Pre-hospital Prognostic Factors of Out-of-Hospital Cardiac Arrest: The Difference Between Pediatric and Adult.

The prognosis of out-of-hospital cardiac arrest (OHCA) is very poor. Although several pre-hospital factors are associated with survival, the different association of pre-hospital factors with OHCA outcomes in pediatric and adult groups remain unclear. To assess the association of pre-hospital factors with OHCA outcomes among pediatric and adult groups, a retrospective observational study was conducted using the emergency medical service (EMS) database in Kaohsiung from January 2015 to December 2019. Pre-hospital factors, underlying diseases, and OHCA outcomes were collected for the pediatric (Age ≤ 20) and adult groups. Kaplan-Meier type plots and multivariable logistic regression were used to analyze the association between pre-hospital factors and outcomes. In total, 7,461 OHCAs were analyzed. After adjusting for EMS response time, bystander CPR, attended by EMT-P, witness, and pre-hospital defibrillation, we found that age [odds ratio (OR) = 0.877, 95% confidence interval (CI): 0.764-0.990, p = 0.033], public location (OR = 7.681, 95% CI: 1.975-33.428, p = 0.003), and advanced airway management (AAM) (OR = 8.952; 95% CI, 1.414-66.081; p = 0.02) were significantly associated with survival till hospital discharge in pediatric OHCAs. The results of Kaplan-Meier type plots with log-rank test showed a significant difference between the pediatric and adult groups in survival for 2 h (p < 0.001), 24 h (p < 0.001), hospital discharge (p < 0.001), and favorable neurologic outcome (p < 0.001). AAM was associated with improved survival for 2 h (p = 0.015), 24 h (p = 0.023), and neurologic outcome (p = 0.018) only in the pediatric group. There were variations in prognostic factors between pediatric and adult patients with OHCA. The prognosis of the pediatric group was better than that of the adult group. Furthermore, AAM was independently associated with outcomes in pediatric patients, but not in adult patients. Age and public location of OHCA were independently associated with survival till hospital discharge in both pediatric and adult patients.

The Association Pattern between Ambient Temperature Change and Leukocyte Counts.

Ambient temperature change is one of the risk factors of human health. Moreover, links between white blood cell counts (WBC) and diseases have been revealed in the literature. Still, we do not know of any association between ambient temperature change and WBC counts. The aim of our study is to investigate the relationship between ambient temperature change and WBC counts. We conducted this two-year population-based observational study in Kaohsiung city, recruiting voluntary community participants. Total WBC and differential counts, demographic data and health hazard habits were collected and matched with the meteorological data of air-quality monitoring stations with participants' study dates and addresses. Generalized additive models (GAM) with penalized smoothing spline functions were performed for the trend of temperature changes and WBC counts. There were 9278 participants (45.3% male, aged 54.3 ± 5.9 years-old) included in analysis. Compared with stable weather conditions, the WBC counts were statistically higher when the one-day lag temperature changed over 2 degrees Celsius, regardless of whether colder or hotter. We found a V-shaped pattern association between WBC counts and temperature changes in GAM. The ambient temperature change was associated with WBC counts, and might imply an impact on systematic inflammation response.

2020 Guideline for Prehospital Management, Emergency Evaluation and Treatment of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the Taiwan Society of Emergency Medicine and Taiwan Stroke Society.

To improve the clinical outcomes of patients with acute ischemic stroke, the public, pre-hospital care system, and hospitals should cooperate to achieve quick assessment and management for such patients and to start treatment as soon as possible. To reach the goal, the Consensus Group, including emergency physicians and neurologists in the Taiwan Society of Emergency Medicine and Taiwan Stroke Society, performed an updated review and discussion for the local guidelines. The guidelines consist of 12 parts, including public education program, evaluation and management in the emergency medical system, emergency medical system, assessment of stroke care capability of the hospital by independent parties, stroke team of the hospital, telemedicine, organization, and multifaceted integration, improvement of quality of care process of stroke system, initial clinical and imaging evaluations after arriving at the hospital, imaging evaluation for indications of intravenous thrombolysis, imaging evaluation for indications of endovascular thrombectomy, and other diagnostics. For detailed contents in Chinese, please refer to the Taiwan Stroke Society Guideline and Taiwan Emergency Medicine Bulletin.

The Association of White Blood Cells and Air Pollutants-A Population-Based Study.

The links of air pollutants to health hazards have been revealed in literature and inflammation responses might play key roles in the processes of diseases. WBC count is one of the indexes of inflammation, however the l iterature reveals inconsistent opinions on the relationship between WBC counts and exposure to air pollutants. The goal of this population-based observational study was to examine the associations between multiple air pollutants and WBC counts. This study recruited community subjects from Kaohsiung city. WBC count, demographic and health hazard habit data were collected. Meanwhile, air pollutants data (SO2, NO2, CO, PM10, and O3) were also obtained. Both datasets were merged for statistical analysis. Single- and multiple-pollutants models were adopted for the analysis. A total of 10,140 adults (43.2% males; age range, 33~86 years old) were recruited. Effects of short-term ambient concentrations (within one week) of CO could increase counts of WBC, neutrophils, monocytes, and lymphocytes. However, SO2 could decrease counts of WBC, neutrophils, and monocytes. Gender, BMI, and smoking could also contribute to WBC count increases, though their effects are minor when compared to CO. Air pollutants, particularly SO2, NO2 and CO, may thus be related to alterations of WBC counts, and this would imply air pollution has an impact on human systematic inflammation.

Association between ambient air pollution and out-of-hospital cardiac arrest: are there potentially susceptible groups?

This study aimed to examine the association between air pollution and out-of-hospital cardiac arrest (OHCA), and the effects of underlying diseases. Between January 2015 and December 2016, data on particulate matter (PM)2.5 and other air pollutants in Kaohsiung City were collected, and an emergency medical service database was used for information on patients who experienced OHCA. Overall, 3566 patients were analyzed and subgroup analyses by sex, age, and preexisting morbidities were performed. Interquartile increments in PM2.5, PM10, and O3 levels on lag 1 and NO2 level on lag 3 were associated with increments of 10.8%, 11.3%, 6.2%, and 1.7% in OHCA incidence, respectively. Subgroup analyses showed that patients with diabetes (1.363; interaction p = 0.009), heart disease (1.612; interaction p = 0.001), and advanced age (≥70 years, 1.297; interaction p = 0.003) were more susceptible to NO2 on lag 3. Moreover, patients were more susceptible to O3 during the cold season (1.194; interaction p = 0.001). We found that PM2.5, PM10, NO2, and O3 may play an important role in OHCA events, and the effects vary by underlying condition, age and season.

Mortality Prediction of Septic Patients in the Emergency Department Based on Machine Learning.

In emergency departments, the most common cause of death associated with suspected infected patients is sepsis. In this study, deep learning algorithms were used to predict the mortality of suspected infected patients in a hospital emergency department. During January 2007 and December 2013, 42,220 patients considered in this study were admitted to the emergency department due to suspected infection. In the present study, a deep learning structure for mortality prediction of septic patients was developed and compared with several machine learning methods as well as two sepsis screening tools: the systemic inflammatory response syndrome (SIRS) and quick sepsis-related organ failure assessment (qSOFA). The mortality predictions were explored for septic patients who died within 72 h and 28 days. Results demonstrated that the accuracy rate of deep learning methods, especially Convolutional Neural Network plus SoftMax (87.01% in 72 h and 81.59% in 28 d), exceeds that of the other machine learning methods, SIRS, and qSOFA. We expect that deep learning can effectively assist medical staff in early identification of critical patients.

Comparing the Outcomes of Reporting and Trigger Tool Methods to Capture Adverse Events in the Emergency Department.

BACKGROUND: Little is known about which methods are best for detecting adverse events in the emergency department (ED). OBJECTIVES: This study compared the ability of trigger tool and reporting methods to capture adverse events in the ED and investigated the characteristics of the adverse events identified by each. METHODS: This 1-year prospective observational cohort study evaluated a monitoring system that combined 2 reporting methods and 5 trigger tool methods to capture adverse events in the ED of an academic medical center. Measurement outcomes included the number, type, and physical impact of the captured adverse events. RESULTS: Among 69,327 adult nontrauma ED visits, 285 adverse events were identified. Of these adverse events, 77.2% were identified using reporting methods, 26% using trigger tool methods, and 3.2% using both methods. Most patients (81.7%) incurred temporary, minor physical impacts. Of the adverse events that occurred, 86.7% were related to clinical performance. Compared with reporting methods, trigger tool methods had a lower positive predictive rate to identify adverse events (odds ratio [OR], 0.1; 95% confidence interval [CI], 0.09-0.16), a greater proportion of adverse events occurring during the preinterventation and postintervention phases (OR, 17.0; 95% CI, 8.48-34.16), and more cases of severe physical impact or death (OR, 5.4; 95% CI, 2.62-11.10). CONCLUSIONS: The reporting methods more effectively captured greater numbers of adverse events, whereas the adverse events captured by the trigger tool methods were more likely to be severe physical impacts. The combined use of the different methods had synergistic benefits for monitoring adverse events in the ED.

Massive Pulmonary Embolism Concomitant With Cardiac Tamponade as Initial Presentation of Lung Adenocarcinoma: A Diagnostic and Therapeutic Dilemma.

Pulmonary embolism and cardiac tamponade are potentially fatal acute conditions that rarely present concomitantly in the emergency department (ED). Both require early diagnosis and urgent intervention, and are usually observed as separate easily identifiable diseases. However, in a patient exhibiting a concomitant presentation of pulmonary embolism with cardiac tamponade, diagnosis and therapeutic intervention are extremely challenging. A 48-year-old woman presented with cardiac tamponade as an initial symptom of an underlying lung adenocarcinoma and masked massive pulmonary embolism (MPE), which led to the development of sudden cardiac arrest after successful pericardiocentesis. She presented with a high index of suspicion for a diagnosis of MPE using echocardiography after successful pericardiocentesis, and this diagnosis was confirmed using computed tomography. Extracorporeal membrane oxygenation and adjusted-dose unfractionated intravenous heparin administration were performed; unfortunately, they were unsuccessful. This report would help ED physicians because this case demonstrates that lung cancer can initially present as pulmonary embolism with cardiac tamponade and pulmonary embolism can be misdiagnosed in the presence of concomitant cardiac tamponade. Bedside echocardiography may fail to diagnose life-threatening MPE with coexisting cardiac tamponade. MPE can also lead to the development of sudden cardiac arrest after successful pericardiocentesis. Thrombolytic and anticoagulant use in MPE with coexisting hemorrhagic cardiac tamponade is a controversial issue. The risk-benefit ratio of both therapies needs to be considered on a case-by-case basis for improved clinical outcomes.

Adverse event and error of unexpected life-threatening events within 24hours of ED admission.

OBJECTIVES: Errors and adverse events associated with unexpected life-threatening events including unplanned transfer to the intensive care unit (ICU) and unexpected death after emergency department (ED) hospitalization are not well characterized. We performed this study to investigate the role of unexpected life-threatening events as a trigger to capture errors and adverse events for ED patient safety. METHODS: This prospective observational study enrolled adult non-trauma patients with unexpected life-threatening events within 24h of general ward admission from the ED of a medical center in Taiwan. The period of study was one year (in 2013); the medical records of enrolled patients were reviewed to identify adverse events and errors. We measured the incidence rate of adverse events or errors. Preventability, type, and physical injury severity of adverse events were investigated. RESULTS: Of 33,224 adult non-trauma ward admissions from the ED, 100 admissions (0.3%) met the study criteria. Incidence rate was 2% and 15% for errors and adverse events, respectively. In admissions involving error, all were preventable and the error type was overlooked of severity. In admissions that involved adverse events, 93.3% were preventable. There were 20% of admissions that resulted in death and 60% developed with severe physical injury. The adverse event types were diagnosis issues (53.3%), management issues (40%), and medication adverse events (6.7%). CONCLUSIONS: Unexpected life-threatening events within 24h of admission from the ED could be a useful trigger tool to identify preventable adverse events with serious physical injury in ED.

Seniority of Emergency Physician, Patient Disposition and Outcome Following Disposition.

OBJECTIVES: The relationship between the seniority of emergency physicians (EPs) and disposition decision-making is not well defined. As most responsibility by EPs involves developing an appropriate disposition plan, this study aimed to examine the influence of EP seniority on decisions regarding patient dispositions in the emergency department (ED). MATERIALS AND METHODS: This retrospective, 1-year, cohort study was conducted in 3 EDs including all day-shift nontraumatic adult patients. The outcome involves patient dispositions at the end of the shift, patient final dispositions and patient 72-hour ED return. The EPs were categorized into the following 3 groups according to seniority: junior group (≤5 years of work experience), intermediate group (6-10 years) and senior group (>10 years). RESULTS: The dispositions of 68,333 ED patients as determined by the 59 full-time EPs were studied. Compared to junior and intermediate EPs, senior EPs kept more patients in the ED (2.7% more than junior EP, 2.3% more than intermediate EP); they had the lowest patient mortality rate especially in first triage patients (3.4% fewer than junior EP, 1.3% fewer than intermediate EP); they took more time for patient discharge (0.2 more hours than junior EP, 0.1 more hours than intermediate EP); they had fewer patients return to the ED within 72 hours after discharge (0.5% fewer than junior EP, 0.3% fewer than intermediate EP). CONCLUSIONS: Senior EPs had the best quality of care (lowest mortality, fewest 72-hour returns). This best quality of care is accompanied with a slightly longer length of stay.

Use of simple clinical and laboratory predictors to differentiate influenza from dengue and other febrile illnesses in the emergency room.

BACKGROUND: Clinical differentiation of influenza from dengue and other febrile illnesses (OFI) is difficult, and available rapid diagnostic tests have limited sensitivity. METHODS: We conducted a retrospective study to compare clinical and laboratory findings between (i) influenza and dengue and (ii) influenza and OFI. RESULTS: Of 849 enrolled patients, the mean time between illness onset and hospital presentation was 1.7, 3.7, and 3 days for influenza, dengue, and OFI, respectively. Among pediatric patients (≤18 years) (445 influenza, 24 dengue, and 130 OFI), we identified absence of rashes, no leukopenia, and no marked thrombocytopenia (platelet counts <100 × 10(9) cells/L) as predictors to distinguish influenza from dengue, whereas rhinorrhea, malaise, sore throat, and mild thrombocytopenia (platelet counts 100-149 × 10(9)/L) were predictors that differentiated influenza from OFI. Among adults (>18 years) (81 influenza, 124 dengue, and 45 OFI), no leukopenia and no marked thrombocytopenia distinguished influenza from dengue, while rhinorrhea and malaise differentiated influenza from OFI. A diagnostic algorithm developed to distinguish influenza from dengue using rash, leukopenia, and marked thrombocytopenia showed >90% sensitivity to identify influenza in pediatric patients. CONCLUSIONS: This study identified simple clinical and laboratory parameters that can assist clinicians to distinguish influenza from dengue and OFI. These findings may help clinicians diagnose influenza and facilitate appropriate management of affected patients, particularly in resource-poor settings.

Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department.

INTRODUCTION: The adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission varies across studies. This study proposed a model to define "delayed admission", and explored the effect of ICU-waiting time on patients' outcome. METHODS: This retrospective cohort study included non-traumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU-waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cut-off point between "delayed" and "non-delayed", subsets from the overall data were made based on ICU-waiting time and the hazard ratio of ICU-waiting hour in each subset was iteratively calculated. The cut-off time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay. RESULTS: The final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU-waiting time in ED > 4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21 ventilator-days mortality and prolonged hospital stay, with odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively. CONCLUSIONS: For patients on mechanical ventilation at the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

Risk factors for complications after a foreign body is retained in the esophagus.

BACKGROUND: Foreign body (FB) ingestion is a common problem presenting to the emergency department (ED). The standard treatment, removal by endoscopy, is well established. However, some patients may refuse this invasive procedure due to their fear of an uncomfortable or painful experience. Obtaining hard evidence of potential complications of not having the FB removed by endoscopy would be helpful in convincing patients to have the procedure. OBJECTIVES: The aim of this study was to identify the risk factors for developing complications after FB ingestion. MATERIALS AND METHODS: The study was conducted over a period of 1 year (April 1, 2006 through March 31, 2007) at a referral medical center. Potential risk factors for developing complications (e.g., age, gender, type of FB, positive finding on radiography) were retrospectively evaluated in patients presenting with esophageal FBs and analyzed using chi-squared or Fisher's exact test and logistic regression. RESULTS: A total of 225 patients were included. Fish bones were found to be the most common FBs (73.4%). The most commonly affected site was the oropharynx (64.5%). The complication rate was 9.7%. Risk factors for complications after FB ingestion were: 1) time interval over 24 h between FB ingestion and presenting to the ED; 2) a positive radiographic finding; 3) age > 50 years. CONCLUSION: If a patient presents to the ED with at least one of the three risk factors identified, it is strongly suggested that the patient undergo endoscopy to remove the FB due to a higher risk for developing complications.

Barriers to surge capacity of an overcrowded emergency department for a serious foodborne disease outbreak.

OBJECTIVE: The purpose of this study was to investigate barriers to surge capacity of an overcrowded emergency department (ED) for a foodborne disease outbreak (FBDO) and to identify solutions to the problems. DESIGN: The emergency response of an overcrowded ED to a serious FBDO with histamine fish poisoning was reviewed. SETTING: The ED of a tertiary academic medical centre (study hospital) with 1600 acute beds in southern Taiwan. RESULTS: Among the 346 patients in the outbreak, 333 (96.2%) were transferred to the study hospital without prehospital management within about 2 h. The most common symptoms were dizziness (58.9%), nausea and vomiting (36.3%). 181 patients (54.4%) received intravenous fluid infusion and blood tests were ordered for 82 (24.6%). All patients were discharged except one who required admission. The prominent problems with surge capacity of the study hospital were shortage of spare space in the ED, lack of biological incident response plan, poor command system, inadequate knowledge and experience of medical personnel to manage the FBDO. CONCLUSIONS: Patients with FBDO could arrive at the hospital shortly after exposure without field triage and management. The incident command system and emergency operation plan of the study hospital did not address the clinical characteristics of the FBDO and the problem of ED overcrowding. Further planning and training of foodborne disease and surge capacity would be beneficial for hospital preparedness for an FBDO.

Hemorrhagic bullae represent an ominous sign for cirrhotic patients.

Hemorrhagic bullae are a clinical manifestation of many underlying diseases, especially soft-tissue infection. The aim of this study was to evaluate the characteristics and prognosis of cirrhotic patients with hemorrhagic bullae. Fifteen patients with liver cirrhosis and hemorrhagic bullae had been admitted to Chang Gung Memorial Hospital, Kaohsiung, from January to December 2003. Their clinical courses were retrospectively reviewed in detail and all of the collected data were analyzed. This study puts emphasis on the clinical presentation and outcome of these cases. The mean age of patients was 55.0 +/- 12.1 years, and 12 patients were male. Prostration and unusual extremity pain were the two leading reasons to visit our Emergency Department. The hemorrhagic bullae were located on the upper or lower extremities and in one patient, on the whole body. In this series all hemorrhagic bullae were infection-related. Although aggressive treatment was started immediately upon arrival, 14 patients died of overwhelming sepsis and 12 patients died within 48 h from the emergence of hemorrhagic bullae. Hemorrhagic bullae in cirrhotic patients usually imply a fatal infection and Gram-negative bacteria are the most common pathogen. Appropriate antimicrobial therapy and early surgical intervention are necessary to achieve survival in these patients.