese medicine (TCM) has been developed and used to treat acute and urgent illness for many thousands of years. TCM has been widely perceived in western societies that TCM may only be effective to treat chronic diseases. The aim of this article is to provide some scientific evidence regarding the application of TCM in emergency medicine and its future potential.
    METHODS: Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) were searched using the terms: Traditional Chinese Medicine/ Chinese Medicine, Emergency Medicine, China. In addition, three leading TCM Journals in China were searched via Oriprobe Information Services for relevant articles (published from 1990—2012). Particular attention was paid to those articles that are related to TCM treatments or combined medicine in dealing with intensive and critical care.
    RESULTS: TCM is a systematic traditional macro medicine. The clinical practice of TCM is guided by the TCM theoretical framework - a methodology founded thousands of years ago. As the methodologies between TCM and Biomedicine are significantly different, it provides an opportunity to combine two medicines, in order to achieve clinical efficacy. Nowadays, combined medicine has become a common clinical model particular in TCM hospitals in China.
    CONCLUSIONS: It is evident that TCM can provide some assistance in emergency although to combine them in practice is still its infant form and is mainly at TCM hospitals in China. The future effort could be put into TCM research, both in laboratories and clinics, with high quality designs, so that TCM could be better understood and then applied in emergency medicine.

    Original Articles
    Evaluating the management of anaphylaxis in US emergency departments: Guidelines vs. practice
    W. Scott Russell, Judith Rosen Farrar, Richard Nowak, Daniel P. Hays, Natalie Schmitz, Joseph Wood, Judi Miller
    2013, 4(2):  98-106.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.003
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    BACKGROUND: Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting. Current guidelines recommend: 1) quick diagnosis using standard criteria; 2) first-line treatment with epinephrine; and 3) discharge with a prescription for an epinephrine auto-injector, written instructions regarding long-term management, and a referral (preferably, allergy) for follow-up. However, studies suggest low concordance with guideline recommendations by emergency medicine (EM) providers. The study aimed to evaluate how emergency departments (EDs) in the United States (US) manage anaphylaxis in relation to guideline recommendations.
    METHODS: This was an online anonymous survey of a random sample of EM health providers in US EDs.
    RESULTS: Data analysis included 207 EM providers. For respondent EDs, approximately 9% reported using agreed-upon clinical criteria to diagnose anaphylaxis; 42% reported administering epinephrine in the ED for most anaphylaxis episodes; and <50% provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge. Most provided some written materials, and follow-up with a primary care clinician was recommended.
    CONCLUSIONS: This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis, treatment, and follow-up of patients with anaphylaxis. The primary gaps are low (or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine. Prospective research is recommended.

    Emergency department rectal temperatures in over 10 years: A retrospective observational study
    Graham A. Walker, Daniel Runde, Daniel M. Rolston, Dan Wiener, Jarone Lee
    2013, 4(2):  107-112.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.004
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    BACKGROUND: Fever in patients can provide an important clue to the etiology of a patient's symptoms. Non-invasive temperature sites (oral, axillary, temporal) may be insensitive due to a variety of factors. This has not been well studied in adult emergency department patients. To determine whether emergency department triage temperatures detected fever adequately when compared to a rectal temperature.
    METHODS: A retrospective chart review was made of 27 130 adult patients in a high volume, urban emergency department over an eight-year period who received first a non-rectal triage temperature and then a subsequent rectal temperature.
    RESULTS: The mean difference in temperatures between the initial temperature and the rectal temperature was 1.3 °F (P<0.001), with 25.9% of the patients having higher rectal temperatures ≥2 °F, and 5.0% having higher rectal temperatures ≥4 °F. The mean difference among the patients who received oral, axillary, and temporal temperatures was 1.2 °F (P<0.001), 1.8 °F (P<0.001), and 1.2 °F (P<0.001) respectively. About 18.1% of the patients were initially afebrile and found to be febrile by rectal temperature, with an average difference of 2.5 °F (P<0.001). These patients had a higher rate of admission (61.4%, P<0.005), and were more likely to be admitted to the hospital for a higher level of care, such as an intensive care unit, when compared with the full cohort (12.5% vs. 5.8%, P<0.005).
    CONCLUSIONS: There are significant differences between rectal temperatures and non-invasive triage temperatures in this emergency department cohort. In almost one in five patients, fever was missed by triage temperature.

    General characteristics of patients with electrolyte imbalance admitted to emergency department
    Arif Kadri Balcı, Ozlem Koksal, Ataman Kose, Erol Armagan, Fatma Ozdemir, Taylan Inal, Nuran Oner
    2013, 4(2):  113-116.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.005
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    BACKGROUND: Fluid and electrolyte balance is a key concept to understand for maintaining homeostasis, and for a successful treatment of many metabolic disorders. There are various regulating mechanisms for the equilibrium of electrolytes in organisms. Disorders of these mechanisms result in electrolyte imbalances that may be life-threatening clinical conditions. In this study we defined the electrolyte imbalance characteristics of patients admitted to our emergency department.
    METHODS: This study was conducted in the Emergency Department (ED) of Uludag University Faculty of Medicine, and included 996 patients over 18 years of age. All patients had electrolyte imbalance, with various etiologies other than traumatic origin. Demographic and clinical parameters were collected after obtaining informed consent from the patients. The ethical committee of the university approved this study.
    RESULTS: The mean age of the patients was 59.28±16.79, and 55% of the patients were male. The common symptoms of the patients were dyspnea (14.7%), fever (13.7%), and systemic deterioration (11.9%); but the most and least frequent electrolyte imbalances were hyponatremia and hypermagnesemia, respectively. Most frequent findings in physical examination were confusion (14%), edema (10%) and rales (9%); and most frequent pathological findings in ECG were tachycardia in 24%, and atrial fibrillation in 7% of the patients. Most frequent comorbidity was malignancy (39%). Most frequent diagnoses in the patients were sepsis (11%), pneumonia (9%), and acute renal failure (7%).
    CONCLUSIONS: Electrolyte imbalances are of particular importance in the treatment of ED patients. Therefore, ED physicians must be acknowledged of their fluid-electrolyte balance dynamics and general characteristics.

    Effect of early goal directed therapy on tissue perfusion in patients with septic shock
    Yuan-hua Lu, Ling Liu, Xiao-hua Qiu, Qin Yu, Yi Yang, Hai-bo Qiu
    2013, 4(2):  117-122.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.006
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    BACKGROUND: This study aimed to observe the effect of early goal directed therapy (EGDT) on tissue perfusion, microcirculation and tissue oxygenation in patients with septic shock.
    METHODS: Patients with early septic shock (<24 hours) who had been admitted to the ICU of Zhongda Hospital Affiliated to Southeast University from September 2009 through May 2011 were enrolled (research time: 12 months), and they didn’t meet the criteria of EGDT. Patients who had one of the following were excluded: stroke, brain injury, other types of shock, severe heart failure, acute myocardial infarction, age below 18 years, pregnancy, end-stage disease, cardiac arrest, extensive burns, oral bleeding, difficulty in opening the mouth, and the onset of septic shock beyond 24 hours. Patients treated with the standard protocol of EGDT were included. Transcutaneous pressure of oxygen and carbon dioxide (PtcO2, PtcCO2) were monitored and hemodynamic measurements were obtained. Side-stream dark field (SDF) imaging device was applied to obtain sublingual microcirculation. Hemodynamics, tissue oxygen, and sublingual microcirculation were compared before and after EGDT. If the variable meets the normal distribution, Student’s t test was applied. Otherwise, Wilcoxon’s rank-sum test was used. Correlation between variables was analyzed with Pearson’s product-moment correlation coefficient method.
    RESULTS: Twenty patients were involved, but one patient wasn’t analyzed because he didn’t meet the EGDT criteria. PtcO2 and PtcCO2 were monitored in 19 patients, of whom sublingual microcirculation was obtained. After EGDT, PtcO2 increased from 62.7±24.0 mmHg to 78.0±30.9 mmHg (P<0.05) and tissue oxygenation index (PtcO2/FiO2) was 110.7±60.4 mmHg before EGDT and 141.6±78.2 mmHg after EGDT (P<0.05). The difference between PtcCO2and PCO2 decreased significantly after EGDT (P<0.05). The density of perfused small vessels (PPV) and microcirculatory flow index of small vessels (MFI) tended to increase, but there were no significant differences between them (P>0.05). PtcO2, PtcO2/FiO2, and PtcCO2 were not linearly related to central venous saturation, lactate, oxygen delivery, and oxygen consumption (P>0.05).
    CONCLUSION: Peripheral perfusion was improved after EGDT in patients with septic shock, and it was not exactly reflected by the index of systemic perfusion.

    CoolClot, a novel hemostatic agent for controlling life-threatening arterial bleeding
    SMJ Mortazavi, A Tavasoli, M Atefi, N Tanide, N Radpey, P Roshan-shomal, H Moradi, S Taeb
    2013, 4(2):  123-127.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.007
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    BACKGROUND: Uncontrolled bleeding is the first leading cause of preventable death in the battlefield and the 2nd cause of mortality in civil accidents. Incompressible hemorrhage control is among the interventions that drastically increase the survival rate in wound individuals. We have previously shown that a certain mixture of bentonite and zeolite minerals can significantly decrease the bleeding in rats.
    METHODS: In this study, nine healthy hybrid dogs were selected and after induction of anesthesia with ether, either arterial puncture by a needle or arteriotomy was performed on both groin regions of the dogs. For control arteries (either the right or left femoral artery), only pressure by sterilized gauze was performed, while for the femoral arteries of the opposite side, our invented hemostatic agent, namely CoolClot, was topically used before applying the pressure. In the second stage of the study, to assess the coagulation time, blood samples were collected from 10 volunteer students.
    RESULTS: CoolClot significantly decreased the bleeding time in animals whose femoral arteries were cut or punctured. In the human phase of the study, the mean coagulation time in control blood samples was 253.4±44.1 seconds, whereas it was 149.5±50.0, 162.3±74.6 and 143.4±114.6 seconds, respectively in blood samples treated with bentonite, zeolite and CoolClot (P<0.05).
    CONCLUSIONS: As controlling bleeding after a life-threatening arterial damage is critical for increasing the chance of survival, the results obtained in this study indicate the significant efficacy of CoolClot in shortening the bleeding time. Our experiments also indicate that CoolClot can significantly reduce the clotting time in human blood samples.

    Perforin gene mutations in 77 Chinese patients with lymphomas
    Qi Ding, Li-yun Yang
    2013, 4(2):  128-132.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.008
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    BACKGROUND: Perforin gene (PRF1) mutations have been reported in patients with lymphoma, but the prevalence and characteristics of PRF1mutation have not been identified in Chinese patients with lymphoma.
    METHODS: Seventy-seven patients with lymphoma, including 6 patients with Hodgkin lymphoma and 71 patients with non-Hodgkin lymphoma, were recruited. DNA samples from peripheral blood were used for PRF1 mutation detection by the PCR-sequencing method.
    RESULTS: Eleven novel PRF1 mutations were found in 8 of the 77 patients with lymphoma. Biallelic or compound monoallelic missense mutations in 3 patients indicated the severe impairment of perforin function, monoallelic missense mutations in 3 patients possibly contributed a genetic predisposition to malignancies, and synonymous mutations in 2 patients showed unknown significance.
    CONCLUSIONS: The frequency of EBV infection was similar in lymphoma patients with PRF1 mutations and those without the mutations. The same PRF1mutations were also found in DNA samples from nails or hair follicles from 4 patients with PRF1 mutations, suggesting that these mutations may be of germ-line origin.

    Effect of ulinastatin on paraquat-induced-oxidative stress in human type II alveolar epithelial cells
    Xiao-xiao Meng, Rui-lan Wang, Shan Gao, Hui Xie, Jiu-ting Tan, Yong-bin Qian
    2013, 4(2):  133-137.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.009
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    BACKGROUND: Ulinastatin (UTI) is a urinary trypsin inhibitor extracted and purified from urine of males. This study aimed to explore the effects of UTI on paraquat-induced-oxidative stress in human type II alveolar epithelial cells.
    METHODS: The human type II alveolar epithelial cells, A549 cells, were cultured in vitro. The A549 cells were treated with different concentrations of paraquat (200, 400, 600, 800, 1 000, 1 200 µmol/L) and ulinastatin(0, 2 000, 4 000, 6 000, 8 000 U/mL) for 24 hours, the cell viability was measured by cell counting kit-8 and the median lethal concentration was selected. In order to establish an in vitro model of paraquat intoxication and to determine the safe dose of ulinastatin, we calculated LD50 using cell counting kit-8 to determine the survival rate of the cells. A549 cells were divided into normal control group, paraquat group and paraquat+ulinastatin group. The levels of malondialdehyde (MDA) and myeloperoxidase (MPO) were detected by biochemistry colorimetry, while the level of reactive oxygen spies (ROS) was detected by DCFH-DA assay.
    RESULTS: The survival rate of A549 cells treated with different concentrations of paraquat decreased in a concentration-dependent manner. Whereas there was no decrease in the survival rate of cells treated with 0-4 000 U/mL ulinastatin. The levels of MDA, MPO, and ROS were significantly higher in the paraquat group than in the normal control group after 24-hour-exposure. And the survival rate of the paraquat+ulinastatin group was higher than that of the paraquat group, but lower than that of the normal control group. The levels of MDA, MPO, and ROS were lower than those of the paraquat group.
    CONCLUSION: Ulinastatin can alleviate the paraquat-induced A549 cell damage by reducing oxidative stress.

    Effect of metoprolol on myocardial apoptosis after coronary microembolization in rats
    Qiang Su, Lang Li, Yang-chun Liu, You Zhou, Wei-ming Wen
    2013, 4(2):  138-143.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.010
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    BACKGROUND: Coronary microembolization (CME) is a serious complication following percutaneous coronary intervention (PCI) in patients with acute coronary syndromes. The use of metoprolol before PCI can significantly protect ischemic myocardium from myocardial damage, but the function of metoprolol in the treatment of CME is not entirely clear. This study was to explore the effect and significance of metoprolol on myocardial apoptosis and caspase-3 activation after CME in rats.
    METHODS: Thirty rats were randomly divided into three groups including sham-operation (control group), CME plus saline (CME group), CME plus metoprolol (metoprolol group), 10 rats for each group. The CME group was induced by injecting 3 000 polyethylene microspheres (42 μm) into the left ventricle during a 10-second occlusion of the ascending aorta; the control group was injected with physiological saline instead of microembolization ball; the metoprolol or saline group was given three intravenous bolus injections before CME. Echocardiography, TUNEL staining, and Western blotting were used to evaluate cardiac function, proportion of apoptotic cells and activation of caspase-3 respectively at 6 hours after operation.
    RESULTS: Echocardiographic parameters displayed that the metoprolol group improved cardiac function significantly compared with the CME group (P<0.05). The myocardial apoptotic rate of the CME group as well as the contents of activated caspase-3 increased significantly (P<0.05), both of which were ameliorated significantly by metoprolol treatment (P<0.05).
    CONCLUSIONS: This study demonstrates that metoprolol can protect the myocardium during CME in rats by inhibiting apoptosis and improving cardiac function. These results suggest that the inhibition of apoptosis can be a potential therapeutic strategy for the treatment of CME.

    Therapeutic effects of smecta or smectite powder on rats with paraquat toxication
    Yin-song Jiang, Yu-ying Ma, Zhan-qing Wang, Guang-jun Li
    2013, 4(2):  144-150.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.011
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    BACKGROUND: The plasma concentration of paraquat is closely related to the prognosis of patients with paraquat toxication, and the most common cause of death from paraquat poisoning is multiple organ failure (MOF). This study aimed to evaluate therapeutic effect of smecta on the plasma concentrations of paraquat and multi-organ injury induced by paraquat intoxication in rats.
    METHODS: A total of 76 healthy adult SD rats were randomly divided into group A (control group, n=6), group B (poisoned group, n=30) and group C (smecta-treated group, n=30). Rats in groups B and C were treated intragastrically with PQ at 50 mg/kg, and rats in group A was treated intragastrically with saline (1 mL). Rats in group C were given intragastrically smecta at 400 mg/kg 10 minutes after administration of PQ, while rats in other two groups were treated intragastrically with 1 mL saline at the same time. Live rats in groups B and C were sacrificed at 2, 6, 24, 48, 72 hours after administration of PQ for the determination of paraquat plasma concentrations and for HE staining of the lung, stomach and jejunum. The rats were executed at the end of trial by the same way in group A.
    RESULTS: The plasma concentration of paraquat (ng/mL) ranged from 440.314±49.776 to 4320.6150±413.947. Distinctive pathological changes were seen in the lung, stomach and jejunum in group B. Lung injuries deteriorated gradually, edema, leukocyte infiltration, pneumorrhagia, incrassated septa and lung consolidation were observed. Abruption of mucosa, hyperemic gastric mucosa and leukocyte infiltration were obvious in the stomach. The hemorrhage of jejunum mucosa, the abruption of villus, the gland damage with the addition of inflammatory cell infiltration were found. Compared to group B, the plasma concentration of paraquat reduced (P<0.01) and the pathological changes mentioned above were obviously alleviated in group C (P<0.05, P<0.01).
    CONCLUSION: Smecta reduced the plasma concentration of paraquat and alleviated pathologic injury of rats with PQ poisoning.

    Case Reports
    Meningitis secondary to Cryptococcus gattii, an emerging pathogen affecting immunocompetent hosts
    Laura Cookman, Maria Hugi
    2013, 4(2):  151-153.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.012
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    BACKGROUND: Meningitis continues to be one of the most important infections diagnosed and treated by emergency physicians. Despite the advent of anti-infective therapy, meningitis carries a mortality rate of 20%-40%. In this study, we describe the first reported emergency medicine case of meningitis associated with Cryptococcus gattii to alert providers of this insidious, emerging global pathogen infecting immunocompetent individuals.
    METHODS: We provided a case report and accompanying review of the literature. A MEDLINE search for the term Cryptoccocus gattii was performed to obtain background information on Cryptococcus gattii.
    RESULTS: After two months of hospitalization, the patient was eventually discharged neurologically intact except for a continued mild bilateral hearing deficit.
    CONCLUSION: Cryptococcus gattii is an emerging world pathogen, which affects otherwise healthy, immunocompetent patients and requires timely identification and treatment in order to prevent severe neurological sequelae.

    Staphylococcal thoracic aortitis complicated by aortic dissection
    Paul Chun Yih Lim, Jean Mui Hua Lee, Yeow Leng Chua, Stanley Chia
    2013, 4(2):  154-156.  doi:10.5847/wjem.j.issn.1920-8642.2013.02.013
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    BACKGROUND: The diagnosis of aortitis is often delayed as symptoms are largely non-specific. We report a case of Staphylococcal thoracic aortitis in a 73-year-old Chinese woman complicated by aortic dissection.
    METHODS: The patient presented with pyrexia of unknown origin, and a contrast enhanced computed tomography aortogram revealed a large thrombus at the anterior aspect of the ascending aorta with two large ulcerations as a result of a chronic type A aortic dissection. A hemiarch replacement with a 28 mm Gleweave Vascutek graft was performed with resuspension of aortic valve commisures. Aortic thrombus cultures were positive for coagulase negativeStaphylococcus aureaus, and histology showed chronic dissection of the aorta.
    RESULTS: The patient was treated with intravenous cefazolin for a 6-week duration and made good progress.
    CONCLUSIONS: This case highlights Staphylococcal infective aortitis complicated by dissection presenting as fever of unknown origin. Timely diagnosis is essential as progression to catastrophic rupture may occur.