Yuwares Sittichanbuncha

Effects of prehospital adrenaline administration on out-of-hospital cardiac arrest outcomes: a systematic review and meta-analysis

IntroductionThe aim of this study was to conduct a systematic review and meta-analysis for determining the effects of prehospital adrenaline administration on return of spontaneous circulation, hospital admission, survival to discharge and discharge with cerebral performance category 1 or 2 in out-of-hospital cardiac arrest patients.MethodsMEDLINE and Scopus databases were searched to identify studies reported to March 2014. Study selection and data extraction were independently completed by two reviewers (PA and SR). The baseline characteristics of each study and number of events were extracted. Risk ratios (RR) and 95% confidence interval (CI) were estimated. Heterogeneity and publication bias were also explored.ResultsIn total 15 studies were eligible and included in the study. Of 13 adult observational studies, four to eight studies were pooled for each outcome. These yielded a total sample size that ranged from 2,381 to 421,459. A random effects model suggested that patients receiving prehospital adrenaline were 2.89 times (95% CI: 2.36, 3.54) more likely to achieve prehospital return of spontaneous circulation than those not administered adrenaline. However, there were no significant effects on overall return of spontaneous circulation (RR = 0.93, 95% CI: 0.5, 1.74), admission (RR = 1.05, 95% CI: 0.80, 1.38) and survival to discharge (RR = 0.69, 95% CI: 0.48, 1.00).ConclusionsPrehospital adrenaline administration may increase prehospital return of spontaneous circulation, but it does not improve overall rates of return of spontaneous circulation, hospital admission and survival to discharge.

What clinical factors are associated with biphasic anaphylaxis in Thai adult patients

BACKGROUND Anaphylaxis is an emergency condition and may be fatal. Approximately 20% of patients with anaphylaxis may develop recurrent episodes of anaphylaxis within 72 hours or biphasic anaphylaxis. The severity of biphasic anaphylaxis can be either more or less severe than the first episode. Knowledge of factors associated with biphasic anaphylaxis in particular in Asian populations is still limited. OBJECTIVES To study predictors for biphasic anaphylaxis in Thai patients at the Emergency Department (ED). METHODS All consecutive patients diagnosed as anaphylaxis at the ED, Ramathibodi Hospital, Mahidol University, Bangkok were enrolled. The study was prospectively conducted from January to December 2011. Patients were divided into two groups; uniphasic and biphasic anaphylaxis. Multivariate logistic regression was used to identify factors associated with biphasic anaphylaxis. RESULTS During the study period, there were 63 patients diagnosed with anaphylaxis at the ED. Of those, 16 patients were excluded due to or treatment of anaphylaxis, concomitant medications or pre hospital treatment. In total, there were 47 patients remaining in the study, including 10 patients with biphasic anaphylaxis (21.28%). The clinical characteristics of the uniphasic and biphasic anaphylaxis groups were comparable. In multivariate logistic regression analyses, only respiratory rate and abdominal pain were significantly associated with biphasic anaphylaxis. The adjusted ORs (95% CI) of both factors were 0.653 (0.457, 0.932) and 15.429 (1.395, 170.690), respectively. CONCLUSION Reduced respiratory rate and the presence of abdominal pain were two significant factors associated with biphasic anaphylaxis.

Is a mobile emergency severity index (ESI) triage better than the paper ESI

This study aims to evaluate the mobile emergency severity index (ESI) tool in terms of validity compared with the original ESI triage. The original ESI and mobile ESI were used with patients at the Department of Emergency Medicine, Ramathibodi Hospital, Thailand. Eligible patients were evaluated by sixth-year medical students/emergency physicians using either the original or mobile ESI. The ESI results for each patient were compared with the standard ESI. Concordance and kappa statistics were calculated for pairs of the evaluators. There were 486 patients enrolled in the study; 235 patients (48.4%) were assessed using the mobile ESI, and 251 patients (51.6%) were in the original ESI group. The baseline characteristics of patients in both groups were mostly comparable except for the ED visit time. The percentages of concordance and kappa statistics in the original ESI group were lower than in the mobile group in all three comparisons (medical students vs gold standard, emergency physicians vs gold standard, and medical students vs emergency physicians). The highest kappa in the original ESI group is 0.69, comparing emergency physicians vs gold standard, while the lowest kappa in the application group is 0.84 comparing the medical students vs gold standard. Both medical students and emergency physicians are more confident with the mobile ESI application triage. In conclusion, the mobile ESI has better inter-rater reliability, and is more user-friendly than the original paper form.

Emergency severity index compared with 4-level triage at the emergency department of Ramathibodi University Hospital

Abstract Background Emergency department (ED) triage is important for categorizing and prioritizing patients. Effective triage may assist in crowd reduction in the ED and appropriate patient management. There are several systems, including the 5-level Emergency Severity Index (ESI) and the 4-level Ramathibodi-nurse triage. Currently, there are limited data by which to compare the 5- versus 4-level triage; particularly on health outcomes, such as length of stay in the ED, mortality, and resource needs. Objective To compare the accuracy of 5- and 4-level triage in an ED. Method This observational study was conducted on a cross-section of patients in the ED at Ramathibodi Hospital of Mahidol University, Bangkok, Thailand. Eligible patients were those who visited the ED and were evaluated by ESI and nurse triage. Each evaluation was blinded to the results of the other. Discrimination performance between the 5- and 4-level triage was compared by using the area under a receiver operating characteristic (ROC) curve and concordance statistic for prediction of life saving intervention. Net reclassification improvement (NRI) of the 5-level ESI over the 4-level triage was performed. Result Study criteria were met by 520 patients. The areas under the ROC curves of the ESI and nurse triage on life-saving intervention were 92.2% (95% confidence intervals were 87.3%, 96.9%) and 81.3% (95% CI 75.2%, 87.3%), respectively. Areas under the ROC curve differed significantly (P < 0.001). The overall reclassification improvement was 42.4%. Conclusion The 5-level emergency severity index was more accurate than the 4-level triage in terms of lifesaving intervention.

Teaching emergency medicine with workshops improved medical student satisfaction in emergency medicine education

Background There are different teaching methods; such as traditional lectures, bedside teaching, and workshops for clinical medical clerkships. Each method has advantages and disadvantages in different situations. Emergency Medicine (EM) focuses on emergency medical conditions and deals with several emergency procedures. This study aimed to compare traditional teaching methods with teaching methods involving workshops in the EM setting for medical students. Methods Fifth year medical students (academic year of 2010) at Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand participated in the study. Half of students received traditional teaching, including lectures and bedside teaching, while the other half received traditional teaching plus three workshops, namely, airway workshop, trauma workshop, and emergency medical services workshop. Student evaluations at the end of the clerkship were recorded. The evaluation form included overall satisfaction, satisfaction in overall teaching methods, and satisfaction in each teaching method. Results During the academic year 2010, there were 189 students who attended the EM rotation. Of those, 77 students (40.74%) were in the traditional EM curriculum, while 112 students were in the new EM curriculum. The average satisfaction score in teaching method of the new EM curriculum group was higher than the traditional EM curriculum group (4.54 versus 4.07, P-value <0.001). The top three highest average satisfaction scores in the new EM curriculum group were trauma workshop, bedside teaching, and emergency medical services workshop. The mean (standard deviation) satisfaction scores of those three teaching methods were 4.70 (0.50), 4.63 (0.58), and 4.60 (0.55), respectively. Conclusion Teaching EM with workshops improved student satisfaction in EM education for medical students.

Clinical Factors Predictive for Intracranial Hemorrhage in Mild Head Injury

Patients with mild head injuries, a GCS of 13–15, are at risk for intracranial hemorrhage. Clinical decision is needed to weigh between risks of intracranial hemorrhage and costs of the CT scan of the brain particularly those who are equivocal. This study aimed to find predictors for intracranial hemorrhage in patients with mild head injuries with a moderate risk of intracranial hemorrhage. We defined moderate risk of mild head injury as a GCS score of 13–15 accompanied by at least one symptom such as headache, vomiting, or amnesia or with alcohol intoxication. There were 153 patients who met the study criteria. Eighteen of the patients (11.76%) had intracranial hemorrhage. There were four independent factors associated with intracranial hemorrhage: history of hypertension, headache, loss of consciousness, and baseline GCS. The sensitivity for the presence of intracranial hemorrhage was 100% with the cutoff point for the GCS of 13. In conclusion, the independent factors associated with intracranial hemorrhage in patients with mild head injury who were determined to be at moderate risk for the condition included history of hypertension, headache, loss of consciousness, and baseline GCS score.

The appropriate troponin T level associated with coronary occlusions in chronic kidney disease patients

Background High-sensitivity troponin T (HS Trop T) plays an important role as a diagnostic marker for acute coronary syndrome. It is also related to cardiovascular outcomes. HS Trop T levels may be varied in individuals with renal dysfunction. This study aimed to find the appropriate HS Trop T cutoff points in chronic kidney disease (CKD) patients who had coronary artery occlusion. Patients and methods The study was conducted at the Emergency Department, Ramathibodi Hospital, Mahidol University, Thailand. CKD patients stage 3–5 who had HS Trop T levels after 2 hours of chest pain and had coronary angiographic results were enrolled. Patients were divided into two groups: those who had significant occlusion of more than 70% of a coronary artery as the coronary artery disease (CAD) group and the non-CAD group. Results In total, 210 patients met the study criteria. There were 132 patients (62.86%) who had significant stenosis of coronary arteries by coronary angiograms. The average age (standard deviation) of all patients was 71.02 (9.49) years. HS Trop T levels were significantly higher in all CKD patients with CAD than the non-CAD group (0.4973 versus 0.0384 ng/mL). Sex and HS Trop T levels were significantly associated with CAD by multivariate logistic regression analysis. The HS Trop T level of 0.041 ng/mL gave sensitivity and specificity of 65.91% and 75.65%, respectively, for CAD. Conclusion The HS Trop T level of 0.041 ng/mL provided diagnostic properties for established coronary artery occlusion in CKD patients.

Clinical predictive score of intracranial hemorrhage in mild traumatic brain injury

Background Mild traumatic brain injury (TBI) is a common condition at the Emergency Medicine Department. Head computer tomography (CT) scans in mild TBI patients must be properly justified in order to avoid unnecessary exposure to X-rays and to reduce the hospital/transfer costs. This study aimed to evaluate which clinical factors are associated with intracranial hemorrhage in Asian population and to develop a user-friendly predictive model. Methods The study was conducted retrospectively at the Emergency Medicine Department in Ramathibodi Hospital, a university-affiliated super tertiary care hospital in Bangkok, Thailand. The study period was between September 2013 and August 2016. The inclusion criteria were age >15 years and having received a head CT scan after presenting with mild TBI. Those patients with mild TBI and no symptoms/deterioration after 24 h of clinical observation were excluded. The predictive model and prediction score for intracranial hemorrhage was developed by multivariate logistic regression analysis. Results During the study period, there were 708 patients who met the study criteria. Of those, 100 patients (14.12%) had positive head CT scan results. There were seven independent factors that were predictive of intracranial hemorrhage. The clinical risk scores to predict intracranial hemorrhage are developed with an accuracy of 92%. The score of >3 had the likelihood of intracranial hemorrhage by 1.47 times. Conclusion Clinical predictive score of >3 was associated with intracranial hemorrhage in mild TBI.

Is a mechanical-assist device better than manual chest compression? A randomized controlled trial

Background Chest compression quality is a determinant of survival from sudden cardiac arrest. The CPR RsQ Assist Device (CPR RAD) is a new cardiopulmonary resuscitation device for chest compression. It is operated manually but it does not pull up on the chest on the up stroke. The aim of this study was to compare the CPR RAD with standard manual compression in terms of chest compression quality in a manikin model. Methods Participants were randomly assigned to either the device or manual chest compression group. Each participant performed a maximum of 4 minutes of hands-only compression with or without the device. During chest compression, the following quality parameters from the manikin were recorded: compression rate, compression depth, and correctness of hand position. Results Duration of chest compression was significantly higher in device users compared with manual compression (223.93±36.53 vs 179.67±50.81 seconds; P<0.001). The mean compression depth did not differ in a statistically significant way between manual compression and device at 2 minutes (56.42±6.42 vs 54.25±5.32; P=0.052). During the first and second minutes, compression rate was higher in cases of standard compression (133.21±15.95 vs 108±9.45; P<0.001 and 127.41±27.77 vs 108.5±9.93; P<0.001). There was no statistically significant difference in the percentage of participants who employed compression that was too shallow or exhibited incorrect hand position. Conclusion The CPR RAD is more effective in chest compression compared with manual chest compression, as using the device led to better results in terms of fatigue reduction and correct compression rate than standard manual compression.

Low oxygen saturation is associated with pre-hospital mortality among non-traumatic patients using emergency medical services: A national database of Thailand

Background Pre-hospital emergency medical services are an important network for Emergency Medicine. It has been shown to reduce morbidity and mortality of patients by medical procedures. The Thai government established pre-hospital emergency medical services in 2008 to improve emergency medical care. Since then, there are limited data at the national level on mortality rates with pre-hospital care and the risk factors associated with mortality in non-traumatic patients. Aims To study the pre-hospital mortality rate and factors associated with mortality in non-traumatic patients using the emergency medical service in Thailand. Methods This study retrieved medical data from the National Institute for Emergency Medicine, NIEMS. The inclusion criteria were adult patients above the age of 15 who received medical services by the emergency medical services in Thailand (except Bangkok) from April 1st, 2011 to March 31st, 2012. Patients were excluded if there was no treatment during pre-hospital period, if they were trauma patients, or if their medical data was incomplete. Patients were categorized as either in the survival or non-survival group. Factors associated with mortality were examined by multivariate logistic regression analysis. Results During the study period, there were 127,602 non-traumatic patients who used pre-hospital emergency medical services in Thailand. Of those, 98,587 patients met the study criteria. For the statistical analyses, there were 66,760 patients who had complete clinical investigations. The mortality rate in this group was 1.89%. Only oxygen saturation was associated with mortality by multivariate logistic regression analysis. The adjusted OR was 0.922 (95% CI 0.8550.994). Conclusion Low oxygen saturation is significantly associated with pre-hospital mortality in a national database of non-traumatic patients using emergency medical services in Thailand. During pre-hospital care, oxygen level should be monitored and promptly treated. Pulse oximetry devices should be available in all pre-hospital services.