Jen-Tang Sun

The Effect of Successful Intubation on Patient Outcomes After Out-of-Hospital Cardiac Arrest in Taipei

Study objective: The effect of out‐of‐hospital intubation in patients with out‐of‐hospital cardiac arrest remains controversial. The Taipei City paramedics are the earliest authorized to perform out‐of‐hospital intubation among Asian areas. This study evaluates the association between successful intubation and out‐of‐hospital cardiac arrest survival in Taipei. Methods: We analyzed 6 years of Utstein‐based registry data from nontrauma adult patients with out‐of‐hospital cardiac arrest who underwent out‐of‐hospital airway management including intubation, laryngeal mask airway, or bag‐valve‐mask ventilation. The primary analysis was intubation success on patient outcomes. The primary outcome was survival to discharge and the secondary outcomes included sustained return of spontaneous circulation and favorable neurologic survival. Sensitivity analysis was performed with intubation attempts rather than intubation success. Subgroup analysis of advanced life support–serviced districts was also performed. Results: A total of 10,853 cases from 2008 to 2013 were analyzed. Among out‐of‐hospital cardiac arrest patients receiving airway management, successful intubation, laryngeal mask airway, and bag‐valve‐mask ventilation was reported in 1,541, 3,099, and 6,213 cases, respectively. Compared with bag‐valve‐mask device use, successful out‐of‐hospital intubation was associated with improved chances of sustained return of spontaneous circulation (adjusted odds ratio [aOR] 1.91; 95% confidence interval [CI] 1.66 to 2.19), survival to discharge (aOR 1.98; 95% CI 1.57 to 2.49), and favorable neurologic outcome (aOR 1.44; 95% CI 1.03 to 2.03). The results were comparable in sensitivity and subgroup analyses. Conclusion: In nontrauma adult out‐of‐hospital cardiac arrest in Taipei, successful out‐of‐hospital intubation was associated with improved odds of sustained return of spontaneous circulation, survival to discharge, and favorable neurologic outcome.

Isolated traumatic pancreatic rupture.

Traumatic pancreatic rupture is associated with high morbidity and mortality. The diagnosis is difficult and usually accompanied with other injuries. We reported a 17-year-old adolescent boy who experienced this disease alone. The diagnosis was first suspected in ultrasonography and then confirmed by computed tomography. Endoscopic retrograde pancreatography showed his pancreatic duct was patent. He made an uneventful recovery after 10 days of hospitalization. Ultrasonography is well known for detecting the presence of hemoperitoneum in blunt abdominal trauma. Furthermore, it can be applied to the assessment of patients with posttraumatic abdominal pain. It provides a real-time, noninvasive, and inexpensive means for screening this kind of patients.

Quality of audio-assisted versus video-assisted dispatcher-instructed bystander cardiopulmonary resuscitation: A systematic review and meta-analysis

AIM This study aimed to conduct a systematic review and meta-analysis comparing the effect of video-assistance and audio-assistance on quality of dispatcher-instructed cardiopulmonary resuscitation (DI-CPR) for bystanders. METHODS Five databases were searched, including PubMed, Cochrane library, Embase, Scopus and NIH clinical trial, to find randomized control trials published before June 2017. Qualitative analysis and meta-analysis were undertaken to examine the difference between the quality of video-instructed and audio-instructed dispatcher-instructed bystander CPR. RESULTS The database search yielded 929 records, resulting in the inclusion of 9 relevant articles in this study. Of these, 6 were included in the meta-analysis. Initiation of chest compressions was slower in the video-instructed group than in the audio-instructed group (median delay 31.5 s; 95% CI: 10.94-52.09). The difference in the number of chest compressions per minute between the groups was 19.9 (95% CI: 10.50-29.38) with significantly faster compressions in the video-instructed group than in the audio-instructed group (104.8 vs. 80.6). The odds ratio (OR) for correct hand positioning was 0.8 (95% CI: 0.53-1.30) when comparing the audio-instructed and video-instructed groups. The differences in chest compression depth (mm) and time to first ventilation (seconds) between the video-instructed group and audio-instructed group were 1.6 mm (95% CI: -8.75, 5.55) and 7.5 s (95% CI: -56.84, 71.80), respectively. CONCLUSIONS Video-instructed DI-CPR significantly improved the chest compression rate compared to the audio-instructed method, and a trend for correctness of hand position was also observed. However, this method caused a delay in the commencement of bystander-initiated CPR in the simulation setting.

Early detection of Blunt traumatic brachial artery pseudoaneurysm by point of care ultrasound: case report

Patient and method A 61-year-old man with hypertension history, presented with progressive left elbow pain and swelling after blunt injury. He was fell down 1 week ago and direct contusion to his arm. He reported no numbness or weakness. His vital signs were stable except high blood pressure (188/108mHg) Physical examination revealed ecchymosis of his arm (Figure 1) and palpable pulsation over brachial, radial and ulnar artery. Laboratory exam showed elevatingCK(793 IU/L) otherwise normal. X-ray exam revealed normal. US revealed an anechoiclesion over elbow with pulsation.(Figures 2 and 3) and some heterogenic lesion over muscle layer, PA and hematoma were considered. CTA of extremity showed PA of brachial artery.(Figures 4 and 5) Patient received endografting and fasciotomy, patient was discharged smoothly after 10 days admission.

Gas-forming pyogenic liver abscess

A 74-year-old male with medical history of diabetes mellitus, hypertension and lung cancer, visited our emergency department (ED) because of fever and decreased consciousness level. At the ED, vital signs were normal except tachycardia (134 beats/min), physical examination revealed mild right-upper quadrant tenderness. Laboratory data showed increased leukocyte count (13 010/μl), glucose (919 mg/dl), serum …

Ultrasonography for proper endotracheal tube placement confirmation in out-of-hospital cardiac arrest patients: two-center experience

Among the 96 patients enrolled, 7 (7.3%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 98.9% (95% confidence interval [CI]: 94.0-99.8%), 100% (95% CI: 61-100.0%), 100% (95% CI: 95.9-100.0%) and 85.7% (95% CI: 48.7-97.4%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1-43.0) and 0.0, respectively.

PNEUMATOSIS INTESTINALIS AND PORTOMESENTERIC VEIN GAS IN ISCHEMIC BOWEL DISEASE

An 85-year-old man presented to our Emergency Department (ED) due to coffee ground vomitus. His past medical history included end-stage renal disease and bleeding of a duodenal ulcer. Vital signs were normal except for sinus tachycardia (130 beats/min). Physical examination demonstrated diffuse abdominal tenderness with peritoneal signs. Laboratory data revealed leukocytosis (25,030 mL) with left shift (neutrophil 87%). Chest X-ray study did not show obvious subphrenic free air, but X-ray study of the kidneys, ureters, and bladder disclosed intestinal intramural air (Figure 1). Computed tomography (CT) scan showed multiple venous gas cysts (portal vein, superior mesenteric vein, and splenic vein) and pneumatosis intestinalis in the ileum and ascending colon (Figure 2). A diagnosis of ischemic bowel disease was made. However, the patient and his family refused an emergent operation. The patient expired the next day due to profound septic shock.

A rare presentation of systemic emphysematous infections secondary to Klebsiella pneumoniae bacteremia in a diabetic patient.

BACKGROUND Diabetic patients are at an increased risk of developing Klebsiella pneumoniae pyogenic liver abscess (KLA) and its extrahepatic complications. This is the first case report depicting the concurrence of pyogenic liver abscess, emphysematous pyelonephritis, and necrotizing fasciitis in 1 patient. CASE REPORT A 29-year-old male with a history of poorly controlled diabetes presented to the emergency department with lower back pain and right lower leg pain for 1 week. Abdominal ultrasound and computed tomography revealed pyogenic liver abscess, bilateral emphysematous pyelonephritis, and right lower-extremity necrotizing fasciitis. The patient then received emergent fasciectomy and bilateral percutaneous nephrostomy. K. pneumoniae was isolated from the blood culture, right nephrostomy tube, and right lower-extremity wound, indicating that it was the cause of these infections. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In diabetic patients diagnosed with KLA, an emergency physician must perform thorough examinations to exclude potential systemic extrahepatic infections. KLA seeding infections are usually hematogenous in origin, as bacteremia is significantly more common in KLA than other pyogenic liver abscess. Documented sites of KLA seeding include eyes, lungs, kidneys, brain, meninges, soft tissues, and bone.

Isolated gallbladder hematoma after a blunt abdominal trauma: case report

Background Sonography has played an important role on detection of intraabdominal injuries with a sensitivity of 86%, a specificity of 98%, and an accuracy of 97% [1]. Negative predictive value achieved about 98% [1]. However, gallbladder injury is rare with incidence around 2.1% [2,3] in blunt abdominal trauma [2], and commonly associated with the solid organ injury or abdominal vascular injury [4]. Isolated gallbladder injury were very few[3] including traumatic cholecystitis, gallbladder tear, and gallbladder perforation ...etc. Ultrasound is very sensitive to gallbladder disease. We presented a rare case of isolated gallbladder hematoma after a blunt abdominal trauma which diagnosis by Focused Gallbladder ultrasound.

The effect of the number and level of emergency medical technicians on patient outcomes following out of hospital cardiac arrest in Taipei

AIM The effect of the number and level of on-scene emergency medical technicians (EMTs) on the outcomes of patients with out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to test the association between the number and level of EMTs and the outcomes of patients with OHCA. METHODS We analysed Utstein-based registry data on OHCA in Taipei from 2011 to 2015. The eligible patients were adults, aged ≥20 years, with non-traumatic OHCA who underwent resuscitation attempts. The exposures were the total number of EMTs or the EMT-Paramedic (EMT-P) ratio >50%. The outcome of interest was survival to discharge. RESULTS During study period, total 8262 OHCA cases were included, of which 1085 (13.1%) were approached by crews with an EMT-P ratio >50%. While an increase in the number of EMTs on-scene was not associated with better chances of survival (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.89-1.08), an EMT-P ratio >50% was significantly associated with improved outcome (aOR 1.36, 95% CI 1.06-1.76). Subgroup analyses showed that EMT-P >50% significantly benefited survival in witnessed OHCA cases with non-shockable rhythm (aOR 1.69, 95% CI 1.01-2.58). Survival was the highest among cases seen by four EMTs with an EMT-P ratio >50% (aOR 2.54, 95% CI 1.43-4.50). CONCLUSION An on-scene EMT-P ratio >50% was associated with improved survival to discharge of OHCA cases, especially in those with witnessed, non-shockable rhythm. The presence of four EMTs with an EMT-P ratio >50% at the scene of OHCA was associated with the best outcome.