Effect of fraction of inspired oxygen baseline level on the mask ventilation time before intubation in emergency patients by monitoring of expiratory oxygen concentration / 中华危重病急救医学

OBJECTIVE@#To investigate the effect of different fraction of inspired oxygen (FiO2) baseline levels before endotracheal intubation on the time of expiratory oxygen concentration (EtO2) reaching the standard in emergency patients with the EtO2 as the monitoring index.@*METHODS@#A retrospective observational study was conducted. The clinical data of patients receiving endotracheal intubation in the emergency department of Peking Union Medical College Hospital from January 1 to November 1 in 2021 were enrolled. In order to avoid interference with the final result due to inadequate ventilation caused by non-standard operation or air leakage, the process of the continuous mechanical ventilation after FiO2 was adjusted to pure oxygen in patients who had been intubated was selected to simulate the process of mask ventilation under pure oxygen before intubation. Combined with the electronic medical record and the ventilator record, the changes of the time required to reach 0.90 of EtO2 (that was, the time required to reach the standard of EtO2) and the respiratory cycle required to reach the standard after adjusting FiO2 to pure oxygen under different baseline levels of FiO2 were analyzed.@*RESULTS@#113 EtO2 assay records were collected from 42 patients. Among them, 2 patients had only one EtO2 record due to the FiO2 baseline level of 0.80, while the rest had two or more records of EtO2 reaching time and respiratory cycle corresponding to different FiO2 baseline level. Among the 42 patients, most of them were male (59.5%), elderly [median age was 62 (40, 70) years old] patients with respiratory diseases (40.5%). There were significant differences in lung function among different patients, but the majority of patients with normal function [oxygenation index (PaO2/FiO2) > 300 mmHg (1 mmHg ≈ 0.133 kPa), 38.0%]. In the setting of ventilator parameters, combined with the slightly lower arterial partial pressure of carbon dioxide of patients [33 (28, 37) mmHg], mild hyperventilation phenomenon was considered to be widespread. With the increased in FiO2 baseline level, the time of EtO2 reaching standard and the number of respiratory cycles showed a gradually decreasing trend. When the FiO2 baseline level was 0.35, the time of EtO2 reaching the standard was the longest [79 (52, 87) s], and the corresponding median respiratory cycle was 22 (16, 26) cycles. When the FiO2 baseline level was increased from 0.35 to 0.80, the median time of EtO2 reaching the standard was shortened from 79 (52, 78) s to 30 (21, 44) s, and the median respiratory cycle was also reduced from 22 (16, 26) cycles to 10 (8, 13) cycles, with statistically significant differences (both P < 0.05).@*CONCLUSIONS@#The higher the FiO2 baseline level of the mask ventilation in front of the endotracheal intubation in emergency patients, the shorter the time for EtO2 reaching the standard, and the shorter the mask ventilation time.

Research on self-regulated learning in the clinical environment of 8-year medical students / 中华医学教育探索杂志

Objective:To explore the change of medical students' self-regulated learning from traditional medicine to clinical practice in emergency department, and to provide direction for optimizing the curriculum system and exploring new education and teaching methods.Methods:Through questionnaires and in-depth interviews, the self-regulated learning scale was applied, and the 6-level Likert scale was used for scoring. A total of 118 medical students, including 8-year undergraduates majoring in clinical medicine of Peking Union Medical College, were evaluated in the traditional medicine course stage (traditional group), emergency clinical practice stage (clinical group), and emergency clinical practice stage of the "4 + 4" reform pilot class ("4 + 4" pilot class group) of clinical medicine. The learning situation and related influencing factors were self-regulated. SPSS 23.0 was used for one-way analysis of variance.Results:Among the eight-year medical students of Peking Union Medical College, there were 48 males (40.7%) and 70 females (59.3%). The three groups of 8-year traditional medicine course stage, 8-year emergency clinical practice stage and "4 + 4" pilot class of emergency clinical practice stage were analyzed. The results showed that the total score of self-regulated learning ability in the clinical group was significantly lower than that in the traditional group [(326.2±31.9) vs. (347.7±40.2) points]. The subscales of self-regulated learning ability were analyzed respectively. In the learning motivation subscale, the score of external goal orientation of the clinical group is significantly lower than that of the traditional group [(8.9±2.3) vs. (10.0±2.9) points] and the score of the "4 + 4" pilot class group is significantly higher than that of the clinical group [(11.0±3.5) vs. (8.9±2.3) points]. In the learning strategy subscale, there was no significant difference among the three groups. In the resource management subscale, the scores of time and study environment [(6.5±1.1) vs. (7.5±1.9) points], learning management [(37.7±4.0) vs. (40.3±3.0) points] and help-seeking [(32.7±5.3) vs. (37.5±9.5) points] of the clinical group decreased significantly compared with those of the traditional group, while the scores of learning management [(40.2±7.3) vs. (37.7±4.0) points] and help-seeking [(38.7±7.6) vs. (32.7±5.3) points] of the "4+4" pilot class group increased significantly compared with those of the clinical group.Conclusion:The self-regulated learning of clinical medical students has changed significantly during the transition from traditional medical class to emergency clinical practice. The decrease of external goal orientation and resource management may be the important reason for the decline of the self-regulated learning ability of 8-year undergraduate medical students in the clinical environment during emergency practice.

Treatment and factors associated with prognosis of hyperkalemia in the emergency department / 中华危重病急救医学

Objective:To survey treatment and prognosis of hyperkalemia patients in the emergency department and to analyze factors associated with all-cause in-hospital mortality.Methods:We implemented electronic hospital information system, extracted demographic characteristics, underlying diseases, laboratory findings, potassium lowering therapy and prognosis of hyperkalemia patients [age ≥ 18 years, serum potassium (K +) concentration ≥ 5.5 mmol/L] in the emergency department of Peking Union hospital in Beijing between June 1st 2019 to May 31st 2020. The enrolled subjects were divided into the non-survival group and the survival group according to their prognosis. Univariate analysis and Cox regression model were adopted to analyze factors affecting all-cause in-hospital mortality of hyperkalemia patients. Results:A total of 579 patients [median age 64 (22) years; 310 men (53.5%) and 269 women (46.5%)] with hyperkalemia were enrolled, among which, 317 (54.7%), 143 (24.7%) and 119 (20.6%) were mild, moderate, and severe hyperkalemia, respectively. 499 (86.20%) patients received potassium-lowering therapy, forty-four treatment regimens were administered. Insulin and glucose (I+G, 61.3%), diuretics (Diu, 57.2%), sodium bicarbonate (SB, 41.9%) and calcium gluconate/chloride (CA, 44.4%) were commonly used for the treatment of hyperkalemiain the emergency department. The combination of insulin and glucose, calcium gluconate/chloride, diuretics and sodium bicarbonate (I+G+CA+Diu+SB) was the most favored combined treatment regimen of hyperkalemia in the emergency department. The higher serum potassium concentration, the higher proportion of administrating combined treatment regimen and/or hemodialysis (HD) (the proportion of administrating combined treatment regimen in mild, moderate, and severe hyperkalemia patients were 58.4%, 82.5% and 94.8%; the proportion of administrating HD in mild, moderate, and severe hyperkalemia patients were 9.7%, 13.3% and 16.0%, respectively). The proportion of achievement of normokalaemia elevated as the kinds of potassium lowering treatment included in the combined treatment regimen increased. The proportion of achievement of normokalaemia was 100% in the combined treatment regimen including 6 kinds of potassium lowering therapy. Among various potassium lowering treatments, HD contributed to the highest rate of achievement of normokalaemia (93.8%). 111 of 579 (19.20%) hyperkalemia patients died in hospital. Cox regression model revealed that complicated with cardiac dysfunction predicted higher mortality [hazard ratio ( HR) = 1.757, 95% confidence interval (95% CI) was 1.155-2.672, P = 0.009]. Achievement of normokalaemia and administration of diuretics attributed to lower mortality ( HR = 0.248, 95% CI was 0.155-0.398, P = 0.000; HR = 0.335, 95% CI was 0.211-0.531, P = 0.000, respectively). Conclusions:Treatment of hyperkalemia in the emergency department were various. Complicated with cardiac dysfunction were associated with higher mortality. Achieving normokalaemia was associated with decreased mortality.

Effect of improved nursing strategy on prognosis of older immunosuppressed patients with pneumonia and sepsis / 中华危重病急救医学

OBJECTIVE@#To investigate the effect of improved nursing strategy on prognosis of older immunosuppressed patients with pneumonia and sepsis.@*METHODS@#A prospective study was conducted. The older immunosuppressed patients with pneumonia and sepsis admitted to the department of intensive care medicine and emergency intensive care unit (ICU) of Peking Union Medical College Hospital from January 2017 to July 2022 were enrolled. In the first stage (from January 2017 to December 2019), patients received the original nursing strategy (original nursing strategy group), including: (1) nurses were randomly assigned; (2) routine terminal cleaning; (3) ICU environmental cleaning twice a day; (4) oral care was performed with chlorhexidine twice a day; (5) original lung physiotherapy [head of bed elevated at 30 degree angle-45 degree angle, maintaining a Richmond agitation-sedation scale (RASS) -2 to 1, sputum aspiration as needed]. After 1 month of learning and training of the modified nursing treatment strategy for nurses and related medical staff, the patients in the second stage (from February 2020 to July 2022) received the improved nursing strategy (improved nursing strategy group). The improved nursing strategy improved the hospital infection prevention and control strategy and lung physical therapy strategy on the basis of the original nursing strategy, including: (1) nurses were fixed assigned; (2) patients were placed in a private room; (3) enhanced terminal cleaning; (4) ICU environmental cleaning four times a day; (5) education and training in hand hygiene among health care workers was improved; (6) bathing with 2% chlorhexidinegluconate was performed once daily; (7) oral care with a combination of chlorhexidine and colistin was provided every 6 hours; (8) surveillance of colonization was conducted; (9) improved lung physiotherapy (on the basis of the original lung physiotherapy, delirium score was assessed to guide early mobilization of the patients; airway drainage was enhanced, the degree of airway humidification was adjusted according to the sputum properties, achieving sputum viscosity grade II; lung ultrasound was also used for lung assessment, and patients with atelectasis were placed in high lateral position and received the lung recruitment maneuver). Baseline patient information were collected, including gender, age, underlying diseases, source of admission, disease severity scores, vital signs, ventilatory parameters, blood gas analysis, life-sustaining treatments, clinical laboratory evaluation, indicators of infection and inflammation, pathogens and drug therapy. The primary outcome was 28-day mortality, and the secondary outcomes were duration of mechanical ventilation, length of ICU stay, and ICU mortality. Multivariate Logistic regression analysis was used to determine the risk factors for 28-day death in older immunosuppressed patients with pneumonia and sepsis.@*RESULTS@#Finally, 550 patients were enrolled, including 199 patients in the original nursing strategy group and 351 patients in the improved nursing strategy group. No significant differences were found in gender, age, underlying diseases, source of admission, disease severity scores, vital signs, ventilatory parameters, blood gas analysis, life-sustaining treatments, clinical laboratory evaluation, indicators of infection and inflammation, coexisting pathogens or drug therapy between the two groups. Compared with patients in the original nursing strategy group, those in the improved nursing strategy group had significantly fewer duration of mechanical ventilation and length of ICU stay [duration of mechanical ventilation (days): 5 (4, 7) vs. 5 (4, 9), length of ICU stay (days): 11 (6, 17) vs. 12 (6, 23), both P < 0.01], and lower ICU mortality and 28-day mortality [ICU mortality: 23.9% (84/351) vs. 32.7% (65/199), 28-day mortality: 23.1% (81/351) vs. 33.7% (67/199), both P < 0.05]. Multivariate Logistic regression analysis showed that the improved nursing strategy acted as an independent protective factor in 28-day death of older immunosuppressed patients with pneumonia and sepsis [odds ratio (OR) = 0.543, 95% confidence interval (95%CI) was 0.334-0.885, P = 0.014].@*CONCLUSIONS@#Improved nursing strategy shortened the duration of mechanical ventilation and the length of ICU stay, and decreased ICU mortality and 28-day mortality in older immunosuppressed patients with pneumonia and sepsis, significantly improving the short-term prognosis of such patients.

The correlation between carotid blood flow and the parameters derived by pulse oximetry plethysmographic waveform during cardiopulmonary resuscitation in a porcine model / 中华急诊医学杂志

Objective:To explore the correlation between carotid blood flow and the parameters derived by pulse oximetry Plethysmographic waveform in cardiopulmonary resuscitation, so as to provide a new index for carotid blood flow monitoring in cardiopulmonary resuscitation.Methods:Seven male domestic pigs were utilized for cardiac arrest model through ventricular fibrillation induced by electrical stimulation. Eight minutes after cardiac arrest, artificial chest compression was given for 4 min, and epinephrine 20 μg/kg was injected intravenously at 2 min after chest compression. The compression frequency, compression depth, right carotid blood flow, pulse oximetry plethysmographic waveform, aortic pressure, right atrium pressure and end tidal carbon dioxide partial pressure were continuously monitored and recorded. From 30 s to 4 min after chest compression, the values of the mean right carotid blood flow, the area under curve (AUC) of pulse oximetry plethysmographic waveform, the mean perfusion index, the mean coronary perfusion pressure and the average end-tidal carbon dioxide partial pressure during 6 s before time point were calculated every 30 s. The correlations between right carotid blood flow and the AUC of pulse oximetry plethysmographic waveform and perfusion index were analyzed respectively.Results:Ventricular fibrillation was induced successfully in seven animals. There were no significant differences in the mean chest compression frequency and depth per min during 4 min of chest compression. Right carotid blood flow at 30 s after chest compression was (92.7±32.7) mL/min, and decreased to (48.5±23.5) mL/min at 1 min after chest compression ( P<0.05). There was no significant difference in blood flow before and after epinephrine injection ( P>0.05). The AUC of the blood oxygen plethysmographic waveform and perfusion index showed synchronous change trends with right carotid blood flow. Both coronary perfusion pressure and end-tidal carbon dioxide partial pressure showed different change trends with right carotid blood flow. There was a positive correlation between the right carotid blood flow and the AUC of blood oxygen plethysmographic waveform ( r=0.66, P<0.01), and also a positive correlation between right carotid blood flow and perfusion index ( r=0.57, P<0.01). Conclusions:Carotid blood flow is positively correlated with the AUC of blood oxygen plethysmographic waveform and perfusion index in a porcine model of cardiopulmonary resuscitation. Real-time monitoring of the two parameters derived by pulse oximetry plethysmographic waveform can reflect the changes of carotid blood flow to a certain extent.

The prognostic value of platelet count related nomogram based on MIMIC-Ⅲ database for critically ill patients / 中华急诊医学杂志

Objective:To explore the relationship between platelet count (PLT) and organ dysfunction and prognosis in critically ill patients and its prognostic evaluation.Methods:A retrospective cohort study was conducted. The relevant records of 35 860 patients were extracted from the US Intensive Care Database (MIMIC-Ⅲ) from 2001 to 2012. According to the PLT count, patients were divided into the thrombocytopenia group (PLT<100×10 9/L), normal platelet group (100×10 9/L≤PLT≤300×10 9/L), and thrombocytosis group (PLT>300×10 9/L). This study included adult patients between 18 and 89 years old. Patients with survival time less than 24 h and lack of vital signs or PLT values were excluded. The outcome event was the hospital mortality of the patient. Survival was analyzed by the Kaplan-Meier method. The prognostic factors were identified by univariate and multivariate COX analyses. The nomogram to predict hospital mortality was built by the significant prognostic factors. In combination with the important prognostic factors, a nomogram was established to predict the prognosis of critically ill patients in hospital, and the AUC value under the ROC curve was used to assess the discriminative power of the nomogram. Results:Compared with the normal PLT group and the thrombocythemia group, organ dysfunction in the thrombocytopenia group was significantly worse; the SOFA score [3 (2, 5) vs. 2.0 (1, 5) vs. 7 (5, 9)], SAPS-Ⅱ score [31 (23, 41) vs. 32 (23, 42) vs. 38 (30, 50) ], hospital mortality (35.0% vs. 45.2% vs. 54.7%), the incidence of mechanical ventilation (50.3% vs. 41.4% vs. 62.8%), and renal replacement therapy (1.3% vs. 1.3% vs. 6.0%) were significantly higher (all P<0.05). COX regression analysis found that thrombocytopenia was an independent predictor of hospital mortality and was entered into a nomogram after final regressions ( HR=1.477, 95% CI: 1.347-1.691, P<0.01). When the above indicators were brought into the nomogram, the AUC of the nomogram was 0.744. Conclusions:Thrombocytopenia is an independent prognostic predictor of hospital mortality for critically ill patients. PLT-related nomograms have good discrimination, which may help clinicians evaluate the prognosis of hospitalized patients.

Research progress of Toll-like receptors and pulmonary infection / 中国医师杂志

Due to the increase of susceptible individual species and drug-resistant pathogens, pulmonary infection is still a global problem that threatens human health. Toll-like receptors (TLR) can identify pathogenic pattern related molecules on the surface of pathogenic microorganisms in innate immunity and initiate innate immune response. It can participate in different anti-infection mechanisms and play an important role in pulmonary infectious diseases caused by different pathogens. In this paper, the research progress of TLR in pulmonary infection at home and abroad in recent years is reviewed.

Prediction of emergency difficult airway by airway evaluation based on CHANNEL process / 中华急诊医学杂志

Objective:To evaluate the accuracy of CHANNEL process in predicting difficult airway of patients in emergency department.Methods:From July 2016 to December 2019, we selected patients who underwent airway management in the emergency department of Peking Union Medical College Hospital. They were evaluated by CHANNEL and improved Mallampati (modified Mallampati test, MMT) classification at the same time. After completion, the glottis was exposed under direct laryngoscope, and then Cormack Lehane classification was performed. Difficult airway was defined as Cormack-Lehane grade Ⅲ or Ⅳ. The receiver-operating characteristics curve was used to evaluate the accuracy of MMT and CHANNEL in predicting difficult airway.Results:122 of 312 patients who underwent emergency airway management were included in the study. The sensitivity of CHANNEL in predicting difficult airway was 100%, the specificity was 90.1%, the area under the curve(95% confidence interval) was 0.948(0.907~0.988).Compared with MMT, the area under the curve of CHANNEL in predicting difficult airway was significantly increased( P<0.05). Conclusion:CHANNEL can accurately predict difficult airway of patients in the emergency department.

Risk factors of acute kindey injury in critical patients in emergency department / 中华急诊医学杂志

Objective:To investigate the incidence and risk factors of acute kidney injury in patients admitted to the resuscitation room of the Emergency Department.Methods:Patients were enrolled from the resuscitation room of our hospital from September to December 2018 by a retrospective cohort study. Patients were divided into AKI group and non-AKI group according to whether AKI occurred within seven days after admission. Demographic characteristics, APACHEⅡ score, whether to use nephrotoxic drugs,24-hour fluid volume, and patients survival time were collected. Multivariate regression analysis was used to explore the risk factors for AKI. Cox regression was used to study the effect of the occurrence of AKI on survival and to analyze the influence of AKI severity on the death risk of patients in the resuscitation room.Results:Among 238 critical patients who were finally included, 108 patients developed AKI(45.4%), 83 patients were in AKI stage 1 (34.9%), and 25 patients were in AKI stage 2-3 ( 10.5%).APACHEⅡ score>13( OR=1.11, 95% CI (1.08-1.16), P <0.01), vasoactive drugs ( OR=2.20, c95% CI (1.08-4.49), P=0.03), diabetes mellitus ( OR=2.33, 95% CI (1.23-4.42), P=0.01), and fluid load> 3 L( OR=3.10, 95% CI (1.17-8.25). P=0.02) were independent risk factors for AKI. After adjustment for APACHEⅡ score and age by multivariate COX regression, AKI remained an independent risk factor for death in emergency patients, and the severity of AKI significantly increased the risk of death in these patients(AKI 1: HR=1.45, 95% CI (1.08-2.03), P =0.04; AKI 2~3: HR=3.15, 95% CI (1.49-4.81), P=0.03). Conclusions:AKI occurred commonly in the resuscitation room of the emergency department. APACHE Ⅱ score>13, vasoactive drugs, diabetes, and fluid load>3 L were independent risk factors for AKI. The risk of death increased with the aggravation of AKI severity.

The predictive value of mean arterial pressure and end expiratory carbon dioxide on severe cardiovascular collapse in early stage after emergency endotracheal intubation / 中华急诊医学杂志

Objective:To analyze the changes of mean arterial pressure (MAP) and end expiratory carbon dioxide (ETCO 2) in patients after emergency endotracheal intubation (ETI). To explore the values of MAP and ETCO 2 monitoring in early prediction of severe cardiovascular collapse (CVC) after emergency ETI. Methods:The clinical data of adult patients who underwent ETI from March 2015 to May 2020 were collected consecutively in the emergency departments of Peking Union Medical College Hospital. The values of MAP and ETCO 2 were observed and recorded at 5, 10, 30, 60 and 120 min after intubation. According to whether severe CVC occurred after ETI, the patients were divided into the severe CVC group and non-severe CVC group. The values of MAP and ETCO 2 were compared at the same time points between the two groups and the adjacent time points within the groups. The correlation between MAP and ETCO 2 after ETI was also analyzed. ROC curve was used to analyze the ability of MAP and ETCO 2 at 5 min and 10 min after ETI to predict severe CVC. Results:Totally 116 patients were enrolled in this study, among them 75 (64.7%) cases had severe CVC after ETI. The majority were male and elderly patients in the severe CVC group. The values of MAP and ETCO 2 in 5, 10, 30, 60 and 120 min after ETI in severe CVC group were significantly lower than those in the non-severe CVC group. The values of MAP and ETCO 2 in the two groups showed simultaneous decrease from 5 min to 30 min after ETI, reached the lowest value at 30 min after ETI, and appeared the synchronous recover from then to 120 min after ETI. After ETI, the changes of MAP was correlated with that of ETCO 2 ( rs = 0.653, P<0.01). At 5 min after ETI, MAP could predict severe CVC (AUC=0.86, P<0.01), MAP≤72 mmHg was the best cutoff value (sensitivity 78.7%, specificity 87.8%); ETCO 2 could also predict severe CVC (AUC=0.85, P<0.01), and ETCO 2≤35 mmHg was the best cutoff value (sensitivity 77.3%, specificity 85.4%). At 10 min after ETI, MAP could predict severe CVC (AUC = 0.90, P<0.01), MAP≤67 mmHg was the best cutoff value (sensitivity 89.3%, specificity 85.4%), ETCO 2 could also predict severe CVC (AUC=0.87, P<0.01), and ETCO 2≤33 mmHg was the best cutoff value (sensitivity 81.3%, specificity 78.0%). There was no significant difference in the ability of prediction between any two indexes of the MAP and ETCO 2 at 5 min and 10 min after ETI ( P>0.05). Conclusions:Patients with severe CVC after ETI have early signs of decreased MAP and ETCO 2, but the delayed recognition and insufficient intervention may be related to the occurrence and development of severe CVC. MAP and ETCO 2 at the early stage after ETI have high accuracy in predicting severe CVC. MAP≤72 mmHg, ETCO 2≤35 mmHg at 5 min after intubation, MAP≤67 mmHg and ETCO 2≤33 mmHg at 10 minutes after intubation all suggest the possibility of severe CVC.

Association between previous bleeding and 90-day mortality and rebleeding in patients with acute upper gastrointestinal bleeding: a real-world study / 中华急诊医学杂志

Objective:To investigate the relationship between previous bleeding history and poor prognosis of patients with acute upper gastrointestinal bleeding.Methods:This study was a prospective multicentre real-world study (Acute Upper Gastrointestinal Real-word study, AUGUR study). The data of patients with UGIB who were admitted to the emergency department of 20 tertiary hospitals in China from June 30, 2020 to February 10, 2021 were collected. According to the number of previous bleeding history, the patients were divided into three groups (0 time, 1-3 times, and≥4 times). Based on the patient’s demographic data, clinical characteristics, laboratory data, treatment, and outcomes, univariate and logistic regression analysis were performed to investigate the correlation between the number of previous bleeding and the 90-day mortality and rebleeding of patients with gastrointestinal bleeding.Results:A total of 1 072 patients with acute UGIB were included in this study. The all-cause mortality and rebleeding rate of all patients were 10.9% (117/1 072) and 11.8% (129/1 072), respectively. Among them, 712 patients (66.42%) had no previous bleeding, 297 patients (27.71%) had previous bleeding 1-3 times, and 63 patients (5.88%) had previous bleeding≥4 times. In univariate analysis, age, vital signs and consciousness on admission, history of liver cirrhosis, onset with hematemesis, admission hemoglobin, varicose veins bleeding, peptic ulcer bleeding, red blood cell infusion, tracheal intubation and the use of vasopressors after admission were risk factors for the 90-day mortality and rebleeding rate. Multivariate logistic regression analysis showed that patients with previous bleeding≥4 times had a higher risk of the 90-day mortality ( OR=2.17, 95% CI: 1.04-4.57, P=0.040) and rebleeding ( OR=2.32, 95% CI: 1.19-4.53, P=0.013). Conclusions:The history of previous bleeding≥ 4 times can be used as an independent risk factor for the 90-day mortality and rebleeding in patients with acute UGIB.

Practice of relieving emergency overcrowding in Peking Union Medical College Hospital / 中华医院管理杂志

Peking Union Medical College Hospital, as one of the most stressful medical institutions in China, is facing the problem of emergency department overcrowding. In order to effectively alleviate the emergency overcrowding, improve the medical quality and patients′ medical experience, the hospital firmly grasped the two incremental links of " throughput" and " output" factors, established a multidisciplinary and multi-department cooperation team, constructed a close medical alliance cooperation mode, and innovated and explored a harmonious emergency overcrowding relief mode with the goal of unblocking the " exit" of patients. The practice showed that the comprehensive measures could effectively alleviate the problem of emergency overcrowding, and improve the medical environment and medical quality.

Practice and effect analysis of emergency cluster management / 中华医院管理杂志

Objective:To analyze the application effect of cluster management measures in improving the quality of emergency medical treatment.Methods:By analyzing the problems existing in the work of emergency department, the cluster management scheme was formulated and the intervention measures were implemented from the aspects of intelligent information system, patient management system and medical service process. The accuracy and efficiency of emergency triage, the satisfaction of patients and medical staff, the incidence of medical complaints and disputes and the rate of sudden death were compared before and after cluster management.Results:Before and after the implementation of cluster management, the accuracy of triage classification was 95.0% and 98.7% respectively, and the triage time was (68.3±12.8) s and (50.5±7.2) s respectively( P<0.001). The satisfaction of patients, doctors and nurses increased, the number of complaints decreased from 15 to 5 in half a year, and the number of sudden death decreased from 39 to 23 with a significant difference( P<0.05). Conclusions:The application of cluster management measures in emergency management can improve the medical quality, the satisfaction of medical staff and patients, and ensure the safety of patients.

Clinical features of 2019 novel coronavirus infection patients and a feasible screening procedure / 中华急诊医学杂志

Objective@#To study the clinical characteristics of 2019 coronavirus (2019-nCoV) pneumonia patients and make a feasible screening process in fever clinic.@*Methods@#Epidemiologic features, clinical presentation, laboratory findings and image features of the screened patients were retrospectively collected and analyzed.@*Results@#Totally, 46 patients were screened, 9 of them were laboratory-confirmed 2019-nCoV infection, and others were defined as laboratory-excluded patients. Laboratory-confirmed patients had higher frequency of travelling or residence in Wuhan within two weeks of onset (P<0.05), but there were no differences on age, sex, other epidemiologic features and comorbidities between the two groups (P>0.05). The most common feature of the laboratory-confirmed patients was fever (100%), but the symptoms showed no differences between the two groups (P>0.05). Laboratory-confirmed patients had lower white blood cell count than the laboratory-excluded patients (P<0.05), and all of them had pneumonia in chest CT scan. None of the patients with normal chest CT had positive 2019-nCoV nucleic acid test.@*Conclusions@#No specific symptom was helpful in the diagnosis of 2019-nCoV infection. However, patients without chest CT scan changes had a very low risk of 2019-nCoV infection despite of the epidemiologic history and fever. We recommended a screening procedure that might be helpful to reduce the rate of miss diagnosis and improve screening efficiency.

Clinical features of novel coronavirus infection patients and a feasible screening procedure / 中华急诊医学杂志

Objective:To study the clinical characteristics of novel coronavirus pneumonia (COVID-19) patients and make a feasible screening process in fever clinic.Methods:Epidemiologic features, clinical presentation, laboratory findings and image features of the screened patients were retrospectively collected and analyzed.Results:A total of 46 patients were screened, 9 of them were laboratory-confirmed novel coronavirus infection, and others were defined as laboratory-excluded patients. Laboratory-confirmed patients had higher frequency of travelling or residence in Wuhan within two weeks of onset ( P<0.05), but there were no differences on age, sex, other epidemiologic features and comorbidities between the two groups ( P>0.05). The most common feature of the laboratory-confirmed patients was fever (100%), but the symptoms showed no differences between the two groups ( P>0.05). Laboratory-confirmed patients had lower white blood cell count than the laboratory-excluded patients ( P<0.05), and all of them had pneumonia in chest CT scan. None of the patients with normal chest CT had positive novel coronavirus nucleic acid test. Conclusions:No specific symptom is helpful in the diagnosis of novel coronavirus infection. However, patients without chest CT scan changes have a very low risk of novel coronavirus infection despite of the epidemiologic history and fever. We recommended a screening procedure that might help to reduce the rate of miss diagnosis and improve screening efficiency.

Analysis on component ratio of 1131 social emergency training instructors in Baoan district, Shenzhen / 中华急诊医学杂志

Objective:To analyze the component ratio of the social emergency training instructors in Baoan District, Shenzhen;Methods:During January 2018 to January 2019,participants, candidate to be social emergency training instructors in Baoan district, Shenzhen, were enrolled in our analysis. they needed orderly pass primary selection and intensive selection to be formal social emergency training instructors. Personal data from candidates including hospital, serving department, degree and professional types were collected. According to serving departments, candidates from pre-hospital emergency, emergency ward and critical care unite is belong to the emergency group and other s who is not from above departments belong to the non-emergency group.Results:Total of 1 270 candidates took part in 7 primary classes and 27 intensive selection until 1131 of them received the formal certifications. 440(38.90%) instructors from emergency group and 691(61.10%) instructors belong to non-emergency group. At category level of hospital, 213 (18.83%) is from three grade, 525 (46.42%) is from two grade, 254 (22.46%) is from specialized hospitals, and 139 (12.29%) is from community health centers. In non-emergency group, ratio of serving departments are consists of: 15.77% from internal medicine, 10.14% from chirurgery, 8.11% from pediatrics, 7.96% from obstetrics and gynecology, 2.62% cases from otorhinolaryngology, 24.29% from medical assistants, 20.11% from community health center and 11.00% from administrative officer. Nurses (64.13%) is the majority professional types of social emergency training instructors. In terms of degree, bachelor mainly occupied at 71.02%. Primary (53.18%) and attending (30.47%) account for majority of position ranks.Conclusions:Our team of social emergency training instructors,mainly from local medical staffers, has a great educational background and competitive team; Among them, emergency team is crucial to provoke other medical staffs from different departments to participate in career at social emergency training.

Preliminary exploration on training of emergency airway management course guided by clinical procedure / 中华医学教育探索杂志

Objective:To promote emergency airway management from the perspective of training and to explore the training mode of emergency airway management based on clinical procedures.Methods:Airway management training courses were designed according to the clinical treatment principle centered on patient safety in combination with actual clinical procedures. The course took the CHANNEL process of airway management as the main line and focused on artificial ventilation, oxygen therapy and rapid induction of intubation techniques. During the teaching, we took the clinical handling process as the main line, and adopted methods of equipment display, video presentation and on-site explanation. Courses were freely registered or oriental enrollment. Online questionnaires were used to collect feedback from the students after class and were then analyzed.Results:A total of 15 training sessions were held in 13 cities across the country, with 566 participants, and 185 questionnaire responses were received. About the content of single course, participants thought that the first three parts were difficult to understand, including oxygen therapy (48, 25.9%), CHANNEL process explanation and practice (48, 25.9%) and rapid induction of intubation process (47, 25.4%). After class, 41 participants (22.2%) changed work procedures of emergency airway management, 140 (75.7%) partially changed work procedures of emergency airway management, and 4 (2.2%) still used the original work procedure.Conclusion:The course of emergency airway management based on clinical procedures meets the current clinical needs and can better improve the training of clinical competency.

A survey of regional citrate anticoagulation for emergency continuous renal replacement therapy / 中华危重病急救医学

Objective:To investigate the status of regional citrate anticoagulation (RCA) in continuous renal replacement therapy (CRRT) in emergency department.Methods:Participants of a national emergency conference from August 1st to August 4th in 2019 from hospitals of different levels in different regions were interviewed by online questionnaire to collect data about the current status and limitations of the application of RCA in emergency CRRT by convenient sampling.Results:Totally 407 questionnaires were collected through internet, and the completeness of the answers was as high as 100%. Twenty-three responses with logic errors were excluded, and 384 questionnaires were finally retrieved, with an effective rate of 94.35%. Representatives from 29 provinces, autonomous regions and municipalities directly under the Central Government participated in the questionnaire survey, and the hospitals in which they worked were mainly class Ⅲ grade A [70.31% (270/384)]. The survey showed that 61.46% (236/384) of the emergency departments could carry out CRRT independently. There were less than 10 CRRT cases per month in most emergency departments [52.87% (166/314)]. In the emergency departments where CRRT were carried out, heparin was a widely used and well-applied anticoagulant [82.17% (258/314)], and 199 emergency departments (63.38%) were proficient in RCA. In clinical practice, heparin [49.68% (156/314)] was preferred to RCA [25.80% (81/314)] and low molecular weight heparin [23.56% (74/384)]. In the emergency departments where RCA could be used skillfully, 4% sodium citrate was the main regional anticoagulant [68.34% (136/199)]. Anticoagulation protocol came from different sources, most of which were from nephrology or dialysis center (29.65%). Most departments could adjust the ionized calcium before the filter to the target safety level [0.9-1.2 mmol/L, 88.94% (177/199)], and adjust the ionized calcium after the filter to the target ideal anticoagulation level [0.2-0.4 mmol/L, 93.47% (186/199)] within 4 hours. The common complications that emergency physicians concerned were accumulation of citrate [58.29% (116/199)], metabolic alkalosis [54.77% (109/199)] and metabolic acidosis [37.19% (74/199)]. In 281 emergency departments that could not use RCA, there were kinds of factors that limited the use of citrate, such as higher cost than heparin (31.67%), unskilled personnel (21.00%), limited source of citrate (17.08%), concerns of complications (11.74%). At present, the substitution fluids used in clinical practice were mainly the commercial products (45.54%). In most cases, emergency CRRT filters had a life span of 12-23 hours (39.49%).Conclusions:The use of RCA in domestic emergency CRRT is low. Compared with the international peers, we are still lacking of adequate understanding of RCA. Therefore, it is necessary to develop an anticoagulation protocol of RCA for emergency departments in China, and promote training of CRRT.

The effect of different ventilation modes on the ventilation rate and prognosis in patients with cardiac arrest after advanced airway placement / 中华急诊医学杂志

Objective To investigate the effect of different ventilation modes on the ventilation rate and prognosis in patients with cardiac arrest after advanced airway placement. Methods Based on the national database of emergency cardiac arrest treatment, patients treated with advanced airway placement during cardiopulmonary resuscitation (CPR) were enrolled in PUMCH Emergency Department from December 2013 to June 2018. The physiological parameters, such as electrocardiograph waveform, pulse oximetry plethysmographic waveform and capnography, were recorded at least 18 minutes. The demographic data and resuscitation parameters were collected. Waveform capnography was used for calculating ventilation rate (VR) and the VR between 8 to 12 breaths/min was defined as the qualified ventilation rate (QVR). According to the ventilation modes, patients were divided into the bag-mask group (BMG) and mechanical ventilation group (MVG). According to the VR, patients in the mechanical ventilation group were divided into two subgroups, the high-frequency ventilation subgroup (HFV subgroup) with the VR more than 20 breaths/min and the low-frequency VR subgroup (LFV subgroup) with the VR less than 20 breaths/min. VR, the qualified ventilation rate ratio (QVRR), the return of spontaneous circulation (ROSC), and 24-h and 7-day survival were compared between the two groups and subgroups. Result A total of 90 patients were enrolled in the analysis with 22 patients in the bag-mask group and 68 patients in the mechanical ventilation group. The total rate of ROSC was 35.6％, 24-h survival was 1.1％ and 7-day survival was 0. The first 18 minutes ventilation data were collected and added up to 1620 min. The median VR was 16.5 (12.0, 26.0) breaths/min and the QVRR was 30％. Compared with the mechanical ventilation group, the VR in the bag-mask group were lower (10 breaths/min vs 21 breaths/min) and the QVRR was higher (88.9％ vs 11.5％). The ROSC, 24-h survival and 7-day survival had no statistical differences between the two groups. In the mechanical ventilation group, the ratio of VR more than 20 breaths/min was 52.6％. Between the two subgroups, there was no statistical difference in ROSC, 24-h survival and 7-day survival. Conclusions Compared with the mechanical ventilation during CPR, the VR is lower with bag-mask ventilation, and the QVRR is higher. But there was no statistical difference on the outcomes. There was no difference on the outcomes between the two mechanical ventilation subgroups.

Survey on the use of point-of-care ultrasound detection in 300 emergency departments of tertiary hospital in China in 2018 / 中华危重病急救医学

Objective To investigate the possession of ultrasound equipment and use of point-of-care ultrasound (POCUS) in emergency department of tertiary hospitals in China to figure out the present condition of POCUS in the emergency department. Methods Questionnaire survey was performed through the internet, which included equipment possession, usage, and the sterile technique of the probe in the emergency department of tertiary hospitals. Results Between September and December in 2018, a total of 2 994 questionnaires link was clicked, and 718 survey responses were collected. After removing duplicated and non-tertiary hospitals questionnaires, the final questionnaire survey covered 300 tertiary hospitals, of which 250 were tertiary A hospitals (83.3%). The number of emergency department which own bedside ultrasound machine was 173 (57.7%), 40.6% (122) of the departments had only one ultrasonic machine. The main sources of equipment were new bought machines (119, 68.8%), given (38, 22.0%) or rented old machines from the ultrasound department (42, 24.3%). None of the emergency physicians in 92 (30.7%) departments mastered the POCUS skills, and 52.7% of the response hospital had less than a quarter emergency physicians grasp the skills. Fees of the POCUS could be charged in 52 (30.1%) of them. The main methods to clean or sterilize the probes were to wipe the probe by cleaning dry paper (97, 56.1%), sterile wet paper (69, 39.9%) or special probe disinfector (23, 13.3%), and used probe protective sleeve and sterile gel (12, 6.9%) as necessary; 79 (45.7%) departments had no conventional probe disinfection measures. When the ultrasonic was used to guide the punctures, the prevention of infection policies were the sterile gloves and saline (106, 61.3%), disposable probe protective sleeve and sterile gel (55, 31.8%). Conclusions The propagation of POCUS in emergency department is needed to develop in tertiary hospitals in China. The right way to clean the probes need to be emphasized.