依托型急救中心急性中毒流行病学与急救特点分析

目的 研究依托型急救中心急诊内科收治急性中毒患者的流行病学与急救特点.方法 采用回顾性研究方法,对2004-2009年在福建省急救中心内科就诊的各类急性中毒患者的性别、年龄、中毒原因、种类、毒物名称、入侵途径、急诊诊断、急救处置、去向及转归等,进行登记并分析.结果 共收治急性中毒患者2867例,男女比例为1∶1.04,平均33.8岁,其中18～40岁年龄组占76.39%.所有中毒例数以1月份最多,占全部11.33%;中毒类别位居前四位的依次是酒精中毒(54.55%),药物中毒(25.95%),农药中毒(5.65%),毒品中毒(4.88%);毒品中毒大部分为年龄≤25岁(56.44%),平均年龄为28.2岁,明显低于药物中毒和酒精中毒(P＜0.01);69.54%患者经急救处理后离院随诊观察,需要住院者占30.39%,仅4例发生死亡.结论 城市急性中毒以酒精和药物为著;依托型急救中心模式中"院前急救-急诊科-院内救治"的急救绿色通道,对于提高急性中毒的抢救成功率和成活率具有重要意义.     

Artificial liver support system in treatment of liver failure after acute poisoning

BACKGROUND:

Acute poisoning (AP) may cause failure of the liver and kidney, and even death. This study aimed to investigate the efficacy of artificial liver support system (ALSS) on the treatment of liver failure after acute poisoning.

METHODS:

A total of 31 patients with liver failure caused by AP were admitted to emergency ICU, central ICU, and Department of Gastroenterology from 2005 to 2009 in Zhongshan Hospital Affiliated to Xiamen University, China. Among them, 13 patients served as a treatment group, and used ALSS in addition to detoxification treatment and protective treatment of liver function, and the other 18 patients served as a control group receiving detoxification treatment and protective treatment of liver function.

RESULTS:

In the treatment group, 10 patients (76.9%) were cured or improved, 2 died, and 1 was discharged against advice. In the 18 patients in the control group, 7 (38.9%) were cured or improved, 3 died, and 8 were discharged against advice. There was a significant difference in the rates of improvement between the two groups (P<0.05).

CONCLUSION:

ALSS is a safe and effective clinical method for the treatment of acute toxic liver failure.KEY WORDS: Toxicity, Liver failure, Artificial liver support system     

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

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 op.

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.KEY WORDS: Acute ischemic stroke, Congenital heart disease, Single ventricle, Fontan operation, Warfarin, Thrombolytic     

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

BACKGROUND:

Acute renal failure (ARF) due to obstructive uropathy is a urological emergency. The standard radiological investigations in the emergency setting include X-ray, ultrasonography and computed tomography. But occasionally the cause of obstruction may be elusive.

METHODS:

We present a case of obstructive uropathy due to bilateral stones presenting as acute renal failure. The patient underwent successful shock wave lithotripsy (SWL) for dissolution of calculi.

RESULTS:

The patient was successfully treated, and reported asymptomatic in a follow-up.

CONCLUSION:

Close collaboration between nephrological, urological, and radiological services is required.KEYWORDS: Bilateral stones, Acute renal failure, Obstructive uropathy     

Images in emergency medicine: giant ascending aortic aneurysm dissection with hemopericardium

BACKGROUND:

Acute chest pain represents a common presentation at emergency department. Aortic dissection in young patients, however, is fortunately rare.

METHODS:

We report a case of giant ascending aortic aneurysm with Stanford type A aortic dissection in an otherwise well 22-year-old male patient. Operative aortic valve and root replacement was undertaken with favourable outcome.

RESULTS:

Histopathologic examination of the resected aorta revealed acute on chronic inflammatory change with Langerhans type giant cells consistent with a diagnosis of giant cell aortitis.

CONCLUSION:

While uncommon, emergencies of the aorta may present in young patients. Predisposing conditions are discussed.KEY WORDS: Aorta, Aneurysm, Tamponade, Dissection     

Emergency department in hospitals,a window of the world: A preliminary comparison between Australia and China

BACKGROUND:

This study aimed to make a preliminary comparison of emergency department (ED) presentations between Australia and China. The comparison could provide insights into the health systems and burden of diseases and potentially stimulate discussion about the development of acute health system in China.

METHODS:

An observational study was performed to compare Australian ED presentations using data obtained from a single adult tertiary-referral teaching hospital in metropolitan Brisbane against Chinese ED presentations using public domain information published in existing Chinese and international medical journals.

RESULTS:

There are major differences in ED presentations between Australia and China. In 2008, 1) 35.4% of patients arrived at a tertiary teaching hospital ED in Brisbane, Australia by ambulance; 2) 1.7% were treated for poisoning; 3) 1.4% for cerebral vascular disease; 4) 1.7% for cardiac disease; and 5) 42.6% for trauma. The top events diagnosed were mental health problems including general psychiatric examination, psychiatric review, alcohol abuse, and counselling for alcohol abuse, which accounted for 5.5% of all ED presentations. Among ED patients in China, 6.7% arrived at a tertiary teaching hospital by ambulance in Shenyang in 1997; 3.7% were treated for poisoning in Shanxi Zhouzhi County People’s Hospital ED in 2006; 14.9% for cerebral vascular diseases at Qinghai People’s Hospital ED in 1993-1995; 1.7% for cardiac diseases at the Second People’s Hospital ED, Shenzhen Longgang in 1993; and 44.3% for trauma at Shanxi Zhouzhi County People’s Hospital ED in 2006. The top events were trauma and poisoning among the young and cerebral infarction in the older population.

CONCLUSIONS:

Compared with Australian, Chinese ED patients had 1) lower ambulance usage; 2) higher proportion of poisoning; 3) higher proportion of cerebral vascular diseases; 4) similar proportion of cardiac disease; 5) similar proportion of trauma; and 6) little reported mental health problems. Possible explanations for these differences in China include a pay for service pre-hospital care system, lack of public awareness about poisons, inadequate hypertension management, and lack of recognition of mental health problems.KEY WORDS: Emergency department, Emergency presentations, Australia, China, Population health     

Intentional and unintentional poisoning in Pakistan: a pilot study using the Emergency Departments surveillance project

Background

Acute poisoning is one of the most common reasons for emergency department visits around the world. In Pakistan, the epidemiological data on poisoning is limited due to an under developed poison information surveillance system. We aim to describe the characteristics associated with intentional and unintentional poisoning in Pakistan presenting to emergency departments.

Methods

The data was extracted from the Pakistan National Emergency Department Surveillance (Pak-NEDS) which was an active surveillance conducted between November 2010 and March 2011. All patients, regardless of age, who presented with poisoning to any of Pakistan's seven major tertiary care centers' emergency departments, were included. Information about patient demographics, type of poisoning agent, reason for poisoning and outcomes were collected using a standard questionnaire.

Results

Acute poisoning contributed to 1.2% (n = 233) of patients with intentional and unintentional injuries presenting to EDs of participating centers. Of these, 68% were male, 54% were aged 19 to 44 and 19% were children and adolescents (<18 years). Types of poisoning included chemical/gas (43.8%), drug/medicine (27%), alcohol (16.7%) and food/plant (6%). In half of all patients the poisoning was intentional. A total of 11.6% of the patients were admitted and 6.6% died.

Conclusion

Poisoning causes more morbidity and mortality in young adults in Pakistan compared to other age groups, half of which is intentional. Improving mental health, regulatory control for hazardous chemicals and better access to care through poison information centers and emergency departments will potentially help control the problem.

     

A potentially life-threatening complication of university orientation activities

BACKGROUND:

This case report describes a university student who participated in an orientation activity and developed exertional rhabdomyolysis.

METHODS:

With prompt intravenous volume expansion started in the accident and emergency department, he made an uneventful recovery despite a marked elevation of creatine kinase. The riskfactors of developing exertional rhabdomyolysis were reviewed. Suggestions based on these risk factors were made to the organizers of such orientation programmes.

RESULTS:

He was discharged on day 6. On follow-up on day 8 after presentation at theaccident and emergency department, the CK level was 46 000 U/L and it fell to 2600 U/L in another 2 weeks. On follow-up 3 weeks after the incident, he remained well without symptoms.

CONCLUSION:

For the clinicians, once rhadbomyolysis is suspected or diagnosed, intravenous fluid therapy with a crystalloid should be initiated as soon as possible to prevent the occurrence of acute renal faiure.KEY WORDS: Rhadbomyolysis, Acute renal faiure     

An academic emergency department: residents’ perspective

BACKGROUND:

Since demographic changes have contributed to the growth of emergency medicine, a highly populous nation such as India needs to give physicians associated due credit and recognition. The management of knowledge source must also be conducted with due care as the work environment is completely different from that of any other clinicians.

METHODS:

The data were collected by direct interaction with residents of the department. Additional information was gathered by observation. The data were verified for validity.

RESULTS:

This study was to bring out the benefits of proactive decisions that could further enhance the emergency department. But such decisions did not always result in positive responses and improved morale. When such decisions were retracted as it causes misalignment with the existing system. An academic emergency department was expected and physicians should enrich their knowledge about emergency medicine.

CONCLUSIONS:

The problems faced by emergency department might be similar but the way in which one tackles the situation would be different. Decision making in this hospital may not be the best but it would’ve been the optimum one given the conditions available.KEY WORDS: Academic emergency department, Administration, India, Case study, Hospital management, Developing nations, HR issues in emergency departments     

Effect of harmless acute pancreatitis score,red cell distribution width and neutrophil/lymphocyte ratio on the mortality of patients with nontraumatic acute pancreatitis at the emergency department

BACKGROUND: Harmless acute pancreatitis score(HAPS), neutrophile/lymphocyte ratio and red blood cell distribution width(RDW) are used to determine the early prognosis of patients diagnosed with nontraumatic acute pancreatitis in the emergency department(ED).METHODS: Patients diagnosed with acute pancreatitis(K 85.9) in the ED according to the ICD10 coding during one year were included in the study. Patients with chronic pancreatitis and those who had missing data in their files were excluded from the study. Patients who did not have computed tomography(CT) in the ED were not included in the study.RESULTS: Ultimately, 322 patients were included in the study. The median age of the patients was 53.1(IQR=36–64). Of the patients, 68.1%(n=226) had etiological causes of the biliary tract. The mortality rate of these patients within the first 48 hours was 4.3%(n=14). In the logistic regression analysis performed by using Balthazar classification, HAPS score, RDW, neutrophile/lymphocyte ratio, age, diabetes mellitus and systolic blood pressure, the only independent variable in determining mortality was assigned as Balthazar classification(OR: 15; 95% CI: 3.5 to 64.4).CONCLUSIONS: HAPS, neutrophile/lymphocyte ratio and RDW were not effective in determining the mortality of nontraumatic acute pancreatitis cases within the first 48 hours. The only independent variable for determining the mortality was Balthazar classifi cation.     

Expression of heat shock protein 70 in lung tissues of acute paraquat poisoned rats and intervention of ulinastatin

BACKGROUND:

Paraquat (PQ) is an effective herbicide and is widely used in agricultural production, but PQ poisoning is frequently seen in humans with the lung as the target organ. Clinically pulmonary pathological changes are often used to predict the severity and prognosis of the patients. In this study, we observed the expression of heat shock protein 70 (HSP70) in rat lung after PQ poisoning and to investigate the therapeutic effects of ulinastatin.

METHODS:

Seventy-two adult healthy SD rats were randomly divided into a control group (group A, n=24), a poisoning group (group B, n=24), and an ulinastatin group (group C, n=24). The rat models of acute PQ poisoning were established by intra-gastric administration of 80 mg/kg PQ to rats of groups B and C, and the rats of group C were intra-peritoneally injected with 100 000 IU/kg ulinastatin 30 minutes after poisoning. The expression of HSP70 in lung tissue was observed, and W/D and histopathological changes in the lung tissue were compared 12, 24, 48 and 72 hours after poisoning. The expression of HSP70 in the lung tissue was assayed by using RT-PCR. All quantitative data were processed with one-way analysis of variance to compare multiple sample means.

RESULTS:

Compared to group A, the expression of HSP70 in the lung of rats in groups B and C increased significantly at all intervals (P<0.05). The pathological changes in lung tissue of rats with PQ poisoning included congestion, leukocytes infiltration and local hemorrhage, whereas those of group C were significantly lessened.

CONCLUSION:

Ulinastatin may ameliorate acute lung injury to some extent after PQ poisoning in rats by enhancing the expression of HSP70.KEY WORDS: Paraquat, Poisoning, Ulilnastatin, Heat shock protein, Acute lung injury     

A continuous quality improvement project to reduce medication error in the emergency department

BACKGROUND:

Medication errors are a common source of adverse healthcare incidents particularly in the emergency department (ED) that has a number of factors that make it prone to medication errors. This project aims to reduce medication errors and improve the health and economic outcomes of clinical care in Hong Kong ED.

METHODS:

In 2009, a task group was formed to identify problems that potentially endanger medication safety and developed strategies to eliminate these problems.

RESULTS:

Responsible officers were assigned to look after seven error-prone areas. Strategies were proposed, discussed, endorsed and promulgated to eliminate the problems identified. A reduction of medication incidents (MI) from 16 to 6 was achieved before and after the improvement work.

CONCLUSION:

This project successfully established a concrete organizational structure to safeguard error-prone areas of medication safety in a sustainable manner.KEY WORDS: Medication error, Medication safety, Continuous Quality Improvement (CQI)     

Acute hyperlipidemic pancreatitis in a pregnant woman

BACKGROUND:

Acute pancreatitis is a serious complication during pregnancy, however the incidence of hyperlipidemia induced by pancreatitis is lower.

METHODS:

We treated a pregnant woman with hypertriglyceridemia-associated acute gestational pancreatitis who simultaneously developed hypoxemic acute respiratory failure (ARF).

RESULTS:

The woman was successfully treated through noninvasive positive pressure ventilation (NPPV), emergent caesarean delivery, drainage of chylous ascites, and peritoneal lavage.

CONCLUSION:

The signs and symptoms of ARF were greatly improved in this patient after NPPV and conventional therapies. Early NPPV may be related to good prognosis of the disease.KEY WORDS: Hyperlipidemia, Pancreatitis, Pregnancy     

Ischemia-modified albumin measured with ultra-filtration assay in early diagnosis of acute coronary syndrome

BACKGROUND:

Patients with acute chest pain remain a great diagnostic challenge to emergency physicians. Ischemia-modified albumin (IMA) is a recently developed biomarker of transient myocardial ischemia. IMA has already been licensed by the US Food and Drug Administration for diagnosis of suspected myocardial ischemia. This study aimed to assess the diagnostic value of IMA in treatment of patients with acute coronary syndrome(ACS).

METHODS:

IMA level was detected by ultra-filtration assay combined with albumin-cobalt binding (ACB) test as well as tests of myoglobin (MYO), creatine kinase-MB (CK-MB) and cardiac troponin I (cTnI) in 169 consecutive patients with acute chest pain onset within 24 hours. Receiver operating characteristic (ROC) curve for IMA in diagnosing ACS was established to determine the cut-off point. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of IMA and its combinations with other agents were analyzed.

RESULTS:

Area under the ROC curve (AUC) was 0.754. As the cut-off point for IMA in this study was 70.4 U/ml, the sensitivity, specificity, PPV and NPV of IMA were 79.8%, 65.2%±77.7%, and 69.7%, respectively. The sensitivity and NPV of IMA combined with the conventional cardiac marker panel for the diagnosis of ACS were 93.4% and 86.0%, respectively.

CONCLUSION:

IMA is a useful biochemical marker for the early diagnosis of ACS. IMA combined with the conventional cardiac marker panel can improve early diagnosis of ACS compared with the traditional combinations of myocardial biochemical markers.KEY WORDS: Ischemia-modified albumin, Acute coronary syndrome     

Alcohol related conditions represent a major psychiatric problem in emergency departments

Background

Alcoholism represents a huge socioeconomic burden in most developed societies.

Methods

In order to determine the impact of conditions associated with alcohol abuse on emergency care, in 2002 all patients with alcohol related pathology presenting to the emergency department (ED) of a large urban university hospital in Germany were assessed.

Results

Of 2194 patients seen by psychiatrists in the ED, the 613 cases associated with alcohol abuse represented the largest diagnostic group (30.7%). Within this group, alcohol intoxication was the most frequent diagnosis (71.4%). Patients with an alcohol related condition needed treatment by different medical specialities and required diagnostic procedures significantly more often and consequently stayed significantly longer in the ED than patients with other psychiatric presentations.

Conclusions

The generally underestimated problem of alcohol abuse in Germany demands an excessive amount of manpower and resources in EDs, where a high yet expensive standard of care is provided. Against this background, how far this burden can be reduced, both in EDs and in society in general, is discussed.     

A single subcutaneous dose of tramadol for mild to moderate musculoskeletal trauma in the emergency department

BACKGROUND:

Mild to moderate musculoskeletal trauma is a common cause for an emergency room visit, and frequent pain is one of the cardinal symptoms of consultation. The objective of this study is to assess the perception of a single subcutaneous dose of 50 mg tramadol for pain management in patients with mild to moderate musculoskeletal trauma, likewise to appraise the perception of pain by subcutaneous injection.

METHODS:

A total of 77 patients, who met inclusion criteria, received a single subcutaneous dose of tramadol. Pain control was evaluated based on the verbal numerical pain scale (0–10) at baseline, 20 and 60 minutes; similarly, pain perception was evaluated secondary to subcutaneous injection of the analgesic.

RESULTS:

On admission, the average pain perceived by patients was 8; twenty minutes later, 89% of the patients reported five or less, and after sixty minutes, 94% had three or less on the verbal numerical pain scale. Of the patients, 88% reported pain perception by verbal numeric scale of 3 or less by injection of the drug, and 6.5% required a second analgesic for pain control. Two events with drug administration (soft tissue infection and mild abdominal rectus injection) were reported.

CONCLUSION:

We conclude that a single subcutaneous dose of tramadol is a safe and effective option for the management of patients with mild to moderate pain and musculoskeletal disease in the emergency department.KEY WORDS: Tramadol, Analgesic routes, Subcutaneous, Acute pain, Emergency department     

Ultrasound-guided percutaneous catheter drainage in early treatment of severe acute pancreatitis

BACKGROUND:

Percutaneous catheter drainage (PCD) is a minimally invasive intervation for severe acute pancreatitis (SAP). This study was undertaken to compare the results of surgery and ultrasound-guided PCD in the treatment of 32 patients with SAP, and to direct clinicians to the most optimal approach for SAP.

METHODS:

In the 32 patients, 19 were proved to have deteriorated clinical signs or symptoms, extensive fluid exudation, and necrosis confirmed by computed tomography (CT) and they underwent operative debridement and drainage. For extensive fluid exudation or necrosis, complete liquefaction and safe catheter implantation, the other 13 patients were given PCD.

RESULTS:

The mortality rate of the surgery group was 26.3%, much higher than that of the PCD group (0%). There was a significant difference between the two groups (P=0.044). The mean time for recovery of the serum C-reactive protein (CRP) level was 43.8 days in the surgery group, which was significantly longer than that of the PCD group (23.8 days) (P=0.034).

CONCLUSION:

Early PCD guided by ultrasound could decrease the mortality of patients with severe acute pancreatitis, alleviate life-threatening inflammatory complications, and avoid unnecessary emergency operation.KEY WORDS: Percutaneous catheter drainage, Operation, Severe acute pancreatitis, Clinical efficacy