Pub Date : 2021-07-28DOI: 10.1177/10249079211033373
Chi-Kit Sin, Bun Young
Background: Direct laryngoscopy is often poorly tolerated in patients with foreign body ingestion. The use of flexible endoscopes, which are reported to be better tolerated, was described. However, studies on endoscopy usage by emergency physicians are lacking. Objective: This study evaluates whether using a bronchoscope is as effective as the direct laryngoscopy for localising pharyngeal foreign bodies by emergency physicians. Methods: This was a randomised cross-over manikin study conducted on 32 emergency physicians. Four foreign bodies were placed at the oropharynx, vallecula, arytenoid and post-cricoid area of a manikin. Participants, being randomised into two groups, examined the pharynx with a bronchoscope and a direct laryngoscope in designated orders. The primary outcome was the complete visualisation rate defined as visualising all the four foreign bodies within the time limit. Secondary outcomes included participants-rated difficulty scores, device preferences, the time needed for complete visualisation and cumulative success rates. Results: Complete visualisation rate was significantly higher using the bronchoscope (93.8%) than the direct laryngoscope (62.5%) p = 0.02. The overall difficulty score was lower using the bronchoscope (median 4, interquartile range: 3–5) than the direct laryngoscope (median 6, interquartile range: 5–8), p < 0.001. The bronchoscope was the preferred method for overall examination (71.9%) over the direct laryngoscope (28.1%), p = 0.001. There were no significant differences in times needed for complete examination for the bronchoscope (median 73.6 s, interquartile range: 54.7–97.7 s) and the direct laryngoscope (median 82.2 s, interquartile range: 40.1–120 s), p = 0.9, and cumulative success rates, p = 0.081. Conclusion: The bronchoscope was associated with an increased complete visualisation rate and was the easier and preferred method for pharyngeal examination.
{"title":"Flexible endoscopy versus direct laryngoscopy for localising impacted pharyngeal foreign bodies in emergency department: A randomised cross-over manikin pilot study","authors":"Chi-Kit Sin, Bun Young","doi":"10.1177/10249079211033373","DOIUrl":"https://doi.org/10.1177/10249079211033373","url":null,"abstract":"Background: Direct laryngoscopy is often poorly tolerated in patients with foreign body ingestion. The use of flexible endoscopes, which are reported to be better tolerated, was described. However, studies on endoscopy usage by emergency physicians are lacking. Objective: This study evaluates whether using a bronchoscope is as effective as the direct laryngoscopy for localising pharyngeal foreign bodies by emergency physicians. Methods: This was a randomised cross-over manikin study conducted on 32 emergency physicians. Four foreign bodies were placed at the oropharynx, vallecula, arytenoid and post-cricoid area of a manikin. Participants, being randomised into two groups, examined the pharynx with a bronchoscope and a direct laryngoscope in designated orders. The primary outcome was the complete visualisation rate defined as visualising all the four foreign bodies within the time limit. Secondary outcomes included participants-rated difficulty scores, device preferences, the time needed for complete visualisation and cumulative success rates. Results: Complete visualisation rate was significantly higher using the bronchoscope (93.8%) than the direct laryngoscope (62.5%) p = 0.02. The overall difficulty score was lower using the bronchoscope (median 4, interquartile range: 3–5) than the direct laryngoscope (median 6, interquartile range: 5–8), p < 0.001. The bronchoscope was the preferred method for overall examination (71.9%) over the direct laryngoscope (28.1%), p = 0.001. There were no significant differences in times needed for complete examination for the bronchoscope (median 73.6 s, interquartile range: 54.7–97.7 s) and the direct laryngoscope (median 82.2 s, interquartile range: 40.1–120 s), p = 0.9, and cumulative success rates, p = 0.081. Conclusion: The bronchoscope was associated with an increased complete visualisation rate and was the easier and preferred method for pharyngeal examination.","PeriodicalId":50401,"journal":{"name":"Hong Kong Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2021-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10249079211033373","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47996939","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-07-25DOI: 10.1177/10249079211030807
Jen-Tang Sun, Sheng-En Chu, C. Fan, Shyh-Shyong Sim
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Dear sir, Reconfirmation of endotracheal tube (ETT) position in intubated patients is mandated especially after transportation. To date, end-tidal CO2 (ETCO2) is recommended for ETT position confirmation. Nevertheless, using a portable or continuous ETCO2 monitor, frequent connect and disconnect of the ETT expose medical staffs to potential aerosol transmissible disease. This idea raises our concern during COVID-19 pandemic. In our practice, during emergent endotracheal intubation, we performed trans-tracheal ultrasound (TTU) to confirm ETT position (Figure 1(a)). We performed TTU again to confirm the ETT position after patient’s transportation. We found that there is accumulation of subglottic secretion just above the cuff of the ETT, especially 30 min after the patient was intubated (Figure 1(b) and (c), video). A routine oral suction performed by nurse staff failed to cleanse the accumulated secretion. Similar findings repeated in many cases, indicating (1) the accumulation of subglottic secretion facilitates direct ultrasound visualization of ETT and (2) routine oral suction could not effectively reduce the accumulated secretion. As the accumulation of subglottic secretion facilitates direct ultrasound visualization of ETT, we propose the usage of bedside TTU in timely reconfirmation of ETT position after transportation, in order to prevent frequent connection of ETT with ETCO2 monitor, especially during the COVID-19 pandemic. Our previous study proposed the usage of tracheal ultrasound exam for real-time confirming tube placement during emergent intubation.1 Currently, there is no study in validating the usage of ultrasonography for reconfirming ETT position. We strongly encourage further study to validate the usage of TTU in reconfirming ETT position after transportation. Micro-aspiration of subglottic secretions through the ETT cuff is considered a significant cause of ventilatorassociated pneumonia (VAP).2 Our another finding showed that routine oral suction could not clear up subglottic secretion in intubated patients. In the aspect of micro-aspiration, maintaining strict oral hygiene may have a little help in preventing VAP.
{"title":"Trans-tracheal ultrasound: A feasible method for endotracheal tube position reconfirmation during COVID-19 pandemic","authors":"Jen-Tang Sun, Sheng-En Chu, C. Fan, Shyh-Shyong Sim","doi":"10.1177/10249079211030807","DOIUrl":"https://doi.org/10.1177/10249079211030807","url":null,"abstract":"Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Dear sir, Reconfirmation of endotracheal tube (ETT) position in intubated patients is mandated especially after transportation. To date, end-tidal CO2 (ETCO2) is recommended for ETT position confirmation. Nevertheless, using a portable or continuous ETCO2 monitor, frequent connect and disconnect of the ETT expose medical staffs to potential aerosol transmissible disease. This idea raises our concern during COVID-19 pandemic. In our practice, during emergent endotracheal intubation, we performed trans-tracheal ultrasound (TTU) to confirm ETT position (Figure 1(a)). We performed TTU again to confirm the ETT position after patient’s transportation. We found that there is accumulation of subglottic secretion just above the cuff of the ETT, especially 30 min after the patient was intubated (Figure 1(b) and (c), video). A routine oral suction performed by nurse staff failed to cleanse the accumulated secretion. Similar findings repeated in many cases, indicating (1) the accumulation of subglottic secretion facilitates direct ultrasound visualization of ETT and (2) routine oral suction could not effectively reduce the accumulated secretion. As the accumulation of subglottic secretion facilitates direct ultrasound visualization of ETT, we propose the usage of bedside TTU in timely reconfirmation of ETT position after transportation, in order to prevent frequent connection of ETT with ETCO2 monitor, especially during the COVID-19 pandemic. Our previous study proposed the usage of tracheal ultrasound exam for real-time confirming tube placement during emergent intubation.1 Currently, there is no study in validating the usage of ultrasonography for reconfirming ETT position. We strongly encourage further study to validate the usage of TTU in reconfirming ETT position after transportation. Micro-aspiration of subglottic secretions through the ETT cuff is considered a significant cause of ventilatorassociated pneumonia (VAP).2 Our another finding showed that routine oral suction could not clear up subglottic secretion in intubated patients. In the aspect of micro-aspiration, maintaining strict oral hygiene may have a little help in preventing VAP.","PeriodicalId":50401,"journal":{"name":"Hong Kong Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2021-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10249079211030807","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42250764","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-07-24DOI: 10.1177/10249079211034272
C. Groombridge, Amit Maini, J. Mathew, Peter Fritz, Yesul Kim, M. Fitzgerald, D. Smit, G. O'Reilly
Background: After failed endotracheal intubation, using direct laryngoscopy, rescued using a supraglottic airway device, the choice of subsequent method to secure a definitive airway is not clearly determined. Objective: The aim of this study was to compare the time to intubation using a fibre-optic airway scope, to guide an endotracheal tube through the supraglottic airway device, with a more conventional approach using a hyperangulated video laryngoscope. Methods: A single-centre randomised controlled trial was undertaken. The population studied were emergency physicians working in an adult major trauma centre. The intervention was intubation through a supraglottic airway device guided by a fibre-optic airway scope. The comparison was intubation using a hyperangulated video laryngoscope. The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000018819). Results: Four emergency physicians completed intubations using both of the two airway devices on four cadavers for a total of 32 experiments. The mean time to intubation was 14.0 s (95% confidence interval = 11.1–16.8) in the hyperangulated video laryngoscope group compared with 29.2 s (95% confidence interval = 20.7–37.7) in the fibre-optic airway scope group; a difference of 15.2 s (95% confidence interval = 8.7–21.7, p < 0.001). All intubations were completed within 2 min, and there were no equipment failures or evidence of airway trauma. Conclusion: Successful intubation of the trachea without airway trauma by emergency physicians in cadavers is achievable by either fibre-optic airway scope via a supraglottic airway device or hyperangulated video laryngoscope. Hyperangulated video laryngoscope was statistically but arguably not clinically significantly faster than fibre-optic airway scope via supraglottic airway device.
{"title":"Comparison of fibre-optic-guided endotracheal intubation through a supraglottic airway device versus hyperangulated video laryngoscopy by emergency physicians: A randomised controlled study in cadavers","authors":"C. Groombridge, Amit Maini, J. Mathew, Peter Fritz, Yesul Kim, M. Fitzgerald, D. Smit, G. O'Reilly","doi":"10.1177/10249079211034272","DOIUrl":"https://doi.org/10.1177/10249079211034272","url":null,"abstract":"Background: After failed endotracheal intubation, using direct laryngoscopy, rescued using a supraglottic airway device, the choice of subsequent method to secure a definitive airway is not clearly determined. Objective: The aim of this study was to compare the time to intubation using a fibre-optic airway scope, to guide an endotracheal tube through the supraglottic airway device, with a more conventional approach using a hyperangulated video laryngoscope. Methods: A single-centre randomised controlled trial was undertaken. The population studied were emergency physicians working in an adult major trauma centre. The intervention was intubation through a supraglottic airway device guided by a fibre-optic airway scope. The comparison was intubation using a hyperangulated video laryngoscope. The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000018819). Results: Four emergency physicians completed intubations using both of the two airway devices on four cadavers for a total of 32 experiments. The mean time to intubation was 14.0 s (95% confidence interval = 11.1–16.8) in the hyperangulated video laryngoscope group compared with 29.2 s (95% confidence interval = 20.7–37.7) in the fibre-optic airway scope group; a difference of 15.2 s (95% confidence interval = 8.7–21.7, p < 0.001). All intubations were completed within 2 min, and there were no equipment failures or evidence of airway trauma. Conclusion: Successful intubation of the trachea without airway trauma by emergency physicians in cadavers is achievable by either fibre-optic airway scope via a supraglottic airway device or hyperangulated video laryngoscope. Hyperangulated video laryngoscope was statistically but arguably not clinically significantly faster than fibre-optic airway scope via supraglottic airway device.","PeriodicalId":50401,"journal":{"name":"Hong Kong Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2021-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10249079211034272","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49651219","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-07-08DOI: 10.1177/10249079211030110
A. Cheung, R. Lam, P. W. Y. Fok, Ethan Pak Hang Ng, Vi Ka Chaang, T. Rainer
Introduction: Interfacility transport with helicopter from remote island clinics to urban hospitals account for a significant portion of the Hong Kong Government Flying Service missions. Currently, doctor and nurse escorts are deployed as volunteers only during the daytime from every Friday to Monday and on public holidays. While most transport runs smoothly, patient deterioration can occur during flight, warranting medical interventions on-board. Yet, little is known about the pattern and any clinical predictors of such interventions during helicopter interfacility transport missions. Methods: We collected Government Flying Service callout records from 1 January to 31 December 2016, and retrieved demographic, clinical and operational data. Interfacility transport mission was dispatched based on ‘Casualty Evacuation’ categories, which range from A+ (unstable), A (borderline) to B (stable). Univariate and multivariable logistic regression were used to identify independent predictors for in-flight medical interventions. Results: Of 1734 callout records, 386 interfacility transport missions escorted by volunteer doctors or nurses or both had complete flight medical records for analysis and 14.9% required in-flight medical interventions. Most interventions were related to oxygen therapy, intravenous fluid and administration of medications. Multivariable logistic regression showed that an age ⩾70 years, Casualty Evacuation A+ category, and any pre-flight emergency medical interventions were independent predictors for in-flight medical interventions. Conclusion: This study identified a few clinical predictors of in-flight medical interventions in an urban helicopter interfacility transport missions setting. Crewman training that focuses on the relevant procedural capabilities and clinical judgement is necessary to address the in-flight medical needs of interfacility transport missions.
{"title":"Predictors for in-flight medical interventions during helicopter interfacility transport in Hong Kong","authors":"A. Cheung, R. Lam, P. W. Y. Fok, Ethan Pak Hang Ng, Vi Ka Chaang, T. Rainer","doi":"10.1177/10249079211030110","DOIUrl":"https://doi.org/10.1177/10249079211030110","url":null,"abstract":"Introduction: Interfacility transport with helicopter from remote island clinics to urban hospitals account for a significant portion of the Hong Kong Government Flying Service missions. Currently, doctor and nurse escorts are deployed as volunteers only during the daytime from every Friday to Monday and on public holidays. While most transport runs smoothly, patient deterioration can occur during flight, warranting medical interventions on-board. Yet, little is known about the pattern and any clinical predictors of such interventions during helicopter interfacility transport missions. Methods: We collected Government Flying Service callout records from 1 January to 31 December 2016, and retrieved demographic, clinical and operational data. Interfacility transport mission was dispatched based on ‘Casualty Evacuation’ categories, which range from A+ (unstable), A (borderline) to B (stable). Univariate and multivariable logistic regression were used to identify independent predictors for in-flight medical interventions. Results: Of 1734 callout records, 386 interfacility transport missions escorted by volunteer doctors or nurses or both had complete flight medical records for analysis and 14.9% required in-flight medical interventions. Most interventions were related to oxygen therapy, intravenous fluid and administration of medications. Multivariable logistic regression showed that an age ⩾70 years, Casualty Evacuation A+ category, and any pre-flight emergency medical interventions were independent predictors for in-flight medical interventions. Conclusion: This study identified a few clinical predictors of in-flight medical interventions in an urban helicopter interfacility transport missions setting. Crewman training that focuses on the relevant procedural capabilities and clinical judgement is necessary to address the in-flight medical needs of interfacility transport missions.","PeriodicalId":50401,"journal":{"name":"Hong Kong Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2021-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10249079211030110","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46499402","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-07-08DOI: 10.1177/10249079211029781
Ebru Unal Akoğlu, H. Akoğlu
Objectives: To systematically review the diagnostic utility of the respiratory variation of the inferior vena cava diameter measured using ultrasonography for predicting fluid responsiveness in adult patients and compare the three commonly used equations, inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability. Methods: We searched PubMed, Scopus, Web of Science and Cochrane library, and included studies investigating the diagnostic accuracy of the respiratory variation of the inferior vena cava measured using ultrasonography compared to a reference standard for measuring cardiac output after a fluid challenge for fluid responsiveness, and stratified participants as fluid responsive or not. We included studies conducted in the emergency department or intensive care unit. We excluded studies on paediatric, prehospital, cancer, pregnant, dialysis patients or healthy volunteers. Results: We retrieved 270 records and excluded 171 because of irrelevance, patient population or publication type. We screened the abstracts of 99 studies and then the full texts of 42 studies. Overall, 21 studies with 1321 patients were included, of whom 689 (52%) were fluid responsive. The mean threshold value for positive inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability was 17%, 35% and 12%, respectively. The heterogeneity between studies was high. Bivariate diagnostic random-effects meta-analysis was used to calculate the summary receiver operating characteristics curves. The overall accuracy, sensitivity and specificity of respiratory variation of the inferior vena cava diameter were 0.85, 0.72 and 0.81, respectively. The accuracy of inferior vena cava distensibility and inferior vena cava collapsibility was similar. The diagnostic utility of respiratory variation of the inferior vena cava diameter was lower but not statistically significant in mechanically ventilated patients compared with spontaneous breathing for predicting fluid responsiveness. Conclusion: The respiratory variation of the inferior vena cava diameter has moderate diagnostic utility for predicting fluid responsiveness independent of the equation used.
目的：系统回顾超声测量的下腔静脉直径呼吸变异在预测成年患者液体反应性中的诊断作用，并比较三个常用方程，下腔静脉扩张性、下腔静脉塌陷性和下腔静脉变异性。方法：我们搜索了PubMed、Scopus、Web of Science和Cochrane图书馆，并纳入了研究使用超声测量下腔静脉呼吸变异的诊断准确性的研究，与测量液体刺激后心输出量的参考标准相比，测量液体反应性，并将参与者分为液体反应性或非液体反应性。我们纳入了在急诊科或重症监护室进行的研究。我们排除了对儿科、院前、癌症、孕妇、透析患者或健康志愿者的研究。结果：我们检索了270份记录，并排除了171份，原因是不相关、患者群体或出版物类型。我们筛选了99项研究的摘要，然后筛选了42项研究的全文。总体而言，纳入了21项研究，涉及1321名患者，其中689人（52%）有液体反应。阳性下腔静脉扩张性、下腔静脉塌陷性和下腔静脉变异性的平均阈值分别为17%、35%和12%。研究之间的异质性很高。双变量诊断随机效应荟萃分析用于计算总结的受试者操作特征曲线。下腔静脉直径呼吸变异的总体准确性、敏感性和特异性分别为0.85、0.72和0.81。下腔静脉扩张性和下腔静脉塌陷性的准确性相似。与自然呼吸相比，机械通气患者下腔静脉直径呼吸变化在预测液体反应性方面的诊断效用较低，但在统计学上并不显著。结论：下腔静脉直径的呼吸变化在预测液体反应性方面具有中等的诊断实用性，与所用方程无关。
{"title":"Does respiratory variation in inferior vena cava diameter predict fluid responsiveness in adult patients? A systematic review and meta-analysis of diagnostic accuracy studies","authors":"Ebru Unal Akoğlu, H. Akoğlu","doi":"10.1177/10249079211029781","DOIUrl":"https://doi.org/10.1177/10249079211029781","url":null,"abstract":"Objectives: To systematically review the diagnostic utility of the respiratory variation of the inferior vena cava diameter measured using ultrasonography for predicting fluid responsiveness in adult patients and compare the three commonly used equations, inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability. Methods: We searched PubMed, Scopus, Web of Science and Cochrane library, and included studies investigating the diagnostic accuracy of the respiratory variation of the inferior vena cava measured using ultrasonography compared to a reference standard for measuring cardiac output after a fluid challenge for fluid responsiveness, and stratified participants as fluid responsive or not. We included studies conducted in the emergency department or intensive care unit. We excluded studies on paediatric, prehospital, cancer, pregnant, dialysis patients or healthy volunteers. Results: We retrieved 270 records and excluded 171 because of irrelevance, patient population or publication type. We screened the abstracts of 99 studies and then the full texts of 42 studies. Overall, 21 studies with 1321 patients were included, of whom 689 (52%) were fluid responsive. The mean threshold value for positive inferior vena cava distensibility, inferior vena cava collapsibility and inferior vena cava variability was 17%, 35% and 12%, respectively. The heterogeneity between studies was high. Bivariate diagnostic random-effects meta-analysis was used to calculate the summary receiver operating characteristics curves. The overall accuracy, sensitivity and specificity of respiratory variation of the inferior vena cava diameter were 0.85, 0.72 and 0.81, respectively. The accuracy of inferior vena cava distensibility and inferior vena cava collapsibility was similar. The diagnostic utility of respiratory variation of the inferior vena cava diameter was lower but not statistically significant in mechanically ventilated patients compared with spontaneous breathing for predicting fluid responsiveness. Conclusion: The respiratory variation of the inferior vena cava diameter has moderate diagnostic utility for predicting fluid responsiveness independent of the equation used.","PeriodicalId":50401,"journal":{"name":"Hong Kong Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2021-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10249079211029781","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43262581","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-07-01DOI: 10.1177/10249079211019870
K. Hung, R. P. Lam, C. Lui
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Despite recent advances in diagnosis and treatment, sepsis remains a significant common final pathway to death in patients with infection worldwide. The constant threat of sepsis to mankind has been amplified during the COVID-19 pandemic. Yet, the effort to fight sepsis is undermined by health inequalities. How to advance prevention, survival, and survivorship of sepsis and COVID-19 was the theme of the World Sepsis Congress 2021 in April 2021 (https://www. worldsepsiscongress.org). It highlights a number of key questions clinicians of our generation need to answer. Emergency departments (EDs) are at the forefront in combating community-acquired infection and sepsis. However, over the years, the role of emergency physicians has weakened with interventions hindered because of the most recent definition of sepsis that heavily relies on laboratory test results to confirm organ dysfunction (the Sepsis-3 definition), a lack of reliable sepsis screening and prognostic tools outside the intensive care unit (ICU), limited ED access to imaging studies to identify the source of infection and ED overcrowding. Technological advances such as novel sepsis biomarkers may help clinicians to make a more precise diagnosis, but the turnaround time, added cost and complexity are creating a force to move sepsis care away from the hands of emergency physicians, especially in resource-poor settings. There is a need to bring sepsis care back to the ED. To achieve this, we need better prognostic tools that are best based on routinely collected clinical or laboratory parameters. We also need to extend the role of emergency physicians in managing severe infection including bloodstream infection. A number of articles featured in this edition represent such endeavours to explore how emergency physicians can improve sepsis care in the ED. One of the key issues is to recognise tissue hypoperfusion quickly with easily available clinical or laboratory parameters in order to avert multi-organ failure and reduce sepsis mortality. In a systemic review and meta-analysis of 13 clinical studies that involved 940 patients, Wang et al. found that the venous-to-arterial carbon dioxide pressure changes and the arteriovenous oxygen content difference ratio (Pcv-aCO2/Ca-vO2), a marker for global anaerobic metabolism, is an important predictor for mortality in patients with sepsis or septic shock. A higher ratio of PcvaCO2/Ca-vO2 was associated with a higher 28-day mortality (risk ratio = 1.89, 95% confidence interval = 1.48–2.41) and a higher Sequenti
1177/10270979211019870《香港急诊医学杂志》编辑部2021
{"title":"Bringing sepsis care back to the emergency department: New prognostic tools and extended role of emergency physicians","authors":"K. Hung, R. P. Lam, C. Lui","doi":"10.1177/10249079211019870","DOIUrl":"https://doi.org/10.1177/10249079211019870","url":null,"abstract":"Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). Despite recent advances in diagnosis and treatment, sepsis remains a significant common final pathway to death in patients with infection worldwide. The constant threat of sepsis to mankind has been amplified during the COVID-19 pandemic. Yet, the effort to fight sepsis is undermined by health inequalities. How to advance prevention, survival, and survivorship of sepsis and COVID-19 was the theme of the World Sepsis Congress 2021 in April 2021 (https://www. worldsepsiscongress.org). It highlights a number of key questions clinicians of our generation need to answer. Emergency departments (EDs) are at the forefront in combating community-acquired infection and sepsis. However, over the years, the role of emergency physicians has weakened with interventions hindered because of the most recent definition of sepsis that heavily relies on laboratory test results to confirm organ dysfunction (the Sepsis-3 definition), a lack of reliable sepsis screening and prognostic tools outside the intensive care unit (ICU), limited ED access to imaging studies to identify the source of infection and ED overcrowding. Technological advances such as novel sepsis biomarkers may help clinicians to make a more precise diagnosis, but the turnaround time, added cost and complexity are creating a force to move sepsis care away from the hands of emergency physicians, especially in resource-poor settings. There is a need to bring sepsis care back to the ED. To achieve this, we need better prognostic tools that are best based on routinely collected clinical or laboratory parameters. We also need to extend the role of emergency physicians in managing severe infection including bloodstream infection. A number of articles featured in this edition represent such endeavours to explore how emergency physicians can improve sepsis care in the ED. One of the key issues is to recognise tissue hypoperfusion quickly with easily available clinical or laboratory parameters in order to avert multi-organ failure and reduce sepsis mortality. In a systemic review and meta-analysis of 13 clinical studies that involved 940 patients, Wang et al. found that the venous-to-arterial carbon dioxide pressure changes and the arteriovenous oxygen content difference ratio (Pcv-aCO2/Ca-vO2), a marker for global anaerobic metabolism, is an important predictor for mortality in patients with sepsis or septic shock. A higher ratio of PcvaCO2/Ca-vO2 was associated with a higher 28-day mortality (risk ratio = 1.89, 95% confidence interval = 1.48–2.41) and a higher Sequenti","PeriodicalId":50401,"journal":{"name":"Hong Kong Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2021-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10249079211019870","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44665206","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-06-16DOI: 10.1177/10249079211022914
M. Man, S. Lam, H. Shum, K. Li, Swan Lau, V. Ip, W. Yan
Introduction: Significant ventilator-associated pneumonia and mortality were found in COVID-19 patients who required mechanical ventilation which calls for non-invasive means in managing respiratory failure. Methods: We retrospectively reviewed patients admitted to the intensive care unit of Pamela Youde Nethersole Eastern Hospital in Hong Kong with severe acute respiratory syndrome coronavirus 2 infection from 28 November to 15 December 2020. Patients’ laboratory, respiratory parameters and outcome data were recorded and analysed. Results: Eleven received prone ventilation. The median age was 67 (inter-quartile range: 59–72) years, and median COVID-19 GRAM score was 151 (inter-quartile range: 133–181), representing a high-risk group. There were significant improvements 1 h after awake proning in SpO2 (95% vs 92%, p = 0.008), FiO2 (0.4 vs 0.5, p = 0.003), SpO2/FiO2 (240 vs 184, p = 0.005), respiratory rate (19 vs 26, p = 0.006) and respiratory rate – oxygenation index (13.22 vs 7.67, p = 0.003; Table 1). Although not reaching statistical significance, the median PaO2, PaCO2 and PaO2/FiO2 improved after proning. The overall intubation rate was 22% and intensive care unit mortality was 22%, which is in contrast to 65.5% and 27.6%, respectively, in the first three waves. Although did not reach statistical significance, those received prone ventilation tend to have a lower ICU mortality (9.1% vs 42.9%, p = 0.245) and hospital mortality (18.2% vs 42.9%, p = 0.326). Conclusion: Awake proning potentially minimizes complications from invasive ventilation and provides a low-cost low-risk treatment option in COVID-19 patients with respiratory failure. This is particularly important when healthcare resources are strained at times of a pandemic.
在需要机械通气的COVID-19患者中发现了明显的呼吸机相关肺炎和死亡率，这需要非侵入性手段来治疗呼吸衰竭。方法:回顾性分析2020年11月28日至12月15日香港东区尤德夫人那打素医院重症监护室收治的冠状病毒2型严重急性呼吸综合征患者。记录和分析患者的实验室、呼吸参数和结局数据。结果:11例患者接受俯卧位通气。年龄中位数为67岁(59-72岁)，COVID-19 GRAM评分中位数为151分(133-181分)，属于高危组。醒后1 h SpO2 (95% vs 92%， p = 0.008)、FiO2 (0.4 vs 0.5, p = 0.003)、SpO2/FiO2 (240 vs 184, p = 0.005)、呼吸速率(19 vs 26, p = 0.006)和呼吸速率-氧合指数(13.22 vs 7.67, p = 0.003;表1).中位PaO2、PaCO2和PaO2/FiO2均改善，但未达到统计学意义。总体插管率为22%，重症监护病房死亡率为22%，而前三波分别为65.5%和27.6%。虽无统计学意义，但俯卧位通气组ICU死亡率(9.1% vs 42.9%， p = 0.245)和住院死亡率(18.2% vs 42.9%， p = 0.326)均较低。结论:清醒倾向可最大限度地减少有创通气并发症，为COVID-19呼吸衰竭患者提供低成本、低风险的治疗选择。当大流行期间卫生保健资源紧张时，这一点尤为重要。
{"title":"Prone positioning in non-intubated patients with coronavirus – A single-centre experience in Hong Kong","authors":"M. Man, S. Lam, H. Shum, K. Li, Swan Lau, V. Ip, W. Yan","doi":"10.1177/10249079211022914","DOIUrl":"https://doi.org/10.1177/10249079211022914","url":null,"abstract":"Introduction: Significant ventilator-associated pneumonia and mortality were found in COVID-19 patients who required mechanical ventilation which calls for non-invasive means in managing respiratory failure. Methods: We retrospectively reviewed patients admitted to the intensive care unit of Pamela Youde Nethersole Eastern Hospital in Hong Kong with severe acute respiratory syndrome coronavirus 2 infection from 28 November to 15 December 2020. Patients’ laboratory, respiratory parameters and outcome data were recorded and analysed. Results: Eleven received prone ventilation. The median age was 67 (inter-quartile range: 59–72) years, and median COVID-19 GRAM score was 151 (inter-quartile range: 133–181), representing a high-risk group. There were significant improvements 1 h after awake proning in SpO2 (95% vs 92%, p = 0.008), FiO2 (0.4 vs 0.5, p = 0.003), SpO2/FiO2 (240 vs 184, p = 0.005), respiratory rate (19 vs 26, p = 0.006) and respiratory rate – oxygenation index (13.22 vs 7.67, p = 0.003; Table 1). Although not reaching statistical significance, the median PaO2, PaCO2 and PaO2/FiO2 improved after proning. The overall intubation rate was 22% and intensive care unit mortality was 22%, which is in contrast to 65.5% and 27.6%, respectively, in the first three waves. Although did not reach statistical significance, those received prone ventilation tend to have a lower ICU mortality (9.1% vs 42.9%, p = 0.245) and hospital mortality (18.2% vs 42.9%, p = 0.326). Conclusion: Awake proning potentially minimizes complications from invasive ventilation and provides a low-cost low-risk treatment option in COVID-19 patients with respiratory failure. This is particularly important when healthcare resources are strained at times of a pandemic.","PeriodicalId":50401,"journal":{"name":"Hong Kong Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2021-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10249079211022914","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43666322","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-06-02DOI: 10.1177/10249079211020868
W. Lo, K. Mok, Ying Ying Poon
Objective: To evaluate the safety and effectiveness of olanzapine compared to midazolam for the pre-hospital management of excited delirium syndrome. Methods: A retrospective review of patients who were treated by ambulance crew for excited delirium syndrome from 2016 to 2019 was performed. The drug of choice was given per Fire Service Department’s paramedic protocol (intramuscular midazolam January 2016 to October 2018 and intramuscular olanzapine October 2018 to December 2019). The primary outcome was the proportion of patients experienced at least one adverse event. The secondary outcome was the successful sedation rate. Results: A total of 201 patients were included in the study. Ninety-nine patients had pre-hospital midazolam and 102 received olanzapine. Thirty-one patients experienced adverse event after arrival to A&E, including a drop of Glasgow Coma Scale score to below 8 (90%), hypotension (6%), and airway obstruction (3%): 17 (17% patients; 1 airway obstruction and 16 Glasgow Coma Scale score below 8) in midazolam group and 14 (14% patients; 2 hypotension and 12 Glasgow Coma Scale score below 8) in olanzapine group (p = 0.41). Sixty-eight patients (69%) in midazolam group achieved successful sedation, compared with 79 (77%) in olanzapine group (p = 0.20). More adverse events were seen with midazolam than olanzapine in alcohol intoxication subgroup with statistical significance (12 vs 2, p = 0.03). Conclusion: Both midazolam and olanzapine can achieve a satisfactory success rate of sedation. More adverse events are associated with midazolam use in patients with acute alcohol intoxication, especially over-sedation and airway compromise. Olanzapine would be a safer choice in the pre-hospital setting where the resource is limited, and differentiation of underlying causes is not always possible.
{"title":"A retrospective study on the safety and effectiveness of olanzapine versus midazolam for pre-hospital management of excited delirium syndrome","authors":"W. Lo, K. Mok, Ying Ying Poon","doi":"10.1177/10249079211020868","DOIUrl":"https://doi.org/10.1177/10249079211020868","url":null,"abstract":"Objective: To evaluate the safety and effectiveness of olanzapine compared to midazolam for the pre-hospital management of excited delirium syndrome. Methods: A retrospective review of patients who were treated by ambulance crew for excited delirium syndrome from 2016 to 2019 was performed. The drug of choice was given per Fire Service Department’s paramedic protocol (intramuscular midazolam January 2016 to October 2018 and intramuscular olanzapine October 2018 to December 2019). The primary outcome was the proportion of patients experienced at least one adverse event. The secondary outcome was the successful sedation rate. Results: A total of 201 patients were included in the study. Ninety-nine patients had pre-hospital midazolam and 102 received olanzapine. Thirty-one patients experienced adverse event after arrival to A&E, including a drop of Glasgow Coma Scale score to below 8 (90%), hypotension (6%), and airway obstruction (3%): 17 (17% patients; 1 airway obstruction and 16 Glasgow Coma Scale score below 8) in midazolam group and 14 (14% patients; 2 hypotension and 12 Glasgow Coma Scale score below 8) in olanzapine group (p = 0.41). Sixty-eight patients (69%) in midazolam group achieved successful sedation, compared with 79 (77%) in olanzapine group (p = 0.20). More adverse events were seen with midazolam than olanzapine in alcohol intoxication subgroup with statistical significance (12 vs 2, p = 0.03). Conclusion: Both midazolam and olanzapine can achieve a satisfactory success rate of sedation. More adverse events are associated with midazolam use in patients with acute alcohol intoxication, especially over-sedation and airway compromise. Olanzapine would be a safer choice in the pre-hospital setting where the resource is limited, and differentiation of underlying causes is not always possible.","PeriodicalId":50401,"journal":{"name":"Hong Kong Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2021-06-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10249079211020868","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48203475","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-05-13DOI: 10.1177/10249079211016225
Wong Yu Him Michael, Poon Tak Shun, NG Wah Shan
Introduction: Neutropenic sepsis is an emergency sequela in post-chemotherapy fever. Its definition comprises of spectrums of diseases with variable quoted mortality. This study aims to evaluate the incidence of “modified” neutropenic sepsis, with a more stringent definition employed. Predictive risk factors toward occurrence of “modified” neutropenic sepsis among Chinese patients would also be explored. Methods: A single-center retrospective longitudinal study was conducted in a medium-sized regional hospital in Hong Kong. All patients with diagnoses of post-chemotherapy fever fulfilling the inclusion and exclusion criteria were recruited. Baseline characteristics and outcome variables of each case subject were collected. Six potential predictive risk factors were chosen for further analysis. Case subjects were followed up for the inpatient progress and outcomes. Relative risks of each risk factor to “modified” neutropenic sepsis were calculated. Results: A total of 135 case subjects were recruited. Five developed “modified” neutropenic sepsis, that is, incidence 3.70% (95% confidence interval = 1.59%–8.38%). Only background hematological malignancy was found to be significantly associated with the outcome of “modified” neutropenic sepsis (Relative Risk [RR] 13.2, 95% confidence interval = 1.56–115.70, p = 0.010), with an incidence of 12.9% (95% confidence interval = 5.14%–28.85%). Hematological malignancy was also found to be significantly associated with lower median absolute neutrophil counts (0.95 × 109/L vs 2.3 × 109/L, p = 0.005) and longer median hospital stay (8 days vs 6 days, p < 0.001). Conclusion: Incidence of “modified” neutropenic sepsis is low. Hematological malignancy is associated with significantly higher rate of “modified” neutropenic sepsis.
{"title":"Incidence and predictive risk factors of neutropenic sepsis in post-chemotherapy febrile patients in emergency department: A single-center retrospective longitudinal study","authors":"Wong Yu Him Michael, Poon Tak Shun, NG Wah Shan","doi":"10.1177/10249079211016225","DOIUrl":"https://doi.org/10.1177/10249079211016225","url":null,"abstract":"Introduction: Neutropenic sepsis is an emergency sequela in post-chemotherapy fever. Its definition comprises of spectrums of diseases with variable quoted mortality. This study aims to evaluate the incidence of “modified” neutropenic sepsis, with a more stringent definition employed. Predictive risk factors toward occurrence of “modified” neutropenic sepsis among Chinese patients would also be explored. Methods: A single-center retrospective longitudinal study was conducted in a medium-sized regional hospital in Hong Kong. All patients with diagnoses of post-chemotherapy fever fulfilling the inclusion and exclusion criteria were recruited. Baseline characteristics and outcome variables of each case subject were collected. Six potential predictive risk factors were chosen for further analysis. Case subjects were followed up for the inpatient progress and outcomes. Relative risks of each risk factor to “modified” neutropenic sepsis were calculated. Results: A total of 135 case subjects were recruited. Five developed “modified” neutropenic sepsis, that is, incidence 3.70% (95% confidence interval = 1.59%–8.38%). Only background hematological malignancy was found to be significantly associated with the outcome of “modified” neutropenic sepsis (Relative Risk [RR] 13.2, 95% confidence interval = 1.56–115.70, p = 0.010), with an incidence of 12.9% (95% confidence interval = 5.14%–28.85%). Hematological malignancy was also found to be significantly associated with lower median absolute neutrophil counts (0.95 × 109/L vs 2.3 × 109/L, p = 0.005) and longer median hospital stay (8 days vs 6 days, p < 0.001). Conclusion: Incidence of “modified” neutropenic sepsis is low. Hematological malignancy is associated with significantly higher rate of “modified” neutropenic sepsis.","PeriodicalId":50401,"journal":{"name":"Hong Kong Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2021-05-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/10249079211016225","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49098539","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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