A Case of Coconut Crab Poisoning

The effects of histamine administered in samples of fish to eight healthy volunteers (4 females and 4 males), aged 21-30 years, were studied. The subjects were given 0, 45 and 90?mg of histamine that had been metabolized from histidine by photobacteria in the fish and 90?mg of histamine added to fresh fish, for breakfast. The subjects were observed during 6?h after breakfast. Special attention was paid to clinical symptoms, blood pressure and ECG. The pH of the gastric contents was recorded continuously from 5 min before to 6?h after the meal. Blood samples to measure the histamine concentration were taken at intervals during 24?h after breakfast. Two of the subjects showed effects (facial flushing, headache) that could be attributed to the ingestion of histamine. No significant changes were observed in the blood pressure and ECG. The pH of the gastric fluids did not decrease significantly. The histamine concentration in plasma correlated closely with the histamine dose ingested (p < 0.001, r = 0.996). The C_max of the dose of 90?mg did not differ statistically significant from the C_max of the dose of 90?mg histamine added to unspoiled fish.     

雪卡毒素中毒２５例分析

目的：探讨雪卡霉素中毒的原因,临床表现、治疗和预防。方法：分析２５例中毒患的临床资料并结合献资料。结果：雪卡毒素广泛存在热带、亚热带深海鱼中,其中石斑鱼、鲈鱼最常见,是鱼类通过食物链获得,中毒后经２－１０h潜伏期,出现以急性胃肠炎为主的消化道症状和心血管症状,２－３d后伴有特征性、较持久的温度感觉倒错。结论：中毒后以温度感觉倒错为特征,预后良好,病程２－３wk,为避免中毒,建议勿食用重１.5kg以上的深海鱼,特别是鱼头和内脏。     

急性重度毒鼠强中毒的抢救及护理体会

目的:探讨急性重度毒鼠强(tetramine)中毒的临床特点及抢救护理。方法:对60例毒鼠强中毒患者的临床资料进行回顾性分析。并观察护理效果。结果:60例患者在2周内临床症状基本消失,无并发症发生;住院时间7~21 d,平均14 d;治愈58例,占96.7%;死亡2例,占3.3%。结论:有反复呕吐、抽搐、昏迷症状及口服该药病史,可迅速做出诊断;迅速清除毒物、控制抽搐、解毒剂和血液灌流的应用及精心护理是抢救成功的关键。     

Emergency Department Gridlock and Out-of-hospital Delays for Cardiac Patients

OBJECTIVES: To determine the effect of simultaneous ambulance diversion at multiple emergency departments (EDs) (gridlock) on transport delays for patients with chest pain. METHODS: Retrospective data on consecutive ambulance patients with chest pain and the diversion status of EDs in Toronto were obtained from January 1998 to December 1999. Gridlock was calculated separately for the four city quadrants as the daily duration of episodes where all EDs in the quadrant were simultaneously diverting ambulances. The primary outcome was 90th percentile ambulance transport interval (scene departure to hospital arrival). RESULTS: Eleven thousand four hundred patients were included (mean age 67 years; female 51%; severity of illness: moderate to life-threatening 89%). Gridlock occurred an average of 1.1 hour/day, and 3,060 patients were transported on days when it occurred. Ninetieth percentile transport interval was 15.5 minutes (95% CI = 15.3 to 15.9) for patients not exposed to gridlock vs. 17.4 minutes (95% CI = 16.8 to 17.8) for patients who were exposed to gridlock. In multivariate analyses, gridlock was associated with both transport and total out-of-hospital interval delays (0.2 min/hour, 95% CI = 0.1 to 0.4 and 0.2 min/hour, 95% CI = 0.04 to 0.4, respectively). Delays were similar regardless of patient severity of illness (p = 0.5). Age (0.8 min/10 years, 95% CI = 0.5 to 1), female gender (1.9 min, 95% CI = 1.3 to 2.6), advanced care paramedics (5.3 min, 95% CI = 4.4 to 6.3), and snowfall (0.8 min/cm, 95% CI = 0.2 to 1.5) were also independently associated with delays. CONCLUSIONS: Ambulance diversion was associated with delays in out-of-hospital ambulance transport for chest pain patients, but only when it resulted in gridlock. The magnitude of the out-of-hospital delay was the same regardless of the patient's severity of illness.     

急诊急性有机磷农药中毒的循证治疗

目的应用循证医学的基本原理和方法为急性有机磷农药中毒患者制定合理的治疗方案。方法针对急性有机磷农药中毒具体病例提出临床问题,以有机磷农药、中毒、胆碱酯酶复能剂肟类、中间综合征等MeSH主题词及自由词为关键词,电子检索ACP Journal Club(1991-2006．4)、Cochrane图书馆(2006年第1期)、MEDLINE(1966-2006．5)和中国生物医学文献数据库(1980-2006．5),查找与肟类复能剂治疗急性有机磷农药中毒有关的系统评价、临床随机对照试验等,并对所获证据进行质量评价。结果检索到2005年的Cochrane系统评价和2006年Meta分析各1篇,其结果均提示,肟类复能剂对急性有机磷农药中毒的治疗效果不肯定。据此临床证据,结合医生经验及患者家属意见,对该患者未使用肟类复能剂,而是小剂量阿托品递减剂量及对症支持治疗。一周后,患者生命体征平稳,临床症状缓解出院。结论采用循证医学的方法为急性有机磷中毒患者选择了合理的治疗方案。肟类复能剂对急性有机磷农药中毒的疗效不肯定,尚待大样本高质量的随机对照试验证实。     

精神药物中毒的抢救及护理

自杀行为是精神科常见的症状之一,顿服大量精神药物是精神病人常采用的自杀方式。本文总结90例服毒病人,就其服药种类、时间、季节以及服毒的原因做一论述,进而抓住抢救的关键环节,加强观察和护理措施,以提高抢救成功率。     

Evaluation and Management of Knee Dislocation in the Emergency Department

BackgroundKnee dislocations are a potentially limb-threatening injury, and it is essential that emergency medicine clinicians are aware of them.ObjectiveThis article provides a review of the diagnosis and management of knee dislocation for the emergency provider.DiscussionKnee dislocations are uncommon injuries with the potential for significant morbidity. A thorough history and examination are important, because 50% of dislocations may have reduced before arrival to the emergency department. Knee dislocations should be quickly reduced in the emergency department setting. The presence of equal pulses does not exclude vascular injury, and all patients should undergo serial vascular examinations and evaluation with ankle-brachial indices. Those with abnormal ankle-brachial indices should receive computed tomographic angiography. Radiographs are important to identify any fractures, while magnetic resonance imaging may be deferred until after admission.ConclusionKnee dislocation is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.     

急性中毒患者460例调查报告

目的探讨综合性医院急诊科收治急性中毒患者的流行病学特点。方法采用前瞻性研究方法，对本科2004年12月至2005年11月收治的460例急性中毒患者的年龄、性别、职业、毒物种类、中毒类型的季节分布、毒物侵入途径、中毒原因、急诊诊断、转归及死亡等项目进行调查统计分析。结果460例急性中毒患者年龄主要集中在25～34岁（占38．7％）。首位的中毒种类是化学品，占33．48％；其次是药物中毒，占28．26％。消化道摄入是急性中毒最常见的途径，占80．22％。自杀者占急性中毒的62．59％。中毒死亡1．52％。结论为综合性医院急诊科医生提供了急性中毒的流行病学资料，为急性中毒的防治提供科学资料和依据。     

The Emergency Department Presentation of Patients with Active Pulmonary Tuberculosis

OBJECTIVE: To determine the clinical presentation of emergency department (ED) patients with active pulmonary tuberculosis (TB). METHODS: This was a retrospective medical record review of adult patients, identified through infection control records, diagnosed as having active pulmonary TB by sputum culture over a 30-month period at an urban teaching hospital. The ED visits by these patients from one year before to one year after the initial positive sputum culture were categorized as contagious or noncontagious, using defined clinical and radiographic criteria. The medical records of patients with contagious visits to the ED were reviewed to determine chief complaint, presence of TB risk factors and symptoms, and physical examination and chest radiograph findings. RESULTS: During the study period, 44 patients with active pulmonary TB made 66 contagious ED visits. Multiple contagious ED visits were made by 12 patients (27%; 95% CI = 15% to 43%). Chief complaints were pulmonary 33% (95% CI = 22% to 46%), medical but nonpulmonary 41% (95% CI = 29% to 54%), infectious but nonpulmonary 14% (95% CI = 6% to 24%), and traumatic/orthopedic 12% (95% CI = 5% to 22%). At least one TB risk factor was identified in 57 (86%; 95% CI% = 76 to 94%) patient visits and at least one TB symptom in 51 (77%; 95% CI = 65% to 87%) patient visits. Cough was present during only 64% (95% CI = 51% to 75%) of the patient visits and hemoptysis during 8% (95% CI = 3% to 17%). Risk factors and symptoms that, if present, were likely to be detected at triage were foreign birth, homelessness, HIV positivity, hemoptysis, and chest pain. CONCLUSIONS: Patients with active pulmonary TB may have multiple ED visits, and often have nonpulmonary complaints. Tuberculosis risk factors and symptoms are usually present in these patients but often missed at ED triage. The diversity of clinical presentations among ED patients with pulmonary TB will likely make it difficult to develop and implement high-yield triage screening criteria.     

五级预检分类系统急诊应用评价

目的：评价五级预检分类系统在三级医院急诊科的应用价值。方法：将五级预检分类系统完成的预检患者资料按5个预检级别自然分组,通过调查死亡率、抢救率、入院率等指标与预检级别的关系,来评估五级预检分类系统的应用价值。结果：选用2011-05-01-2012-09-30的13602例样本,经统计学处理,抢救率、入院率、死亡率等指标与预检级别具有明显的相关性（P〈0.01）。结论：五级预检分类系统与相关标准一致,能够反映患者病情的轻重缓急,可应用于急诊预检分诊工作。     

Faculty Triage Shortens Emergency Department Length of Stay

OBJECTIVE: To determine whether faculty triage (FT) activities can shorten emergency department (ED) length of stay (LOS). METHODS: This was a comparison study measuring the impact of faculty triage vs no faculty triage on ED LOS. It was set in an urban county teaching hospital. Subjects were patients presenting to the registration desk between 9 AM and 9 PM on 16 consecutive Mondays (August 2 to November 15, 1999). On eight Mondays, an additional faculty member was stationed at the triage desk. He or she was asked to expedite care by rapid evaluation orders for diagnostic studies and basic therapeutic interventions, and by moving serious patients to the patient care areas. He or she was not provided with detailed instructions or protocols. The ED LOS, time of registration (TIMEREG), inpatient admission status (ADMIT), x-ray utilization (XRAY), total patients registered each day between 9 AM and 9 PM (TOTREG), and patients who left without being seen (LWBS) were determined using an ED information system. The LOS was analyzed in relation to FT, ADMIT, and XRAY by the Mann-Whitney U test. The LOS was related to TIMEREG and TOTREG by simple linear regression. Stepwise multiple linear regression models to predict LOS were generated using all the variables. RESULTS: Patients without FT (n = 814) had a mean LOS of 445 minutes. Patients with FT (n = 920) had a mean LOS of 363 minutes. Mean difference in LOS was -82 minutes (95% CI = -111 to -53), a reduction of 18%. The LOS was also related to: ADMIT +203 minutes (95% CI = 168 to 238), TOTREG -2.7 min/additional patient registered (95% CI = -1.15 to -4.3), and TIMEREG +0.14 min/min since 9 AM (95% CI = 0.07 to 0.21). The LWBS was reduced by 46% with FT. In multiple regression analysis, ADMIT, FT, TIMEREG, and XRAY were all related to LOS, but the model explained only a small part of variance (adjusted R(2) = 0.093). The faculty cost is estimated to be $11.98/patient. CONCLUSIONS: Faculty triage offers a moderate increase in efficiency at this ED, albeit with relatively high cost.     

网络智能信息化预检分诊系统在急诊中的应用

目的:探讨网络智能信息化预检分诊系统在急诊中的应用方法及效果。方法:随机选取2014年1月1日~2016年12月31日急诊就诊患者500例为对照组,采用传统的急诊预检分诊方法;随机选取2017年1月1日~2019年12月31日急诊就诊患者500例为观察组,采用网络智能信息化预检分诊系统进行预检分诊。比较两组分诊准确率、分诊所需时间及患者就医满意度。结果:两组分诊准确率、分诊所需时间、患者就医满意度比较差异有统计学意义(P<0.05,P<0.01)。结论:网络智能信息化预检分诊系统可有效提高患者分诊准确率,缩短分诊时间,提高就医满意度。     

No Relationship between Emergency Department Activity and Triage Categorization

Objective: To examine the consistency of Australasian National Triage Scale (NTS) categorization in a large hospital ED, especially in relation to daily activity.
Methods: This was a prospective, observational study of the relationship between NTS category, presenting features, and disposition in a large Australian adult ED. The "admission rate" was defined as the percentage of presentations whose dispositions were recorded as admitted to hospital, transferred to another hospital for admission, or died in the ED. A "busy" weekday was defined as one during which >140 presentations were recorded in the 24 hours from midnight. For a "busy" weekend day, a figure of 100 presentations in 24 hours was used. "Nonbusy" days were defined as those during which presentation numbers were less than or equal to these thresholds.
Results: Data describing triage and disposition were available for 94,681 presentations in the 2-year period, representing 100% of ED presentations. "Busy" weekday admission rates in the 5 triage categories were 93.2%, 67.6%, 43.6%, 15.4%, and 1.6%, respectively. "Nonbusy" weekday admission rates were 91.4%, 68.3%, 43.7%, 15.6%, and 2.0%. Weekend days had a higher admission rate in NTS category 4 and 5 patients, but none of the differences between "busy" and "nonbusy" days reached statistical significance at the 0.05 level. Admission rates varied according to the time of day of presentation and increased with age, but did not change significantly over the 2 years of the study.
Conclusions: In this ED, triage categorization according to the Australasian NTS does not vary with daily activity and has been consistent over time. Further study in other settings is required, particularly to identify variation dependent on the presenting population.     

Supplemented Triage and Rapid Treatment (START) Improves Performance Measures in the Emergency Department

Background: Emergency Department (ED) crowding is well recognized, and multiple studies have demonstrated its negative effect on patient care. Study Objectives: This study aimed to assess the effect of an intervention, Supplemented Triage and Rapid Treatment (START), on standard ED performance measures. The START program complemented standard ED triage with a team of clinicians who initiated the diagnostic work-up and selectively accelerated disposition in a subset of patients. Methods: This retrospective before–after study compared performance measures over two 3-month periods (September–November 2007 and 2008) in an urban, academic tertiary care ED. Data from an electronic patient tracking system were queried over 12,936 patients pre-intervention, and 14,220 patients post-intervention. Primary outcomes included: 1) overall length of stay (LOS), 2) LOS for discharged and admitted patients, and 3) the percentage of patients who left without complete assessment (LWCA). Results: In the post-intervention period, patient volume increased 9% and boarder hours decreased by 1.3%. Median overall ED LOS decreased by 29 min (8%, 361 min pre-intervention, 332 min post-intervention; p < 0.001). Median LOS for discharged patients decreased by 23 min (7%, 318 min pre-intervention, 295 min post-intervention; p < 0.001), and by 31 min (7%, 431 min pre-intervention, 400 min post-intervention) for admitted patients. LWCA was decreased by 1.7% (4.1% pre-intervention, 2.4% post-intervention; p < 0.001). Conclusions: In this study, a comprehensive screening and clinical care program was associated with a significant decrease in overall ED LOS, LOS for discharged and admitted patients, and rate of LWCA, despite an increase in ED patient volume.     

Predicting Hospital Admission and Returns to the Emergency Department for Elderly Patients

Objectives: Methods to accurately identify elderly patients with a high likelihood of hospital admission or subsequent return to the emergency department (ED) might facilitate the development of interventions to expedite the admission process, improve patient care, and reduce overcrowding. This study sought to identify variables found among elderly ED patients that could predict either hospital admission or return to the ED. Methods: All visits by patients 75 years of age or older during 2007 at an academic ED serving a large community of elderly were reviewed. Clinical and demographic data were used to construct regression models to predict admission or ED return. These models were then validated in a second group of patients 75 and older who presented during two 1-month periods in 2008. Results: Of 4,873 visits, 3,188 resulted in admission (65.4%). Regression modeling identified five variables statistically related to the probability of admission: age, triage score, heart rate, diastolic blood pressure, and chief complaint. Upon validation, the c-statistic of the receiver operating characteristic (ROC) curve was 0.73, moderately predictive of admission. We were unable to produce models that predicted ED return for these elderly patients. Conclusions: A derived and validated triage-based model is presented that provides a moderately accurate probability of hospital admission of elderly patients. If validated experimentally, this model might expedite the admission process for elderly ED patients. Our models failed, as have others, to accurately predict ED return among elderly patients, underscoring the challenge of identifying those individuals at risk for early ED returns. ACADEMIC EMERGENCY MEDICINE 2010; 17:252–259 © 2010 by the Society for Academic Emergency Medicine     

Victim of Carbon Monoxide Poisoning Identified by Carbon Monoxide Oximetry

Background: Carbon monoxide (CO) is known as a leading cause of unintentional poisoning death in many countries. Diagnosis is usually made by measuring carboxyhemoglobin (COHb), but due to the non-specific symptoms, the crucial step is considering CO poisoning. A possible solution might be screening emergency department (ED) patients. A cutaneous sensor that measures oxygen and CO saturation simultaneously could accomplish that. Objectives: We report a case in which CO-oximetry screening helped to identify CO poisoning in a patient with otherwise non-specific complaints presenting to a busy university hospital ED. Case Report: A 53-year-old woman presented to our ED, reporting non-specific but common symptoms including emesis and diarrhea, one-sided headache, paresthesia, and palpitations. Whereas conventional pulse oximetry showed normal results, a COHb level of 28% was measured using a CO-oximeter. This allowed a diagnosis of CO poisoning to be made at admission. The patient was treated with 100% oxygen continuous positive airway pressure ventilation, and CO washout was monitored continuously and non-invasively. In the meantime, the local fire department was alerted and found a malfunctioning water heater as the source of CO in the patient's residence. As COHb fell to normal levels and the patient reported feeling well, she was discharged the next day. Conclusion: CO-oximetry served as a powerful tool in both identifying and monitoring a CO-poisoned patient in a busy ED. Future studies should address possible sources of error using this method on a long-term basis and its level of acceptance by ED staff.     

Trauma Team Activation Criteria as Predictors of Patient Disposition from the Emergency Department

Many trauma centers use mainly physiologic, first-tier criteria and mechanism-related, second-tier criteria to determine whether and at what level to activate a multidisciplinary trauma team in response to an out-of-hospital call. Some of these criteria result in a large number of unnecessary team activations while identifying only a few additional patients who require immediate operative intervention. OBJECTIVES: To separately evaluate the incremental predictive value of individual first-tier and second-tier trauma team activation criteria for severe injury as reflected by patient disposition from the emergency department (ED). METHODS: This was a prospective cohort study in which activation criteria were collected prospectively on all adult patients for whom the trauma team was activated during a five-month period at an urban, Level 1 trauma center. Severe injury disposition ("appropriate" team activation) was defined as immediate operative intervention, admission to the intensive care unit (ICU), or death in the ED. Data analysis consisted of recursive partitioning and multiple logistic regression. RESULTS: Of the 305 activations for the mainly physiologic first-tier criteria, 157 (51.5%) resulted in severe injury disposition. The first-tier criterion that caused the greatest increase in "inappropriate" activations for the lowest increase in "appropriate" activations was "age > 65." Of the 34 additional activations due to this criterion, seven (20.6%) resulted in severe injury disposition. Of the 700 activations for second-tier, mechanism-related criteria, 54 (7.7%) resulted in ICU or operating room admissions, and none resulted in ED death. The four least predictive second-tier criteria were "motorcycle crash with separation of rider," "pedestrian hit by motor vehicle," "motor vehicle crash with rollover," and "motor vehicle crash with death of occupant." Of the 452 activations for these four criteria, only 18 (4.0%) resulted in ICU or operating room admission. CONCLUSIONS: The four least predictive second-tier, mechanism-related criteria added little sensitivity to the trauma team activation rule at the cost of substantially decreased specificity, and they should be modified or eliminated. The first-tier, mainly physiologic criteria were all useful in predicting the need for an immediate multidisciplinary response. If increased specificity of the first-tier criteria is desired, the first criterion to eliminate is "age > 65."