Singapore Defibrillation Guidelines 2016.

The most common initial rhythm in a sudden cardiac arrest is ventricular fibrillation or pulseless ventricular tachycardia. This is potentially treatable with defibrillation, especially if provided early. However, any delay in defibrillation will result in a decline in survival. Defibrillation requires coordination with the cardiopulmonary resuscitation component for effective resuscitation. These two components, which form the key links in the chain of survival, have to be brought to the cardiac victim in a timely fashion. An effective chain of survival is needed in both the institution and community settings.

Nationwide improvement of door-to-balloon times in patients with acute ST-segment elevation myocardial infarction requiring primary percutaneous coronary intervention with out-of-hospital 12-lead ECG recording and transmission.

STUDY OBJECTIVE: Reducing door-to-balloon times for acute ST-segment elevation myocardial infarction (STEMI) patients has been shown to improve long-term survival. We aim to reduce door-to-balloon time for STEMI patients requiring primary percutaneous coronary intervention by adoption of out-of-hospital 12-lead ECG transmission by Singapore's national ambulance service. METHODS: This was a nationwide, before-after study of STEMI patients who presented to the emergency departments (ED) and required percutaneous coronary intervention. In the before phase, chest pain patients received 12-lead ECGs in the ED. In the after phase, 12-lead ECGs were performed by ambulance crews and transmitted from the field to the ED. Patients whose ECG showed greater than or equal to 2 mm ST-segment elevation in anterior or greater than or equal to 1 mm ST-segment elevation in inferior leads for 2 or more contiguous leads and symptom onset of less than 12 hours' duration were eligible for percutaneous coronary intervention activation before arrival. RESULTS: ECGs (2,653) were transmitted by the ambulance service; 180 (7%) were suspected STEMI. One hundred twenty-seven patients from the before and 156 from the after phase met inclusion criteria for analysis. Median door-to-balloon time was 75 minutes in the before and 51 minutes in the after phase (median difference=23 minutes; 95% confidence interval 18 to 27 minutes). Median door-to-balloon times were significantly reduced regardless of presentation hours. Overall, there was significant reduction in door-to-activation, door-to-ECG, and door-to-cardiovascular laboratory times. No significant difference was found pertaining to adverse events. CONCLUSION: This study describes a nationwide implementation of out-of-hospital ECG transmission resulting in reduced door-to-balloon times, regardless of presentation hours. Out-of-hospital ECG transmission should be adopted as best practice for management of chest pain.

Hand injuries seen at an emergency department in Singapore.

We aim to define the characteristics of patients with hand injuries in the emergency department (ED), their management and operative findings. Decision on admission was also analyzed between the ED and the hand and reconstructive microsurgical team. We reviewed 504 patients seen at the ED over a 3-month period with isolated hand injuries and found more males (88%) who were between 20 and 30 years of age (51%). Most had industrial injuries (43%) from lacerations or crush. Left hand injuries were more common. About 62% of the patients were discharged after treatment at the ED while 38% were admitted. A high level of concurrence in the decisions made by the ED and hand and reconstructive microsurgery signifies good quality assessment performed by the ED. The operative findings of fractures, tendon, nerve and vessel injuries for those who were admitted to the wards are higher than those admitted to 'day surgery'.

To study the effectiveness and safety of ketamine and midazolam procedural sedation in the incision and drainage of abscesses in the adult emergency department.

The objective of the report was to study the efficacy and safety of ketamine and midazolam combination in the procedural sedation of incision and drainage of abscesses in the adult emergency department (ED) patients. This prospective observational study enrolled patients aged 16-60 years (American Society of Anesthesiologists class I) requiring abscess drainage in an adult ED. Patients received 2 mg/kg of ketamine infusion over 5 min and midazolam 2-5 mg titrated to deep sedation according to Ramsay sedation scale. Primary outcome was patient satisfaction using pain score after procedure. Secondary outcomes included adverse effects, hemodynamics alterations and recovery time. Descriptive statistics were calculated using SPSS software. Fifteen patients were recruited. One patient was excluded because of difficulty with pain score interpretation. Seventy-nine percent were male patients. The mean age was 29. The mean size of abscess was 3.4 cm. The mean dose of midazolam was 3.2 mg. Eighty-six percent did not experience any pain for the procedure. Only two patients (14%) reported mild pain during the procedure. There were no significant adverse events or complications. Three patients had giddiness, two had vomiting and only one reported an unpleasant dream. The median systolic blood pressure and heart rate elevation were 30+/-5.1 mmHg and 12.5+/-3.2/min, respectively. The median time for blood pressure and pulse rate to return to baseline was 20+/-2.7 min. The use of ketamine and midazolam sedation is both well tolerated and effective for adults in the ED undergoing incision and drainage of abscesses. This study is limited by the small sample size.