Table of Content

15 June 2012, Volume 3 Issue 2

Previous Issue    Next Issue

Review Article

An overview of emergency ultrasound in the United States

Jeremy A. Michalke

2012, 3(2):  85-90.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.001

Asbtract    HTML    PDF (402KB)   

BACKGROUND: As emergency ultrasound use explodes around the world, it is important to realize the path its development has taken and learn from trials and tribulations of early practitioners in the field.

METHODS: Approaches to education, scanning, documentation, and organization are also described.

RESULTS: Machines have reduced in price and once purchased further material costs are low. Staffing costs in terms of training, etc have yet to be assessed, but indications from elsewhere are that these are low. Length of stay in the emergency department dramatically decreases, thus increasing patient satisfaction while maintaining an even higher standard of care.

CONCLUSION: Emergency screening ultrasound is now a nationally accepted tool for the rapid assessment of the emergency patient.

Original Articles

Emergency department visits: Why adults choose the emergency room over a primary care physician visit during regular office hours?

Courtney Rocovich, Trushnaa Patel

2012, 3(2):  91-97.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.002

Asbtract    HTML    PDF (247KB)   

BACKGROUND: It has been estimated that up to one third of all emergency department (ED) visits may be "inappropriate" or non-emergent. Factors that have been speculated to be associated with non-emergent use have been noted to include low socioeconomic status, lack of access to primary care, lack of insurance, convenience of "on demand care" and the patient's individual perception of their complaint urgency. The objective of this study is to identify the reasons contributing to self-perceived non-emergent adult emergency department visits during primary care physician office hours of operation.

METHODS: This study was a single-center, descriptive study with questionnaire. The questionnaire was collected from patients meeting exclusion/inclusion criteria who were triaged into an acute or fast track part of the emergency department during regular business hours on Monday through Friday, 8:00 am-5:00 pm during the months of July 2011 and August 2011. Questionnaire data were categorical and summarized using counts and percentages. Data collected included patient demographics, information about the patient's primary care provider, and information about the emergency department visit in question. All responses were compared among patients with visits considered to be non-emergent to those considered to be emergent by using individual chi-square tests.

RESULTS: There were 262 patients available for the study. The patients were grouped according to their perception of the severity of their complaints. Roughly half of the patients placed themselves into the non-emergent category (n=129), whereas the other half of the patients categorized themselves into the emergent group (n=131). There were statistically significant differences in marital status and employment status between the two groups. It was found that 61.5% of the non-emergent patients were single, while 58.3% of the emergent patients were married. In the non-emergent group, 59.7% were unemployed, but in the emergent group 60.3% were employed (P<0.05). However, no other factors were significantly different.

CONCLUSIONS: Our study did not identify a statistically significant factor to the reasoning behind why patients choose the emergency department over a primary care physician during regular office hours. The only significant demographic indicating who was more likely to make this choice during the specified time frame was being single and employed with perceived non-emergent complaint. Patients without insurance and/or without a primary care physician were no more likely to visit the emergency department with a self-perceived non-emergent issue than patients with insurance and/or with an established primary care physician.

Emergency department operations and management education in emergency medicine training

Bret A Nicks, Darrell Nelson

2012, 3(2):  98-101.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.003

Asbtract    HTML    PDF (204KB)   

BACKGROUND: This study was undertaken to examine the current level of operations and management education within US-based Emergency Medicine Residency programs.

METHODS: Residency program directors at all US-based Emergency Medicine Residency programs were anonymously surveyed via a web-based instrument. Participants indicated their levels of residency education dedicated to documentation, billing/coding, core measure/quality indicator compliance, and operations management. Data were analyzed using descriptive statistics for the ordinal data / Likert scales.

RESULTS: One hundred and six (106) program directors completed the study instrument of one hundred and fifty-six (156) programs (70%). Of these, 82.6% indicated emergency department (ED) operations and management education within the training curriculum. Dedicated documentation training was noted in all but 1 program (99%). Program educational offerings also included billing/coding (83%), core measure/quality indicators (78%) and operations management training (71%). In all areas, the most common means of educating came through didactic sessions and direct attending feedback or 69%-94% and 72%-98% respectively. Residency leadership was most confident with resident understanding of quality documentation (80%) and less so with core measures (72%), billing/coding/RVUs (58%), and operations management tools (23%).

CONCLUSIONS: While most EM residency programs integrate basic operational education related to documentation and billing/coding, a smaller number provide focused education on the day-to-day management and operations of the ED. Residency leadership perceives graduating resident understanding of operational management tools to be limited. All respondents value further resident curriculum development of ED operations and management.

An automated dispensing system for improving medication timing in the emergency department

Michael J. Ward, Jeremy S. Boyd, Nicole J. Harger, John M. Deledda, Carol L. Smith, Susan M. Walker, Jeffrey D. Hice, Kimberly W. Hart, Christopher J. Lindsell, Stewart W. Wright

2012, 3(2):  102-107.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.004

Asbtract    HTML    PDF (271KB)   

BACKGROUND: Numerous medical conditions require timely medication administration in the emergency department (ED). Automated dispensing systems (ADSs) store premixed common doses at the point-of-care to minimize time to administration, but the use of such automation to improved time to medication administration has not been studied. Since vancomycin is a commonly used empiric antimicrobial, we sought to quantify the effect of using an ADS on time to drug delivery in patients presenting to the ED. The study aimed to determine the efficacy of utilizing an ADS to improve time to administration of vancomycin and determine any negative effects on dosing appropriateness.

METHODS: The institional review board approved the retrospective quality improvement study took place in a single, urban academic tertiary care ED with an annual census of 80 000. Study subjects were all patients receiving vancomycin for the management of sepsis between March 1 to September 30, 2008 and the same time period in 2009. The primary outcome was the proportion of patients who received vancomycin within one hour of bed placement and the secondary outcome was dosing appropriateness.

RESULTS: Sixty-three patients had weight and dosing information available (29 before and 34 after intervention) and were included in the study. Before intervention, no patient received vancomycin in less than 60 minutes, while after intervention 14.7% of the patients received it in less than 60 minutes (difference in proportions 14.7%, 95% CI 0.39%-30.0%, P=0.04). A similar proportion of the patients received correct dosing before and after intervention (44.8% vs. 41.2%, difference in proportions 3.7%, 95% CI -20.0%-26.7%, P=0.770).

CONCLUSION: The use of an ADS may improve the timing of medication administration in patients presenting to the ED without affecting dosing appropriateness.

Association of ALOX5AP with ischemic stroke in eastern Chinese

Yao Wang, Gan-nan Wang, Hao Sun, Chen Chen, Hang Xiao, Jin-song Zhang

2012, 3(2):  108-113.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.005

Asbtract    HTML    PDF (335KB)   

BACKGROUND: 5-lipoxygenase protein (ALOX5AP) has been recognized as a susceptibility gene for stroke and coronary artery diseases. The present study was to explore the role of this gene in the eastern Chinese patients with ischemic stroke.

METHODS: Using a case-control design, we studied 658 patients with ischemic stroke and 704 unrelated population-based controls who were age- and sex-matched. The 658 patients were classified by the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Two single-nucleotide polymorphisms (SNPs) covering ALOX5AP were genotyped.

RESULTS: The genotype frequencies of TG of the SNPs rs17222919 located in the promoter of the ALOX5AP gene were significantly higher in patients with ischemic stroke than in controls (OR^*=1.34, 95%CI^*=1.02-1.75), especially in patients with ischemic stroke caused by small-artery occlusion (SAO) (OR^*=1.40, 95%CI^*=1.02-1.93). Meanwhile, the genotype frequencies of TG and TG/GG were higher in female patients than in the controls. After specification, the genotype frequencies of TG and TG/GG were higher in the patients than in controls with hypertension. The genotype frequencies of AG and AG/GG of the SNPs rs9579646 located in the intron of the ALOX5AP gene were higher in the controls than in the patients. After specification, the genotype frequencies of TG were higher in the controls than patients without hypertension.

CONCLUSION: The present study suggests that sequence variants in the ALOX5AP gene are significantly associated with ischemic stroke.

Modified shock index and mortality rate of emergency patients

Ye-cheng Liu, Ji-hai Liu, Zhe Amy Fang, Guang-liang Shan, Jun Xu, Zhi-wei Qi, Hua-dong Zhu, Zhong Wang, Xue-zhong Yu

2012, 3(2):  114-117.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.006

Asbtract    HTML    PDF (247KB)   

BACKGROUND: This study aimed to determine whether modified shock index (MSI) is associated with mortality that is superior to heart rate, blood pressure, or the shock index (SI) in emergency patients.

METHODS: A retrospective database review was performed on 22 161 patients who presented to Peking Union Medical College Hospital Emergency Department and received intravenous fluids from January 1 to December 31, 2009. We gathered data of the patients on age, gender, vital signs, levels of consciousness, presenting complaints, and SI and MSI were calculated for all patients.

RESULTS: Multivariate regression analysis was performed to determine the correlation between risk factors and outcome. There is a significant correlation between emergency patient mortality rate and patient's vital signs obtained at the triage desk (HR>120 beats/min, systolic BP<90 mmHg, diastolic BP<60 mmHg). MSI is a stronger predictor of emergency patient mortality compared to heart rate and blood pressure alone, whereas SI does not have a significant correlation with emergency patient mortality rate.

CONCLUSION: MSI is a clinically significant predictor of mortality in emergency patients. It may be better than using heart rate and blood pressure alone. SI is not significantly correlated with the mortality rate of the emergency patient.

Induction of therapeutic hypothermia via the esophagus:a proof of concept study

Erik B. Kulstad, D. Mark Courtney, Donald Waller

2012, 3(2):  118-122.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.007

Asbtract    HTML    PDF (221KB)   

BACKGROUND: Induction of hypothermia (a 4 °C decrease from baseline) improves outcomes in adult cardiac arrest and neonatal hypoxic ischemic encephalopathy, and may benefit other conditions as well. Methods used to implement or prevent hypothermia typically require skin contact with blankets or pads or intravascular access with catheter devices. The study was to evaluate the potential to induce mild therapeutic hypothermia via an esophageal route in a porcine model.

METHODS: Single-animal proof-of-concept study of a prototype esophageal device in a 70 kg Yorkshire swine. We measured the rate of temperature change after placement of a prototype device to induce hypothermia via the esophagus, and compared this rate to known temperature changes that occur under similar laboratory conditions without a hypothermic device.

RESULTS: Swine temperature decreased from a starting temperature of 37.8 °C to 33.8 °C (achieving the goal of a 4 °C decrease) in 175 minutes, resulting in a cooling rate of 1.37 °C/h. Histopathology of the esophagus showed normal tissue without evidence of injury.

CONCLUSION: A prototype of an esophageal cooling device induced hypothermia effectively in a large single-swine model.

Association of genetic variants in the IRAK-4 gene with susceptibility to severe sepsis

Jun Yin, Yao Chen-ling, Cheng-long Liu, Zhen-ju Song, Chao-yang Tong, Pei-zhi Huang

2012, 3(2):  123-127.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.008

Asbtract    HTML    PDF (308KB)   

BACKGROUND: The association of genetic variation in the IRAK-1 gene with sepsis outcome has been proved. However, few studies have addressed the impact of the IRAK-4 gene variants on sepsis risk. This study aimed to determine whether the polymorphisms in the IRAK-4 gene are associated with susceptibility to and prognosis of severe sepsis in the Chinese Han ethnic population.

METHODS: In this case-control study, 192 patients with severe sepsis hospitalized in the emergency department of Zhongshan Hospital from February 2006 to December 2009 and 192 healthy volunteers were enrolled. Exclusion criteria included metastatic tumors, autoimmune diseases, AIDS or treatment with immunosuppressive drugs. This study was approved by the ethical committee of Zhongshan Hospital, Fudan University. Sepsis patients were divided into a survival group (n=124) and a non-survival group (n=68) according to the 30-day mortality. Primer 3 software was used to design PCR and sequencing primers. Genomic DNA was extracted from peripheral blood mononuclear cells. Seven tagSNPs in IRAK-4 were selected according to the data of the Chinese Han population in Beijing from the Hapmap project and genotyped by direct sequencing. The chi-square test was used to evaluate the differences in genotype and allele frequencies between the two groups.

RESULTS: The distributions of all tagSNPs were consistent with Hardy-Weinberg equilibrium. The allele and genotype frequencies of rs4251545 (G/A) were significantly different between the severe sepsis and healthy control groups (P=0.015, P=0.035, respectively). Carriers of the rs4251545A had a higher risk for severe sepsis compared with carriers of the rs4251545G (OR=1.69, 95% CI: 1.10-2.58). The allele and genotype frequencies of all SNPs were not significantly different between the survival group and non-survival group.

CONCLUSION: These findings indicate that the variants in IRAK-4 are significantly associated with susceptibility to severe sepsis in the Chinese Han ethnic population.

Effects of environmental hypothermia on hemodynamics and oxygen dynamics in a conscious swine model of hemorrhagic shock

Cheng Zhang, Guang-rong Gao, Hui-yong Jiang, Chen-guang Lv, Bao-lei Zhang, Ming-shuang Xie, Zhi-li Zhang, Li Yu, Xue-feng Zhang

2012, 3(2):  128-134.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.009

Asbtract    HTML    PDF (294KB)   

BACKGROUND: Hypothermia is associated with poor outcome in trauma patients; however, hemorrhagic shock (HS) model with anesthetized swine was different from that of clinical reality. To identify the effects of environmental hypothermia on HS, we investigated hemodynamics and oxygen dynamics in an unanesthetized swine model of HS under simulating hypothermia environment.

METHODS: Totally 16 Bama pigs were randomly divided into ambient temperature group (group A) and low temperature group (group B), 8 pigs in each group. Venous blood (30 mL/kg) was continuously withdrawn for more than 15 minutes in conscious swine to establish a hemorrhagic shock model. Pulmonary arterial temperature (Tp), heart rate (HR), mean arterial pressure (MAP), pulmonary arterial pressure (PAP), pulmonary arterial wedge pressure (PAWP), central venous pressure (CVP), cardiac output (CO), hemoglobin (Hb), saturation of mixed venous blood (SvO₂) and blood gas analysis were recorded at the baseline and different hemorrhagic shock time (HST). The whole body oxygen delivery indices, DO₂I and VO₂I, and the O₂ extraction ratio (O₂ER) were calculated.

RESULTS: Core body temperature in group A decreased slightly after the hemorrhagic shock model was established, and environmental hypothermia decreased in core body temperature. The mortality rate was significantly higher in group B (50%) than in group A (0%). DO₂I and VO₂I decreased significantly after hemorrhage. No difference was found in hemodynamics, DO₂I and VO₂I between group A and group B, but the difference in pH, lactic acid and O₂ER was significant between the two groups.

CONCLUSION: Environmental hypothermia aggravated the disorder of oxygen metabolism after hemorrhagic shock, which was associated with poor prognosis.

Effects of hyperbaric oxygen on intestinal mucosa apoptosis caused by ischemia-reperfusion injury in rats

Shi-hui Zhou, Yan-fei Sun, Gang Wang

2012, 3(2):  135-140.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.010

Asbtract    HTML    PDF (586KB)   

BACKGROUND: Hyperbaric oxygen (HBO) is an effective adjuvant therapy for ischemia- reperfusion (I/R) injury of the brain, small intestine and testis in addition to crushing injury. Studies have shown that HBO increases the activity of villi of the ileum 30 minutes after I/R injury. The present study aimed to observe the effect of HBO on apoptosis of epithelial cells in the small intestine during different periods of I/R and to elucidate the potential mechanisms.

METHODS: Rats were subjected to 60-minute ischemia by clamping the superior mesenteric artery and 60-minute reperfusion by removal of clamping. The rats were randomly divided into four groups: I/R group, HBO precondition or HBO treatment before ischemia (HBO-P), HBO treatment during ischemia period (HBO-I), and HBO treatment during reperfusion (HBO-R). After 60-minute reperfusion, samples of the small intestine were prepared to measure the level of ATP by using the colorimetric method and immunochemical expression of caspase-3. The levels of TNF-α in intestinal tissue were measured using the enzyme-linked immunosorbent assay method (Elisa).

RESULTS: TNF-α levels were significantly lower in the HBO-I group than in the HBO-P (P<0.05), HBO-R and I/R groups; there was no significant difference between the HBO-R and I/R groups (P>0.05). The expression of caspas-3 was significantly lower in the HBO-I group than in the HBO-P group (P<0.05); it was also significantly lower in the HBO-P group than in the I/R and HBO-R groups (P<0.05). ATP level was significantly lower in the HBO-I group than in the HBO-P group (P<0.05), and also it was significantly lower in the HBO-P group than in the I/R and HBO-R groups (P<0.05).

CONCLUSIONS: There is an association between HBO, small intestinal I/R injury, and mucosa apoptosis. HBO maintains ATP and aerobic metabolism, inhibites TNF-α production, and thus prevents intestinal mucosa from apoptosis. Best results can be obtained when HBO is administered to patients in the period of ischemia, and no side effects are produced when HBO is given during the period of reperfusion.

Continuing Education

Basic life support: knowledge and attitude of medical/paramedical professionals

Shrestha Roshana, Batajoo KH, Piryani RM, Sharma MW

2012, 3(2):  141-145.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.011

Asbtract    HTML    PDF (300KB)   

BACKGROUND: Basic life support (BLS), a key component of the chain of survival decreases the arrest - cardiopulmonary resuscitation interval and increases the rate of hospital discharge. The study aimed to explore the knowledge of and attitude towards basic life support (BLS) among medical/paramedical professionals.

METHODS: An observational study was conducted by assessing response to self prepared questionnaire consisting of the demographic information of the medical/paramedical staff, their personnel experience/attitude and knowledge of BLS based on the 2005 BLS Guidelines of European Resuscitation Council.

RESULTS: After excluding incomplete questionnaires, the data from 121 responders (27 clinical faculty members, 21 dental and basic sciences faculty members, 29 house officers and 44 nurses and health assistants) were analyzed. Only 9 (7.4%) of the 121 responders answered ≥11, 53 (43%) answered 7-10, and 58 (48%) answered <7 of 15 questions correctly. The clinical faculty members, house officers and nurses/HA had a mean score of 7.4±3.15, 7.37±2.02 and 6.63±2.16 respectively, while dental/basic sciences faculty members attained a least mean score of 4.52 ±2.13 (P<0.001). Those who had received cardiopulmonary resuscitation (CPR) training within 5 years obtained a highest mean score of 8.62±2.49, whereas those who had the training more than 5 years back or no training obtained a mean score of 5.54±2.38 and 6.1±2.29 respectively (P=0.001). Those who were involved in resuscitation frequently had a higher median score of 8 in comparison to those who were seldom involved or not involved at all (P<0.001).

CONCLUSIONS: The average health personnel in our hospital lack adequate knowledge in CPR/BLS. Training and experience can enhance knowledge of CPR of these personnel. Thus standard of CPR/BLS training and assessment are recommended at our hospital.

Case Reports

Successful emergency endovascular treatment of juxtarenal and infrarental mycotic aortic aneurysms in patients with small diameter aortae using Cook^® Zenith ESLE Stentgrafts

Chan YC, Ting AC, Yiu WK, Cheng SW

2012, 3(2):  146-149.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.012

Asbtract    HTML    PDF (354KB)   

BACKGROUND: Endovascular repair of mycotic aneurysm is an alternative to open repair if the patho-anatomy is suitable. The aortic size above and below the mycotic aneurysm may be small.

METHODS: A retrospective review was made of prospectively collected departmental computerised database.

RESULTS: Three oriental patients with juxta- and infra-renal mycotic aortic aneurysms with a small aortic diameter of 17 mm to 18 mm underwent successful emergency endovascular treatment using Cook^® Zenith ESLE stentgrafts. These are ancillary devices aimed at iliac extensions usually.

CONCLUSION: This is to our knowledge the first case series of Cook^® Zenith ESLE iliac component endografts for the treatment of aortic mycotic aneurysms with small aortae, and short- and mid-term results are encouraging.

Perforated gastrointestinal ulcers presenting as acute respiratory distress

Bennidor Raviv, Shlomo H. Israelit

2012, 3(2):  150-153.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.013

Asbtract    HTML    PDF (271KB)   

BACKGROUND: Dyspnea is one of the most common complaints facing the emergency medicine physician. Some of the gastrointestinal causes of dyspnea are self-limited and not life-threatening, yet others are, and early diagnosis and treatment are crucial.

METHODS: In this article we presented one of these life-threatening conditions through a clinical description of a patient presenting with acute respiratory distress that was finally diagnosed to be the result of a perforated gastric ulcer.

RESULTS: An emergent thoracotomy revealed a small ulcer with perforation in the fundus of the stomach. The patient was transferred after the operation to the intensive care unit and after a prolonged hospitalization discharged home. Biopsies taken from the ulcer showed diffuse inflammation, with no evidence of microorganisms or malignancy.

CONCLUSION: Perforation of gastric and duodenal ulcers is a rare yet existing cause of dyspnea and respiratory failure and should be kept in mind by the emergency physician, especially when other more common causes are ruled out.

Acute ischemic stroke in a child with cyanotic congenital heart disease due to non-compliance of anticoagulation

Misbahuddin Mohammad, Anish F. James, Raheel S. Qureshi, Sapan Saraf, Tina Ahluwalia, Joy Dev Mukherji, Tamorish Kole

2012, 3(2):  154-156.  doi:10.5847/wjem.j.issn.1920-8642.2012.02.014

Asbtract    HTML    PDF (284KB)   

BACKGROUND: Stroke is a common presentation in geriatric patients in emergency department but rarely seen in pediatric patients. In case of acute ischemic stroke in pediatric age group, management is different from that of adult ischemic stroke where thrombolysis is a good option.

METHODS: We report a case of a 17-year-old male child presenting in emergency with an episode of acute ischemic stroke causing left hemiparesis with left facial weakness and asymmetry. The patient suffered from cyanotic congenital heart disease for which he had undergone Fontan operation previously. He had a history of missing his daily dose of warfarin for last 3 days prior to the stroke.

RESULTS: The patient recovered from acute ischemic stroke without being thrombolyzed.

CONCLUSION: In pediatric patients, acute ischemic stroke usually is evolving and may not require thrombolysis.