Long-term effect of hyperoxemia during chronic obstructive pulmonary disease exacerbation managed by emergency medical service and emergency department: a prospective, exploratory study.

OBJECTIVE: Long-term effects of hyperoxemia during acute exacerbation of chronic obstructive pulmonary disease (AECOPD) remained unknown. We aimed to explore these effects of hyperoxemia during AECOPD. METHODS: This was an exploratory follow-up study of a cohort with AECOPD managed by Emergency Medical Service and two emergency departments (EDs). Patients were classified as hyperoxemic (PaO2 > 65 mmHg) or nonhyperoxemic (PaO2 ≤ 65 mmHg). Patients discharged from ED/inpatient care were followed up prospectively for 1 year. The primary outcome was 1-year all-cause mortality in hyperoxemic vs. nonhyperoxemic groups. Secondary outcomes were 3-month all-cause mortality and median number of repeat AECOPD hospitalizations within 1 year. We generated Kaplan-Meier curves and compared them using log-rank test. The primary outcome was also analyzed using Cox proportional-hazards model. We reported crude and adjusted hazard ratios, their 95% confidence intervals (CIs) and P values. We adjusted for two a priori predictors of delayed mortality; age ≥ 70 years and repeat AECOPD hospitalizations. RESULTS: A total of 231 patients were analyzed. One-year mortality rates in hyperoxemic vs. nonhyperoxemic groups were 26/137 (19.0%) and 12/94 (12.8%), respectively (P = 0.693). Although Kaplan-Meier curves showed divergent courses favoring nonhyperoxemic group, log-rank test was not statistically significant (P = 0.203). The crude and adjusted hazard ratios (reference: nonhyperoxemic group) were 1.55 (95% CIs, 0.78-3.08; P = 0.207) and 1.57 (95% CIs, 0.79-3.13; P = 0.196), respectively. Secondary outcomes did not differ. CONCLUSIONS: Our study reported no effect on 1-year all-cause mortality associated with hyperoxemia during AECOPD. Further studies are needed to prove/disprove our findings.

Most impactful predictors for hyperoxaemia in exacerbation of chronic obstructive pulmonary disease managed by Emergency Medical Services and Emergency Department.

INTRODUCTION: Hyperoxemia in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) leads to adverse outcomes. It remains prevalent in the pre-hospital Emergency Medical Services (EMS) and Emergency Department (ED). OBJECTIVE: To determine the key predictors for hyperoxemia in AECOPD in EMS and ED. METHODS: This was a prospective observational study of AECOPD patients in EMS and two EDs. Hyperoxemia was defined as PaO2 > 65 mm Hg (corresponds to SpO2 > 92%). We determined apriori candidate factors in Patient, Organization and Staff domains. Primary outcomes were the key predictors for hyperoxemia. Secondary outcomes were in-hospital mortality and mechanical ventilation rates in hyperoxemic versus non-hyperoxemic groups. We generated a logistic regression model for each domain. We reported the adjusted odds ratios (AORs), 95% CIs and p values. We selected the output factors using AOR ≥2.0 and ≥2.5 for modifiable and non-modifiable factors, respectively. These selected factors were fed into a final model with eventual factors selected based on: threshold AORs as stated above and/or 95% CIs including these AORs. RESULTS: Three hundred and twenty-six patients were analysed; 60.7% had hyperoxemia. We found three eventual modifiable factors; first, ED SpO2 > 95% [AOR 2.62 (95% CIs: 1.61-4.33); P < 0.001], EMS non-rebreathing mask [AOR 2.01 (95% CIs: 1.06-3.97); P = 0.04]; and ED nasal cannula [AOR 1.69 (95% CIs: 1.05-2.72); P = 0.03]. Secondary outcomes did not differ between groups. CONCLUSION: We identified three key modifiable predictors. We intend to conduct an interventional study using them to reduce hyperoxemia rate in AECOPD.

An unusual cause of haemorrhagic shock from a subcutaneous haematoma: a Morel-Lavallée lesion.

20-year-old man presented to our emergency department after he was hit by a forklift. He developed haemorrhagic shock from a subcutaneous haematoma in his left thigh and required monitoring in the surgical intensive care unit. He stabilised with aggressive fluid resuscitation with crystalloids and blood transfusion. The recovery was complicated by an infection of the subcutaneous haematoma. Following open drainage of the infected subcutaneous haematoma, he improved and was discharged. To the best of our knowledge, this is the first reported case of a subcutaneous haematoma causing haemorrhagic shock.

Severe chlorate poisoning successfully treated with methylene blue.

BACKGROUND: Chlorate poisoning as a cause of methemoglobinemia is regarded in current literature to be resistant to treatment by methylene blue due to the oxidizing and denaturing properties of the chlorate anion, and often leads to severe renal and hematological complications with a high mortality rate. Recent case studies suggest practitioners have eschewed the use of methylene blue in such situations. OBJECTIVES: This report describes a case of chlorate poisoning presenting as severe methemoglobinemia successfully treated with methylene blue alone, believed to be a first in reported literature. CASE REPORT: A 34-year-old male construction worker presented 4 h after accidental ingestion of an industrial chemical, with giddiness and breathlessness. Physical examination did not reveal any abnormal cardiorespiratory findings, although arterial blood gas analysis and pulse oximetry revealed an "oxygen saturation gap." Methemoglobin levels were found to be severely elevated at 66.8% 6 h after ingestion, and the patient was promptly treated with methylene blue. Clinical examination and laboratory tests suggested the absence of hemolysis at the time of treatment. The patient was discharged after a brief and uneventful hospital stay. Subsequent tests revealed the chemical ingested to be sodium chlorate. CONCLUSION: The successful outcome in our case suggests that a window of opportunity as long as 6 h may exist during which treatment of chlorate poisoning with methylene blue may be of clinical value. We postulate that the absence of significant hemolysis and hematological alterations at the time of antidote administration may be a necessary prerequisite for treatment success.

Review of studies and guidelines on fasting and procedural sedation at the emergency department.

AIM: Procedural sedation and analgesia allows urgent procedures to be performed safely by preserving patients' airway reflexes. Fasting, which is required before deeper levels of sedation, and where the airway reflexes are not preserved, is difficult to impose in emergencies. This paper aims to synthesise evidence on the need for pre-procedure fasting to minimise aspiration among adults undergoing procedural sedation and analgesia for emergency procedures. METHODS: Overviews, guidelines with graded recommendations and primary studies on aspiration and pre-procedure fasting in procedural sedation and analgesia were retrieved from Medline, Cochrane, and Center for Reviews and Dissemination Databases. Terms searched were procedural sedation, fasting, emergency and sedation. RESULTS: One primary study and one guideline were included. The American College of Emergency Physicians Clinical Policies Subcommittee on Procedural Sedation and Analgesia issued a recommendation based on 'preliminary, inconclusive or conflicting evidence, or on panel consensus'. The recommendation states: 'recent food intake is not a contraindication for administering procedural sedation and analgesia...'. The primary study conducted by Bell in an emergency department in Australia compared patients who last ate or drank more than 6 and 2 h from induction, respectively, with those who last ate or drank within 6 and 2 h. There were no cases of aspiration in both groups. Out of 118 patients who fasted, 1 (0.8%) vomited, as did one of 282 patients (0.4%) who did not fast. CONCLUSIONS: Aspiration risk is expected to be lower in procedural sedation and analgesia than in general anaesthesia. Current guidelines rely on expert consensus due to the lack of primary studies. Contextualisation of existing guidelines are quick and efficient strategies for developing locally relevant tools.

Profiling acute presenting symptoms of geriatric patients attending an urban hospital emergency department.

OBJECTIVE: To study the profile of geriatric patients warded to the emergency department (ED) of an Asian acute care general hospital and determine if they are 'more ill', more likely to have atypical presentations and have a higher utilisation of healthcare resources when compared to a younger group of patients. MATERIALS AND METHODS: This is a retrospective chart review of consecutive patients aged 45 years and above presenting to the study ED over a period of 4 weeks from 4 June 2006 to 1 July 2006. The following data were obtained: (i) demographics, (ii) mode of arrival and triage acuity, (iii) presence of co-morbidities, (iv) investigations ordered in the ED, (v) clinical symptoms and diagnoses, (vi) disposition, (vii) length of hospital stay, (viii) injuries and outcomes of elderly fallers. The study population was divided into 2 groups--a study group with patients aged 65 years and above, and a control group with patients aged 45 to 64. RESULTS: There were 2847 patients in the study group and these were compared against 2875 in the control group. Those 65 years and above had greater representation in the ED population compared to the general population. In the study group, the proportion of females, the number arriving by ambulance and the likelihood of having a higher triage acuity increased with age. The elderly had higher rates of co-morbidities. They also had a higher resource utilisation rate. Falls was their commonest presenting complaint. CONCLUSION: It is crucial that EDs recognise the special needs of elderly patients due to the growing ageing population. Healthcare policy makers when allocating resources should take into account the profile of elderly patients presenting to an ED and their resource utilisation.