Sheng-Chuan Hu

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.

Rhabdomyolysis in diabetic emergencies

Rhabdomyolysis (RM) is a clinical and laboratory syndrome resulting from leakage of muscle cell contents into plasma. The increased plasma concentration of the substances released such as creatine kinase (CK) permits the clinician to diagnose this syndrome. Non-traumatic RM has occasionally been reported in patients with diabetic decompensation. We encountered about 44 cases of RM in 265 diabetic emergencies (including DKA or hyperosmolar, or both) during the period from 1984-1 to 1990-6, diagnosed based on (1) serum creatine kinase (CK) > 1000 IU/l and (2) the absence of acute myocardial infarction, stroke and end-stage renal disease. On admission, those who presented with RM had significantly higher concentration of blood urine nitrogen (BUN) (83.3 +/- 5.9 vs. 58.8 +/- 2.4 mg/dl, P < 0.05), creatine (4.45 +/- 0.4 vs. 2.97 +/- 0.1 mg/dl, P < 0.05) and serum osmolarity (386.5 +/- 5.2 vs. 351.6 +/- 2.4 mOsm/kg, P < 0.05). The mortality within 1 week of diabetic emergencies (38.5% for DKA, 35.5% for HHNK) was higher in patients with RM than those without RM (9.7% for DKA, 26.7% for HHNK). There was a correlation (r = 0.49, P < 0.05) between the levels of serum creatinine and CK in patients with RM.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Continuous flumazenil infusion in preventing complications arising from severe benzodiazepine intoxication

A prospective, randomly controlled study was conducted to test the effect of continuous flumazenil infusion in preventing complications arising from severe benzodiazepine (BZ) intoxication. Patients who were believed to be suffering benzodiazepine intoxication and whose Glasgow Coma Scale (GCS) score was below 10 were enrolled after showing a clear-cut response to flumazenil 0.5 or 1 mg (an improvement by 4 or more on the GCS). The patients were consecutively enrolled and randomized into two groups: a continuous infusion group (CI, n = 50) who were immediately given flumazenil 0.5 mg/h for 5 hours, and a control group (CIN, n = 50). Age, sex, incidence of underlying disease, GCS score at several time points, and complication rate were compared in the two groups. Although the CI group had a higher GCS score at most time points, the complication rate did not significantly differ between the two groups (14 of 36 in the CI group v 12 of 38 in the CIN group, P = .684). A greater incidence of underlying disease and an older age seemed to contribute to the higher complication rates in both groups. Several patients (in both groups) resedated into deeper coma after showing an initial response to flumazenil or after the cessation of flumazenil infusion. For severe BZ intoxication, treatment with flumazenil infusion should still be considered skeptically and should not be recommended as routine management BZ-intoxicated patients with an underlying disease, an older age, and resedation into a deep comatose state after showing an initial response to flumazenil should be treated in an intensive care unit.

Diagnostic and therapeutic utility of flumazenil in comatose patients with drug overdose

From July 1, 1990 and June 30, 1991, 61 unconscious patients with drug intoxication were prospectively enrolled into this study in order to evaluate the efficacy and safety of flumazenil in the management of this patient population. Flumazenil was injected intravenously as a 0.3-mg bolus in the first minute followed by 0.2-mg and 0.3-mg doses every minute until a total dose of 1 mg was given or until the patient responded. The Glasgow coma scale and a sedation-level scoring system were checked prior to and at 1, 5, and 30 minutes after the dose eliciting response or on completion of the full dose of flumazenil. The patients were divided into two groups based on their response to flumazenil: group 1, responders (N = 55), and group 2, nonresponders (N = 6). Eleven patients from group 1 allowed us to retrieve drug information from these patients once mental status had recovered and patients were treated accordingly. In two cases endotracheal intubation and artificial ventilation were rendered unnecessary by the use of flumazenil. No undesirable hemodynamic effects were noted after flumazenil injection in this study, although none of the patients overdosed on antidepressants. Flumazenil may serve as a useful diagnostic and therapeutic tool in the management of selected cases of drug-induced coma.

The Role of Flumazenil in the Management of Patients With Acute Alteration of Mental Status in the Emergency Department

1 There are a few case reports which suggest that flumazenil can be used as a diagnostic tool in coma of unknown aetiology but no large scale studies have proved its efficacy and cost-effectiveness. 2 Fifty five patients with acute alteration of mental status of unknown aetiology were enrolled prospectively during a time period of one year. Flumazenil was injected intravenously in a regimen of 0.3 mg in the first minute followed by alternate 0.2 mg, 0.3 mg doses every minute until a total dose of 1 mg was given or until the patients responded. 3 Patients were divided into two groups based on their response to flumazenil: Group 1, responders and Group 2, non-responders. The hospital stay was shortened significantly and interventional procedures, such as CT of brain and endotracheal intubation, were rendered unnecessary in several patients in Group 1. The Group 1 patients had a more favourable outcome than that of Group 2. 4 We concluded that flumazenil may serve as a useful tool in diagnosis and management of carefully selected patients with acute alteration of mental status.

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.

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.

Results and Implications of Active Compression-Decompression Cardiopulmonary Resuscitation in an Emergency Room in Taiwan

Background: Since it was first introduced, active compression-decompression cardiopulmonary resuscitation (ACD-CPR) quickly grabbed the medical community’s attention in Taiwan. To assess the effectiveness of this new ACD-CPR method for patients and its applicability in ERs, we conducted a randomized controlled trial. The purpose of this study was prospectively to compare ACD-CPR with conventional CPR (Con-CPR) on Chinese patients who developed cardiac arrest during their emergency room (ER) stay. Methods: Forty cardiac arrest patients were randomly assigned to either ACD-CPR or the Con-CPR groups in an emergency room of a 2800-bed tertiary-care hospital. Recommendations from the American Heart Association (the 1992 new CPR-guidelines) were followed. Whenever a patient was assigned to ACD-CPR, a hand-held ACD device was used instead of the bare hands as in Con-CPR. The ACD device was placed over the lower sternum, approximately 2.5 to 5 cm above the border of the lower rib cage. Compressions were performed according to the American Heart Association recommendations at a rate of 80 to 100/mm using a 50% duty cycle and a depth of 3.75 to 5 cm; the other procedures were the same as in Con-CPR. Results: The initial success of resuscitation, defined as return of spontaneous circulation (ROSC), was the same at 62.5% for both groups. However, the survival rate dropped significantly with 70% of study subjects dying within 8 hours. The ACD-CPR group patients showed a better continued survival than those of the Con-CPR group patients, up to 40 hours after ROSC. Patients with a serum potassium level greater than or equal to 5 mmol /L were 1.4 times (RR = 1.38, 95% CI. 0.88, 2.17) more likely to survive. Only two patients who received Con-CPR survived to hospital discharge, one signed out against medical advice, and the other was discharged without neurological deficit. Conclusion: This trial demonstrated slightly better intermediate outcomes among patients who received ACD- CPR, but the final results showed no differences. Reperfusion injury and preconditioning may have important clinical relevance to the unanticipated results, but their underlying mechanisms are far from clear. A combined effort using a multidisciplinary approach to link molecular and cellular cardiology studies with clinical observation may help to clarify the puzzle.

Analysis of the Characteristics of Emergency Patients in Taipei City

In order to determine the disease prevalence and the ranking of trauma mechanisms among patients admitted to emergency departmens (ED) in Taipei City for general reference and use in the development of injury prevention plans and public health plans, a prospective chart review study was conducted from July 1, 1995 to June 30, 1996. Date was collected from the EDs of 8 hospitals in Taipei City. Full time research assistants were used to input the major diagnostic category and other relevant material of each ED patient into a computer based on the impression obtained from the patients history chart. Particular attention was focused on acute myocardial infarction (AMI); dead on arrival (DOA) and acute abdominal cases as the management of these patients is known to be problematic. The trauma mechanism and type of injury was recorded in all cases of trauma. Acute gastroenteritis (AGE) and acute upper respiratory infection (URI) were the 2 leading diseases in both adult and pediatric ED (14.3% and 12.6% of adult ED patients; 15.4% and 43.8% of pediatric ED patients, respectively). The leading 3 trauma mechanisms in adult patients were traffic accident (35.7%); trip (22.3%) and hit by object (9.3%), however, in pediatric patients, the sequence was trip (39.5%); hit by object (22.1%) and traffic accident (11.6%). Acute abdomen was responsible for 5.9% of adult emergency patients, of which 23.3% were cases with unknown cause followed by biliary tract stone or infection (15.2%) and appendicitis (12.5%). In pediatric EDs, differential diagnosis was not accomplished in 56.9% of acute abdomen cases, followed by 15.4% of appendicitis and 7.7% of functional gastrointestinal disorders. Of the total of 43 cases of AMI(0.2% of adult ED patients), 54% were sent to ED within 12 hours of the onset of symptoms and only 31.7% were treated with thrombolytic agents in the ED. The results of this study clearly indicate that the establishment of a comprehensive disease and trauma surveillance system in ED is both feasible and important.(Tzu Chi Med J 1998;10:9-17)