Jeffrey Tsai

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.

Utilization of emergency department in patients with non-urgent medical problems: patient preference and emergency department convenience.

BACKGROUND/PURPOSE We investigated the factors associated with emergency department (ED) use among patients with non-urgent medical problems, with a focus on convenience and preference to use the ED instead of primary care clinics. METHODS A five-level triage system was adopted by research nurses to decide each patients triage level and the maximum time to physician interview. Patients who had a maximum time to physician interview of more than 60 minutes were assumed to be non-urgent in this study. RESULTS More than half of ED visits were considered to be non-urgent. Non-urgent patients were more likely to be unmarried, government employees, visit the ED due to trauma, have a history of chronic illness, and present in the day time or at the weekend. ED visits were also more likely to occur in patients who took less than 15 minutes to reach the ED, chose the ED for its convenience, agreed that they could have chosen another facility for their visit, did not agree that the ED was convenient for receiving medical care. Multivariate logistic regression showed that marital status, time of presentation, time needed to get to the ED, and occupation were associated with non-urgent ED visits. CONCLUSION Preference for using EDs for medical care and their convenience might contribute to non-urgent ED visits. A five-level triage system reliably stratified patients with different admission rates and utilization of medical resources, and could be helpful for reserving limited medical resources for more urgent patients.

Renal abscess: Early diagnosis and treatment

The purpose of this study was to identify initial clinical characteristics that can lead to early diagnosis of renal abscess in the emergency department and predict poor prognosis. A retrospective review of 88 renal abscess patients, from April 1979 through January 1996, was conducted. Patients were categorized into two groups. In group 1, renal abscess was diagnosed by an emergency physician, whereas in group 2 renal abscess was not diagnosed by an emergency physician. Clinical characteristics included demographic data, predisposing medical problems, duration of illness before diagnosis, time spent in hospital diagnosis, initial signs and symptoms, laboratory tests, and radiology studies that may have been useful in the early diagnostic regimes. Clinical factors were also analyzed for their value in predicting poor prognosis. The mean age of 88 patients with renal abscess was 59.8 years. The most common predisposing disorder was diabetes mellitus, followed by renal calculi and ureteral obstruction. The duration of diagnosis by emergency physicians was shorter for group 1 patients (1.2 +/- .4 v group 2, 2.8 +/- 2.9 days; P < .01) and the blood urea nitrogen level was higher in group 1 (55.7 +/- 42.2 mg/dL, v group 2, 33.5 +/- 33.5 mg/dL; P = .02). In the early diagnosis of renal abscess, emergency physicians should focus on patients who have predisposing disorders, ie, diabetes mellitus, renal stones, immunosuppression, longer duration of symptoms of urinary tract infection, and renal failure, who should promptly be investigated with ultrasound in the emergency department. The cure rate after treatment with routine antibiotics plus percutaneous drainage was 64%. This therapy is recommended for initial treatment. Poor prognosis is associated with elderly patients with lethargy and with elevation of the serum blood urea nitrogen level.

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.

Nonemergent emergency department visits under the National Health Insurance in Taiwan

OBJECTIVES To explore the magnitude of nonemergent emergency department visits under the Taiwan National Health Insurance program and to identify significant factors associated with these visits. METHODS A cross-sectional analysis of the 2002 Taiwan National Health Insurance Research Database was used to identify nonemergent emergency department conditions according to the New York University algorithm. The data contained 43,384 visits, of which 83.89% could be classified. Multivariate logistic regression identified individual and contextual factors associated with nonemergent emergency department visits. RESULTS Nearly 15% of all emergency department visits were nonemergent; an additional 20% were emergent-preventable with primary care. Patients likely to make nonemergent emergency department visits were older, female, categorized as a Taiwan National Health Insurance Category IV beneficiary, and without major illness. Hospital accreditation level, teaching status, and location were associated with an increased likelihood of nonemergent emergency department visits. CONCLUSION Understanding the factors leading to nonemergent emergency department visits can assist in evaluating the overall quality of a health care system and help reduce the use of the emergency department for nonemergent conditions. Policy makers desiring cost-effective care should assess emergency department visit rates in light of available resources for specific populations.

EMS characteristics in an Asian metroplis

A prospective citywide cohort study was conducted from August 1, 1993, through May 31, 1994 to analyze the epidemiological characteristics of emergency medical services (EMS) in an Asian city. Of 5,459 studied cases, the leading 3 causes were trauma (49.7%), alcohol intoxication (8.6%), and altered mental status (AMS) (6.9%). Half of the studied cases needed no prehospital care and 16.4% needed advanced life support (ALS) care. Traffic accidents accounted for 68% of trauma cases. Of 897 cases requiring ALS care, the two most common causes were AMS and dead on arrival (DOA) (32.1% and 21.2% in medical group, 10.1% and 4.5% in trauma group, respectively). The response time, time on scene, and transportation time were 4.6, 4.3, and 9.4 minutes, respectively. This Oriental EMS system experienced very short prehospital times, many traffic accidents, and extremely few DOA cases. Because few patients required ALS care, an emergency medical technician-based EMS system would probably be able to handle the majority of prehospital patients.

The Clinical Im p lication of Theophylline Intoxication in the Emergency Department

We reviewed the clinical manifestations of 53 episodes of theophylline intoxication in 50 patients over a one year study period, in order to identify the specific features as they presented to the Emergency Department (ED). There was a trend to an increase in the serum theophylline concentration with increased severity of clinical features, but the difference between the mild and the moderate cases was not statistically significant. The most common symptoms and signs were gastrointestinal complaints, sinus tachycardia, and atrial arrhythmias. Mixed atrial and ventricular arrhythmias, which are rarely mentioned as a specific feature of theophylline intoxication, were found in 16% of our patients and accounted for 29% of the cardiovascular manifestations. Four patients developed rhabdomyolysis, which presumably was secondary to a seizure or profound hypokalaemia. Cases of theophylline intoxication presenting to the ED had higher serum concentrations of theophylline and tended to have more severe toxicity than those patients in the non-ED group. Delayed diagnosis may contribute to the severity of the outcome, since severe cases in the ED were usually suspected to have developed intoxication at some point later in the stay in the ED than at the time of presentation, or after admission to the hospital, thus permitting the occurrence of an additional iatrogenic component to the intoxication. They also complained of symptoms not associated with the theophylline toxicity, which may have diverted the physicians attention from recognizing this concurrent problem. The other possible contributory reason for the severe and fatal outcomes was the use of a large dose of theophylline in the ED in the presence of coexisting factors that ordinarily indicate a low dose of theophylline.

Comparison of Risks Factors for Unplanned ICU Transfer after ED Admission in Patients with Infections and Those without Infections

Background. The objectives of this study were to compare the risk factors for unplanned intensive care unit (ICU) transfer after emergency department (ED) admission in patients with infections and those without infections and to explore the feasibility of using risk stratification tools for sepsis to derive a prediction system for such unplanned transfer. Methods. The ICU transfer group included 313 patients, while the control group included 736 patients randomly selected from those who were not transferred to the ICU. Candidate variables were analyzed for association with unplanned ICU transfer in the 1049 study patients. Results. Twenty-four variables were associated with unplanned ICU transfer. Sixteen (66.7%) of these variables displayed association in patients with infections and those without infections. These common risk factors included specific comorbidities, physiological responses, organ dysfunctions, and other serious symptoms and signs. Several common risk factors were statistically independent. Conclusions. The risk factors for unplanned ICU transfer in patients with infections were comparable to those in patients without infections. The risk factors for unplanned ICU transfer included variables from multiple dimensions that could be organized according to the PIRO (predisposition, insult/infection, physiological response, and organ dysfunction) model, providing the basis for the development of a predictive system.

The Impact of Alcohol-Related Problems on the Emergency Department Workload

Background: In order to determine the impact of alcohol-related problems (ARPs) on the emergency department (ED) workload, we conducted a prospective investigation to demonstrate the clinical presentations and outcomes of patients with ARPs, and to evaluate which factors influenced the impacts of ARPs on the ED. Methods: Emergency patients were included if the clinical diagnosis or injury was attributed to an acute alcohol effect, due to an acute illness or acute complication of a chronic disease related to chronic alcohol abuse, or due to alcohol-related violence. Results: Among the 196 emergency patients with ARPs, 105 (53.6%) were for alcohol-related injuries (ARIs), and 91 (46.4%) for alcohol-related non-injuries (ARNIs). Fifty-nine patients (30.1%) were intoxicated, with a blood alcohol concentration (BAC) exceeding 100 mg/dl, and 73.2% of patients who responded to questions on drinking behaviors admitted drinking at least once a week. Over 1/2 of the patients visited the ED during 00:00 to 08:00, and 1/3 were admitted. Patients with ARPs had a 2-fold higher rate of hospital admission (32.1% vs. 16.1%, p＜0.0l) and rate of admission to the intensive care unit (8.4% vs. 3.8%, p＜0.0l). Of all patients, 13 (6.6%) interfered with the ED work. Intoxicated patients were 15 times more likely to interfere with the ED work, and the average ED stay was longer for intoxicated patients (247.3 vs. 138.2 mi p＜0.0l). Conclusion: ARPs pose a major burden on the ED, especially on night shift personnel, and among intoxicated patients. Caution should be exercised, and patients highly likely to cause trouble in the ED should be identified, such as those with a BAC exceeding 100 mg/dl.

Quality of Interpretation Of Computed Tomography Images In The Emergency Department

Patient care is increasingly dependent on emergency department services. Teleradiology provides a method of supplementing radiology services. We conducted a prospective study to evaluate the accuracy of interpretation for cranial computed tomography (CT) images transmitted by Picture Archives Communication System (PACS), with the image viewed on a computer screen. In addition, incidents of misinterpretation leading to an alteration in patient care were reviewed. Five hundred and thirty-four patients undergoing cranial CT scanning in the emergency department (ED) from December 1995 to January 1996 were reviewed. The PACS transmitted 483 patients’ cranial CT images successfully. The interpretations of the PACS transmitted images, by emergency physicians (EPs), were compared with those of the original films, by radiologists. We then asked the EPs to read the original CT films in a randomly selected 25% (121 out of 483) of successfully transmitted cases, in order to compare differences in image reading between original films and PACS images. The leading three indications for CT scanning were neurologic focal signs (200, 37.5%), altered mental status (144, 27.0%), and trauma (120, 22.5%). The other indications were headache (41, 7.7%), seizure (38, 7.1%) and dizziness, vertigo and/or vomiting (30, 5.6%). The CT scans were reported to be positive by radiologists in 403 cases (75.5%). The top ten abnormalities were infarction (53.1%), subcortical arteriosclerotic encephalopathy, SAE (22.1%), parenchymal hemorrhage (16.6%), brain atrophy (14.9%), calcification (12.9%), cerebral edema (8.4%), scalp hematoma (7.7%), midline shift (7.4%), mass (6.7%), and subarachnoid hematoma (6.2%). Non-concordance between the CT interpretations by the EPs and radiologists were found in 132 cases (27.3%). These non-concordances included 6 major false negatives (1.2%), 96 minor false negatives (19.9%), 17 minor false positives (3.5%), 13 minor false negative + minor false positives (2.7%), and no major false positives. Most of the non-concordant interpretations by EPs were lacunar infarction, calcification, SAE, sinusitis and brain atrophy. The six cases with major false negative included 3 infarctions, 2 masses, and I subdural hematoma, however, no patient was managed inappropriately, and none had an adverse outcome. The same results were achieved in 76 cases (62.8%) when the EPs read the original CT films, as compared to reading the PACS transmitted images. The EPs reported more .findings in 15 cases (12.4%), and less in the other 30 cases (24.8%). The time to interpretation post CT scan was 2.1 ±3.0 hours for EPs, and 20.3 ±22.3 hours for radiologists (p＜0.001). Misinterpretation of cranial CT scans by EPs is of potential clinical concern, however, no resultant clinical errors were found in this study. We recommend that formal training in CT interpretation be included in residency training and continuing medical education programs for EPs, to ensure important errors are not made during the acute early phase of care.