Chen Hsen Lee

The clinical experience of acute cyanide poisoning.

The authors reviewed the clinical manifestations, complications, and the prognosis affected by Lilly Cyanide Antidote in 21 victims of acute cyanide poisoning over a 10-year period. The clinical signs and symptoms in cyanide poisoning are variable. Among 21 cases, loss of consciousness (15), metabolic acidosis (14), and cardiopulmonary failure (9) were the three leading manifestations of cyanide intoxication. Anoxic encephalopathy (6) was not uncommon in the severely intoxicated victims. Diabetes insipidus (1) or clinical signs and symptoms mimicking diabetes insipidus (3) may be an ominous sign to encephalopathy victims. The major cause of fatal cyanide poisoning is the intentional ingestion of cyanide compounds as part of a suicide attempt. Decrease of arteriovenous difference of O2 partial pressure may be a clue for the suspicion of cyanide intoxication. Although the authors cannot show a statistically significant difference (P = .47) for the Lilly cyanide antidote kit in terms of improving the survival rate for victims of cyanide poisoning, the antidote kit was always mandatory in our study in the cases of severely intoxicated victims who survived. Early diagnosis, prompt, intensive therapy with antidote, and supportive care are still the golden rules for the treatment of acute cyanide poisoning, whether in the ED or on the scene.

Athletic performance and serial weight changes during 12- and 24-hour ultra-marathons

Objective:The principal objective of this study was to evaluate serial weight changes in athletes during 12- and 24-hour ultra-marathons and to correlate these changes with athletic performance, namely the distance covered. Design:This was a prospective study. Setting:The 2003 Soochow University international ultra-marathon. Participants:Fifty-two race participants. Interventions:12- or 24-hour ultra-marathon. Main Outcome Measurements:Body weight changes were measured before, at 4-hour intervals during, and immediately after the 12- and 24-hour races. Results:Significant overall decreases in body weight were apparent at the conclusion of both races. The mean relative body weight change after the 12-hour race was −2.89 ± 1.56%, ranging from 0 to 6.5%. The mean relative body weight change after the 24-hour race was −5.05 ± 2.28%, ranging from −0.77% to −11.40%. Of runners in the 24-hour race, 26% lost greater than 7% of baseline body weight during the race. During both the 12- and 24-hour races, the greatest weight change (decrease) occurred during the first 4 hours. Weight remained relatively stable after 8 hours, although a further decrease was apparent between 16 and 20 hours in the 24-hour participants. Weight change had no bearing on performance in the 12-hour race, whereas weight loss was positively associated with performance in the 24-hour race. Conclusions:Our findings demonstrate that the majority of weight decrease/dehydration in both the 12- and 24-hour races occurred during the first 8 hours. Hence, to maintain body weight, fluid intake should be optimized in the first 8 hours for both 12- and 24-hour runners and in 16 to 20 hours for 24-hour marathon runners.

Clinical Factors and Outcomes in Patients with Acute Mesenteric Ischemia in the Emergency Department

Background: The purpose of this study was to determine the initial clinical characteristics of acute mesenteric ischemia and identify variables associated with adverse outcomes in the emergency department (ED). Methods: The charts of 124 consecutive patients with surgically and pathologically identified acute mesenteric ischemia from September 1990 to September 2000 were reviewed retrospectively to obtain data about demographics, initial clinical presentations, predisposing diseases, previous medications, laboratory tests, and common findings on computed tomography scans with contrast. Only patients admitted through the ED and treated on medical or surgical wards were enrolled. Results: Mean patient age was 71.1 years (range, 25‐100 years). The overall mortality rate was 50%. There were no significant differences in gender, underlying disease, previous medication, initial signs and symptoms, and causes of mesenteric infarction, between survivors and non‐survivors. Univariate analysis demonstrated that older age, bandemia, hepatic and renal impairment, hyperamylasemia, metabolic acidosis, hypoxia, intramural pneumatosis, and septic syndrome, were more frequent in patients who died than in those who survived (p < 0.05). Logistic regression identified the following variables as independent predictors of death: old age (odds ratio, OR, 1.077; 95% confidence interval, CI, 1.013, 1.146; p = 0.02); bandemia (OR, 3.894; 95% CI, 1.160, 13.074; p = 0.03); elevated serum aspartate aminotransferase (AST; OR, 4.532; 95% CI, 1.274, 16.122; p = 0.02); increased blood urea nitrogen (BUN; OR, 7.219; 95% CI, 1.166, 44.696; p = 0.03); and metabolic acidosis (OR, 6.604; 95% CI, 1.804, 24.171; p < 0.01). Conclusion: A high index of suspicion and aggressive diagnostic imaging can facilitate early diagnosis and improve outcomes for patients with acute mesenteric ischemia. Risk stratification showed that elderly patients with metabolic acidosis, bandemia, or elevated AST and BUN had a poor prognosis. Greater therapeutic intervention is advocated to reduce mortality in high‐risk patients with acute mesenteric ischemia.

Emergency Department Neurologic Deterioration in Patients With Spontaneous Intracerebral Hemorrhage: Incidence, Predictors, and Prognostic Significance

OBJECTIVESnu2002 The objective was to explore the incidence, predictors, and prognostic significance of emergency department (ED) neurologic deterioration in patients with spontaneous intracerebral hemorrhage (SICH).nnnMETHODSnu2002 This was a retrospective cohort study conducted at the ED, neurocritical care unit, and general intensive care unit of a university-affiliated medical center. Consecutive adult SICH patients treated in our ED from January 2002 through December 2009 were included, identified from the registered stroke data bank. These were cross-checked for coding with International Classification of Diseases, Ninth Revision, Clinical Modification 431 and 432.9. Enrolled patients had SICH with elapsed times of <12 hours and Glasgow Coma Scale (GCS) scores ≥ 13 on arrival. ED neurologic deterioration was defined as having a two-or-more-point decrease in consciousness noted in any GCS score assessment between ED presentation and admission. Comparisons of numerical data were performed using an unpaired t-test (parametric data) or Mann-Whitney U-test (nonparametric data). Comparisons of categorical data were done by chi-square tests. Variables with p < 0.1 in univariate analysis were further analyzed using multiple logistic regression. No variable automated or manual selection methods were used.nnnRESULTSnu2002 Among the 619 patients with SICH included in the study, 22.6% had ED neurologic deterioration. Independent predictors for ED neurologic deterioration included regular antiplatelet use, ictus to ED arrival time under 3 hours, initial body temperature ≥ 37.5°C, intraparenchymal hemorrhage associated with intraventricular hemorrhage (IVH), and presence of a midline shift of greater than 2 mm on computed tomography (CT). ED neurologic deterioration was associated with 1-week mortality, 30-day mortality, and poor neurologic outcome on discharge.nnnCONCLUSIONSnu2002 Nearly one-quarter of SICH patients with an initial GCS of 13 to 15 had a two points or more deterioration of their GCS while in the ED. ED neurologic deterioration was associated with death and poor neurologic outcomes on discharge. Several risk factors that are available early in the patients courses appear to be associated with ED neurologic deterioration. By identifying patients at risk for early neurologic decline and intervening early, physicians may be able to improve patient outcomes.

Arterial oxygen desaturation during emergent nonsedated upper gastrointestinal endoscopy in the emergency department

A prospective study was conducted to see whether emergent esophagogastroduodenoscopy (EGD) in patients with active upper gastrointestinal (GI) bleeding is associated with more oxygen desaturation than nonemergent EGD. Emergent EGD was performed in the study patients with active upper GI bleeding. Nonemergent EGD was performed in the control patients. Determination of oxygen saturation (Sao2) was measured by pulse oximeter. A decrease in Sao2 of > 4% was more frequent in the study patients (26%, 13 of 50) than in controls (6%, 3 of 50) (P < .01). During EGD, mean oxygen saturation decreased significantly in both groups of patients. After EGD, mean oxygen saturation did not recover toward the pre-endoscopy insertion level in the study group (P < .01). A linear association was found that oxygen desaturation = 5.46 + 0.15 (status) -0.06 (baseline oxygen saturation). Emergent EGD for active upper GI bleeding in the emergency department tends to be associated with more frequent significant oxygen desaturation than nonemergent EGD. Continuous oxygen supplementation and oxygen saturation monitoring may be used during emergent nonsedated EGD in the emergency department.

Using an integrated infection control strategy during outbreak control to minimize nosocomial infection of severe acute respiratory syndrome among healthcare workers.

n Summaryn n Healthcare workers (HCWs) are at risk of acquiring severe acute respiratory syndrome (SARS) while caring for SARS patients. Personal protective equipment and negative pressure isolation rooms (NPIRs) have not been completely successful in protecting HCWs. We introduced an innovative, integrated infection control strategy involving triaging patients using barriers, zones of risk, and extensive installation of alcohol dispensers for glove-on hand rubbing. This integrated infection control approach was implemented at a SARS designated hospital (‘study hospital’) where NPIRs were not available. The number of HCWs who contracted SARS in the study hospital was compared with the number of HCWs who contracted SARS in 86 Taiwan hospitals that did not use the integrated infection control strategy. Two HCWs contracted SARS in the study hospital (0.03 cases/bed) compared with 93 HCWs in the other hospitals (0.13 cases/bed) during the same three-week period. Our strategy appeared to be effective in reducing the incidence of HCWs contracting SARS. The advantages included rapid implementation without NPIRs, flexibility to transfer patients, and re-inforcement for HCWs to comply with infection control procedures, especially handwashing. The efficacy and low cost are major advantages, especially in countries with large populations at risk and fewer economic resources.n n

Rapid creation of a temporary isolation ward for patients with severe acute respiratory syndrome in Taiwan.

OBJECTIVESnTo rapidly establish a temporary isolation ward to handle an unexpected sudden outbreak of severe acute respiratory syndrome (SARS) and to evaluate the implementation of exposure control measures by healthcare workers (HCWs) for SARS patients.nnnDESIGNnRapid creation of 60 relatively negative pressure isolation rooms for 196 suspected SARS patients transferred from 19 hospitals and daily temperature recordings of 180 volunteer HCWs from 6 medical centers.nnnSETTINGnA military hospital.nnnRESULTSnOf the 196 patients, 34 (17.3%) met the World Health Organization criteria for probable SARS with positive results of serologic testing for SARS-associated coronavirus (SARS-CoV), reverse transcriptase polymerase chain reaction (RT-PCR) from nasopharyngeal or throat swabs for SARS-CoV, or both. Seventy-four patients had suspected SARS based on unprotected exposure to SARS patients; three of them had positive results on RT-PCR but negative serologic results. The remaining 88 patients did not meet the criteria for a probable or suspected SARS diagnosis. Of the 34 patients with probable SARS, 13 were transferred to medical centers to receive mechanical ventilation due to rapid deterioration of chest x-ray results, and three patients died of SARS despite intensive therapy in medical centers. During the study period, one nurse developed probable SARS due to violation of infection control measures, but there was no evidence of cross-transmission to other HCWs.nnnCONCLUSIONSnDespite the use of full personal protection equipment, the facility failed to totally prevent exposures of HCWs to SARS but minimized the risk of nosocomial transmission. Better training and improvements in infection control infrastructure may limit the impact of SARS.

Alternations of heart rate variability at lower altitude in the predication of trekkers with acute mountain sickness at high altitude.

Objective:To determine the change and relationship of spectral components of heart rate variability (HRV) measurements in subjects with or without acute mountain sickness (AMS) at both low and high altitude. Design:A prospective study. Setting:A 12-day itinerary by trekking to the Namche Bazaar, 3440 m in Nepal. Participants:A total of 32 subjects were recruited. Interventions:The alternations were measured by heart rate (HR), arterial oxygen saturation (SpO2), and spectral analysis of HRV at sea level, 1317 m, 3440 m, 1317 m, and sea level, respectively. Main Outcome Measures:Spectral analysis of HRV. Results:There were statistically significant increases in HR and decreases in SpO2 in all subjects at high altitude. In HRV, the values of R-R interval, total variance, high frequency (HF), low frequency (LF), and HF% were significantly lower at 3440 m than at sea level, respectively (P < 0.05). The subjects with AMS had significantly lower total variance, HF, and HF%, respectively, but higher LF:HF ratio (P < 0.05) at 3440 m. Subjects with both HF% < 20% (nu) and LF:HF ratio > 1.3 measured at 1317 m had odds ratios of 7.00 (95% confidence interval, 1.11 to 44.06; P = 0.047) to get AMS at 3440 m. Conclusions:The HRV measurements in total variances, HF, and HF% in trekkers with AMS were statistically significantly lower at high altitude. HF% < 20% (nu) or LF:HF ratio > 1.3 at lower altitudes could be an important predication parameter of trekkers with AMS at higher altitudes.

Expression of the triggering receptor expressed on myeloid cells‐1 mRNA in a heterogeneous infected population

This study is to investigate the clinical utility of detection of peripheral blood triggering receptor expressed on myeloid cells (TREM)‐1 mRNA as an early indicator of sepsis among critically ill patients and to compare the results of TREM‐1 with those of C‐reactive protein (CRP). A prospective, non‐interventional study of 127 patients with at least two criteria of the systemic inflammatory response (SIRS) was performed. TREM‐1 was assessed by real‐time quantitative reverse transcription‐polymerase chain reaction.

Hemodynamic response of modified fluid gelatin compared with lactated ringer's solution for volume expansion in emergency resuscitation of hypovolemic shock patients: Preliminary report of a prospective, randomized trial

Abstract. The objective of this study was to compare the cardiac and hemodynamic responses to a rapid infusion of 1000 ml of modified fluid gelatin (group A) or 1000 ml of lactated Ringers solution (group B) in emergency room patients suffering from shock. This prospective, randomized, open, noncrossover study was performed at a medical center university hospital in a surgical resuscitation room in the emergency department. The subjects were 34 patients with either hypovolemic or neurogenic shock who were admitted to the emergency room. A resuscitation protocol according to Advanced Trauma Life Support (ATLS) with an additional central venous line or Swan-Ganz catheters for hemodynamic monitoring was used. Physical parameters and hemodynamic variables were measured at baseline and 15 minutes, 30 minutes, and 1 hour after the infusion of each fluid. In both groups the mean arterial blood pressure (MAP), systolic and diastolic pressure, central venous pressure (CVP), and pulmonary artery occlusion pressure (PAOP) increased significantly. The CVP and PAOP increased significantly more in the modified fluid gelatin resuscitation group. In patients with traumatic or neurogenic shock due to acute volume deficiency, there was significantly better hemodynamic improvement, judged by CVP and PAOP measurements using the modified fluid gelatin for volume replacement than with lactated Ringers solution during the first hour of resuscitation.