Chung-Hsien Chaou

Comparisons of ice packs, hot water immersion, and analgesia injection for the treatment of centipede envenomations in Taiwan

Objective. To compare the effectiveness of ice packs and hot water immersion for the treatment of centipede envenomations. Methods. Sixty patients envenomated by centipedes were randomized into three groups and were treated with ice packs, hot water immersion, or analgesia injection. The visual analog score (VAS) for pain was measured before the treatment and 15 min afterward. Demographic data and data on local and systemic effects after centipede bites were collected. The VAS scores and the pain decrease (ΔVAS) were compared between the three groups. Results. All patients suffered from pain at the affected sites; other local effects included redness (n = 49, 81.7%), swelling (n = 32, 53.3%), heat (n = 14, 23.3%), itchiness (n = 5, 8.3), and bullae formation (n = 3, 5.0%). Rare systemic effects were reported. All three groups had similar VAS scores before and after treatment. They also had similar effectiveness in reducing pain caused by centipedes bites (ΔVAS = 2.55 ± 1.88, 2.33 ± 1.78, and 1.55 ± 1.68, with ice packs, analgesia, and hot water immersion, respectively, p = 0.165). Conclusion. Ice packs, hot water immersion, and analgesics all improved the pain from centipede envenomation. Ice pack treatment is a safe, inexpensive, and non-invasive method for pre-hospital management in patients with centipede envenomation.

Prognostic value of serial serum cholinesterase activities in organophosphate poisoned patients.

OBJECTIVES Organophosphate (OP) poisoning is a worldwide concern. Several factors have been identified to predict outcomes of OP poisoned patients. This study focuses on the relationship between the trend in Serum cholinesterase (SChE) activity and its clinical outcome in acute OP poisoned patients. METHODS We retrospectively reviewed the medical records of all adult acute OP poisoned patients that visited the Emergency Department from 2000 to 2006. These patients were divided into two groups: the deceased patients as the sample group and all others as the control group. We collected data on the following: demographical factors, poisoning history, clinical manifestation, Glasgow Coma Scale (GCS), APACHE II score, all SChE data within 48 hours, hourly 2-PAM dosage, intubation, and mortality. Chi-Square test then examined the relationship between the trend of SChE activity and mortality. RESULTS 86 patients were enrolled. Follow-up measurements of SChE activity within 48 hours of poisoning were available in 50 cases. Among these, eight patients died. We found no significant difference between the sample and control groups on initial SChE activity, time interval to initial SChE data, and hourly 2-PAM dosage. The sampled group possessed a worse GCS score, lower systolic blood pressure, and a higher APACH II score. Increase patient mortality rates associated with the absence of elevating SChE activity within 48 hours of poisoning. (P = .006, odds ratio:11). CONCLUSIONS We propose that the absence of elevating SChE activity level within 48 hours of poisoning appears to associate with higher mortality in acute OP poisoned patients.

An investigation of snakebite antivenom usage in Taiwan

BACKGROUND/PURPOSE Four types of antivenom are used to treat snakebites by the six species of venomous snakes native to Taiwan. Research into antivenom use in Taiwan and its outcomes, as well as the utility of current Taiwan Poison Control Center guidelines for antivenom use, has been limited. We aimed to provide increased understanding by investigating the treatment and outcomes of patients treated for snakebite in Taiwan. METHODS On the basis of data collected from the 2009 Taiwan National Health Insurance database, patients with snakebites were identified and categorized into two sets of groups according to types of antivenom administered. The relationships between antivenom types, dosage and the variables of antibiotic use, surgical intervention, acute respiratory failure acute, renal failure, antivenom-related allergic reaction, mortality, need for hospital admission, and length of hospitalization were analyzed by multivariate logistic regression and the Kruskal-Wallis test. RESULTS The majority of patients were successfully treated by administration of 1 vial of antivenom and discharged without complications. However, patients treated for neurotoxic-type venom snakebite required administration of larger doses of antivenom and > 30% required surgical intervention, particularly those treated for Chinese cobra snakebite. Approximately 10% of patients were administered two types of antivenom. CONCLUSION The results partially support Taiwan Poison Control Center guidelines for treating the hemorrhagic-type venom snakebite. However, deficit in the guidelines for treatment of neurotoxic-type venom snakebite is obvious and new guidelines for treatment of neurotoxic-type venom snakebite and diagnosis should be developed.

Chlorpyrifos is associated with slower serum cholinesterase recovery in acute organophosphate-poisoned patients

Purpose. Organophosphate poisoning (OPP) accounts for 200,000 deaths annually in developing countries. Serum cholinesterase (SChE) is of diagnostic value in patients with OPP and is checked repeatedly during the course of treatment. This study aimed to investigate the recovery pattern in patients with OPP using linear mixed models. Methods. Using a retrospective cohort study design, we included 212 adult OPP patients who had visited the emergency department (ED) in a tertiary medical center between 2000 and 2010. One hundred and thirty-one patients were available for analysis, as 81 patients did not meet the criteria and were excluded. Information regarding basic personal characteristics, initial vital signs and severity scores, laboratory data, type and amount of organophosphate ingested, treatment, and serial SChE values was collected. A random coefficient model with a random intercept and a random slope of time were added to address the dynamic relationships of SChE with time and other associated factors. Results. The initial SChE activity and recovery rates varied among patients with OPP. The type of organophosphate, the first SChE activity, and the initial APACHE II score were significantly related to the SChE recovery trend. Chlorpyrifos and methamidophos had significantly slower and faster SChE recovery rates, respectively, than other organophosphates. Sex, dose of Pralidoxim (2-PAM), and delay in obtaining medical assistance did not significantly affect SChE recovery. Conclusions. This study demonstrated the pattern and associated correlates of SChE activity recovery in patients with acute OPP. Chlorpyrifos appeared to have a slower SChE activity recovery rate than other organophosphates.

Diagnostic Accuracy of Lipopolysaccharide-Binding Protein as Biomarker for Sepsis in Adult Patients: A Systematic Review and Meta-Analysis.

Introduction Lipopolysaccharide-binding protein (LBP) is widely reported as a biomarker to differentiate infected from non-infected patients. The diagnostic use of LBP for sepsis remains a matter of debate. We aimed to perform a systematic review and meta-analysis to assess the diagnostic accuracy of serum LBP for sepsis in adult patients. Methods We performed a systematic review and meta-analysis to assess the accuracy of LBP for sepsis diagnosis. A systematic search in PubMed and EMBASE for studies that evaluated the diagnostic role of LBP for sepsis through December 2015 was conducted. We searched these databases for original, English language, research articles that studied the diagnostic accuracy between septic and non-septic adult patients. Sensitivity, specificity, and other measures of accuracy, such as diagnostic odds ratio (DOR) and area under the receiver operating characteristic curve (AUC) of LBP were pooled using the Hierarchical Summary Receiver Operating Characteristic (HSROC) method. Results Our search returned 53 reports, of which 8 fulfilled the inclusion criteria, accounting for 1684 patients. The pooled sensitivity and specificity of LBP for diagnosis of sepsis by the HSROC method were 0.64 (95% CI: 0.56–0.72) and 0.63 (95% CI: 0.53–0.73), respectively. The value of the DOR was 3.0 (95% CI: 2.0–4.0) and the AUC was 0.68 (95% CI: 0.64–0.72). Meta-regression analysis revealed that cut-off values accounted for the heterogeneity of sensitivity and sample size (> = 150) accounted for the heterogeneity of specificity. Conclusions Based on the results of our meta-analysis, LBP had weak sensitivity and specificity in the detection of sepsis. LBP may not be practically recommended for clinical utilization as a single biomarker.

Comparison of prehospital triage and five-level triage system at the emergency department

Objective There is lack of scientific evidence regarding the effectiveness of prehospital triage systems. This study compared the two-level Taiwan Prehospital Triage System (TPTS) with the five-level Taiwan Triage and Acuity Scale (TTAS) at ED arrival regarding the prediction of patient outcomes and the utilisation of medical resources. Design This was a retrospective cohort study. Adult patients transported via the emergency medical service (EMS), who arrived at the ED of a medical centre in northern Taiwan during the study period were enrolled. TTAS acuity levels 1–2 were considered comparable to the designation of ‘emergent’ by the prehospital TPTS system. The outcomes were analysed by comparing TPTS and TTAS by acuity levels. Results Among 4430 enrolled patients, 25.2% and 74.8% were classified as emergent and non-emergent by TPTS; 44.1% and 55.9% were classified as levels 1–2 and levels 3–5 by TTAS. Of the TPTS emergent patients, 15.2% were classified as TTAS levels 3–5, whereas 30.4% of TPTS non-emergent transports were classified as TTAS levels 1–2 at the ED. TTAS levels 1–2 showed better predictability than TPTS emergent level for hospitalisation rate with a sensitivity of 70.3% (95% CI 68.3% to 72.2%) versus 41.1% (95% CI 39.0% to 43.2%), and a negative predictive value of 74.8% (95% CI 73.4% to 76.0%) versus 62.6% (95% CI 61.7% to 63.5%). Conclusion The current prehospital triage system is insufficient and inappropriate in classifying patients transported to the ED. The present study offers supporting evidence for the introduction of a five-level triage system to prehospital EMS systems.

Factors associated with ED length of stay during a mass casualty incident

BACKGROUND The aim of this study was to examine the factors associated with emergency department (ED) length of stay (LOS) using the patient registry data from a medical burns center during a burn injury mass casualty incident (MCI) after a dust explosion in New Taipei City, Taiwan. METHODS This was a retrospective cohort study conducted at an urban, tertiary care teaching hospital during an MCI event that occurred on June 27, 2015. A celebratory party was held at the Formosa Fun Water Park in New Taipei City, Taiwan. At 20:32, the was an explosion caused by an overheated spotlight accidentally igniting colored cornstarch powder that had been sprayed on the stage. Factors associated with ED LOS were compared. RESULTS In total, 48 burn injury patients were enrolled for study analysis. The median total body surface area of second- to third-degree burns was 35.0% (interquartile range [IQR], 15.8%-55.0%). The median ED LOS was 121.5 minutes (IQR, 38.3-209.8 minutes). The output time interval accounted for the longest interval with a median time of 56.0 minutes (IQR, 15.3-117.3 minutes). In multivariate analysis of the variables, triage level (level III; hazard ratio, 0.06; 95% confidence interval, 0.01-0.52) and output time (hazard ratio, 0.97; 95% confidence interval, 0.96-0.98) were significant influential factors. CONCLUSIONS The triage level and output time intervals were significantly associated with ED LOS in a burn-related MCI. Time effectiveness analyses, using a patient flow model, might serve as an important indicator during a hospital MCI response.

The effect of personal protective equipment on emergency airway management by emergency physicians: a mannequin study.

Objective Emergency medical personnel are at risk of secondary contamination when treating victims of chemical–biological–radiological–nuclear incidents. Hence, it is crucial to train them on the appropriate management of patients involved in chemical–biological–radiological–nuclear incidents. Personal protective equipment (PPE) plays an important role in treating patients suffering from various types of poisoning. However, very few studies have examined whether the use of PPE impedes airway management in an emergency department setting. The present study evaluated the effect of PPE on physicians’ performance of emergency airway management using mannequins. Methods Forty emergency physicians with 1–4 years of experience participated, and were divided by years of experience (1–2 vs. 3–4 years). Each participant both intubated a tracheal tube and inserted a laryngeal mask airway into a mannequin, with and without wearing protection using preassembled intubation aids. The intubation time for both methods was assessed along with participants’ preferences and experiences in airway management. Results The mean (SD) times to successful tracheal tube/mask placement with and without protection were similar [tracheal tube: 17.86 s (6.38) vs. 17.83 s (11.13), P=0.99; laryngeal mask: 10.51 s (4.39) vs. 9.65 s (3.29), P=0.32]. Conclusion Protective equipment had no effect on physicians’ emergency airway placement time. The effect of wearing PPE is limited if postintubation care is excluded from the evaluation. Furthermore, intubation experience influenced participants’ preferred approach for airway management.

Significance of blood pH value and automated external defibrillator shock in determining the outcomes of out-of-hospital cardiac arrest patients

Background: The prognosis of out-of-hospital cardiac arrest is generally poor. It is known that the survival of out-of-hospital cardiac arrest patients depends on treatments delivered in a very short time frame. Identifying outcome-associated factors may provide valuable information for decision-making in clinical practices. Aim: The objective of the present study was to assess the associations between various factors (e.g. serum biomarker levels and prehospital factors) and outcomes in adult, non-traumatic out-of-hospital cardiac arrest patients. Methods: Data from 386 consecutive out-of-hospital cardiac arrest patients treated from January 2012 to December 2015 at Taoyuan Chang Gung Memorial Hospital (Taiwan, ROC) were collected. While performing cardiopulmonary resuscitation in the emergency room, the levels of creatinine, aspartate aminotransferase, sodium, potassium, troponin-I, hydrogen bicarbonate and haemoglobin were determined, blood pH and pCO2 were measured and the white blood cell count was calculated. The response time and scene time interval were also recorded. Results: Here we found that out-of-hospital cardiac arrest patients with blood pH values of <7.34 had a lower chance of survival to 24 h (Odds Ratio (OR) = 2.77), survival to discharge (OR = 7.06) and a good neurological outcome (OR = 64.59). Moreover, patients without an automated external defibrillator shock had a lower chance of being discharged (OR = 4.27) and enjoying good neurological outcomes (OR = 25.09). Conclusion: Our data suggest that the blood pH and an automated external defibrillator shockable rhythm are two easily measurable factors strongly associated with the outcomes of out-of-hospital cardiac arrest patients.

Segmented regression analysis of emergency departments patient visits from Septicemia in Taiwan

Abstract Background The protocol for early goal-directed therapy (EGDT) is effective for improving both the costs and outcomes of septicemia treatment, including a significant reduction in case fatality. However, this complicated protocol may have a downside. Furthermore, the Joint Taiwan Critical Care Medicine Committee has launched a nationwide educational program after the publication of the Surviving Sepsis Campaign (SSC) to improve the overall survival rate from septicemia in the emergency care system of Taiwan. Objectives To assess the impact of the EGDT protocol and SSC education programs on island-wide septicemia-related emergency department (ED) visits. Methods Segmented regression techniques were utilized to assess the differences in annual rates and changes in septicemia-related ED visits between 1998 and 2012. We considered annual incidence of two medical comorbidities as potential confounders: metastatic malignant neoplasms and malignant neoplasms of the lymphatic and hematopoietic tissues. Results The EGDT protocol was associated with decreased septicemia-related ED visits in 2002 (level change; p < 0.001), while the SSC education program led to a slight increase in septicemia-related ED visits in 2007 (slope change; p < 0.001). For the EGDT protocol, the number of patient visits decreased by 32.9% after the protocol was implemented in 2002 compared with the expected number without the intervention. For the SSC education program, the number of patient visits increased by 20.2% (compared with the predicted number) in 2007 after the education program was implemented. Conclusions The EGDT protocol and SSC education program were associated with significant immediate changes and lagged intervention effects on island-wide septicemia-related ED visits.