Prevalence of abnormal cranial CT scan in Nontraumatic headache patients with red flag symptoms at the emergency department in Hospital Universiti Sains Malaysia.

INTRODUCTION: Data on the prevalence of nontraumatic headaches with red flag symptoms in Asia are sparse. Therefore, the objectives of this study were to determine the final diagnosis and prevalence of abnormal CT scans in patients who presented to the emergency department (ED) with red flag symptoms. MATERIALS AND METHODS: This was a retrospective study based on the Radiology Department database of patients who presented to the ED with complaints of nontraumatic headache, had red flag symptoms, and underwent cranial CT scans. The inclusion criteria were adult patients presenting through the ED with nontraumatic headache who underwent cranial CT scans. Multivariate analysis was performed based on logistic regression to analyse the significance of the predictive value for abnormal CT scans. RESULTS: A total of 216 patients underwent cranial CT scans in the ED. More than half of the cases (53.7%) were male. A total of 146 patients (67.6%) had no obvious abnormalities in the CT scans, while 41 patients (19.0%) had cranial infarction, 9 patients (4.2%) had intracranial bleeding, and 20 patients (9.3%) had brain tumours. The most common diagnosis was primary headache syndrome, followed by cerebral vascular accident (CVA). Multivariate analysis showed that three factors were associated with abnormal CT scans: age, systolic blood pressure (SBP), and mean arterial pressure (MAP). New onset of headache at the age of 50 years or older (Odds Ration, OR 3.21, 95% Confidence Interval, CI 1.15, 8.94), SBP (OR 4.82. 95%CI 2.29, 10.40) and MAP (OR 6.21, 95%CI 2.71, 14.70) were significant. CONCLUSION: The prevalence of abnormal CT scan findings in nontraumatic headache patients with red flag symptoms was 32%. Primary headache syndrome is the most common diagnosis. An age greater than 50 years old during the onset of headache, SBP greater than 180mmHg and MAP greater than 120mmHg were associated with a higher risk of abnormal cranial CT scans.

Brain tumour in adolescents and young adults: Challenges in making the diagnosis for frontliners.

No abstract available.

Factors associated with severe envenomation of snakebite cases at emergency department, Hospital Sultan Abdul Halim, Kedah, Malaysia.

INTRODUCTION: Snakebite envenomation is a medical emergency and cases continue to be encountered in Malaysian hospitals. This study aims to determine the prevalence of snakebite presentations and the associated factors with severe envenomation of snakebite in Sungai Petani, Kedah, Malaysia. MATERIALS AND METHODS: This was a retrospective, crosssectional study involving snakebite patients presented at the Emergency Department (ED), Hospital Sultan Abdul Halim (HSAH), Kedah from 1 July 2015 to 30 June 2019. The cases were extracted from the computerized system and the case records of patients were retrieved from the Medical Record Unit. Patients that met the study criteria were included and their sociodemographic features, clinical presentations including use of anti-venom were collected. Logistic regression analysis was performed to determine the factors associated with severe envenomation. RESULTS: A total of 220 snakebite cases with the mean age of patients was 39.66 (SD±21.79) years old. Majority of them were Malay and males. 41.4% of snakebite cases occurred in late evenings and the mean time-lapsed to arrive at HSAH was 108.6 minutes. 81.4% of snakebite cases occurred while engaging in outdoor activities and 43.6% of the snakebite cases involved work-related incidents. 58.2% of the patients were bitten in the lower limb. 78.6% of patients were bitten by the identified snake species, predominantly from Viperidae family. The prevalence of severe envenomation was 50.9%. Malay ethnicity (adj. OR =2.549, 95% CI =1.277,5.089), bite to the upper limb (adj. OR =2.125, 95% CI =1.192, 3.790), and bite by snakes from Viperidae family (adj. OR =3.017, 95% CI =1.613, 5.642) were found to have significant associations with severe envenomation of snakebite. CONCLUSION: The prevalence of severe envenomation was more than 50% of snakebite cases. Malay ethnicity, upper limb snake bites, and snakebite from a Viperidae family had a higher chance of severe envenomation.

Milk-alkali syndrome: The forgotten diagnosis for altered sensorium.

Milk-alkali syndrome (MAS) is one of the causes of hypercalcaemia. We report a case of a 75-year-old lady with a history of thyroidectomy, presented with an altered mental state and had an extremely high calcium concentration of 4.96mmol/L. The hypercalcemia was attributed to the ingestion of large doses of calcium supplements, including calcium carbonate and calcium lactate, leading to MAS. She was managed with intravenous fluids, diuretics and withdrawal of calcium supplements. The patient responded well to treatment and regained consciousness. Details of the case including clinical presentations, electrocardiogram (ECG) findings and treatment plan, are discussed in this article.

Outcome of acute ischaemic stroke patients after intravenous alteplase in Hospital Universiti Sains Malaysia.

INTRODUCTION: Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) is effective in treating acute ischaemic stroke. Our primary objective is to assess the outcome of these acute ischaemic stroke (AIS) patients after IV alteplase with the modified Rankin scale (mRS). METHODS: This is a cross-sectional study in which patients receiving IV alteplase in Hospital Universiti Sains Malaysia, from January 2017 to April 2020 were recruited. Demographical data, National Institutes of Health Stroke Scale (NIHSS) scores, door-to-needle time were recorded. Modified Rankin scale (mRS) scores were evaluated at 90 days after initial therapy. Good and poor functional outcomes were defined as 0-2 and 3-6, respectively. RESULTS: A total of 30 patients were included in the study with a mean age of 59±11.47 years old. 76.7% of them were male and the rest were female. From the study, onset-toneedle time was 197.47±51.74 minutes, whereas door-toneedle time was 120.93±53.63 minutes. Seventeen (56.3%) patients achieved a favourable score of 0-2 on the mRS at 90 days after treatment. Haemorrhagic transformation occurred in eight (26.7%) of the patients with a mortality rate of 13.3%. CONCLUSION: 56.7% of our patients showed improvement in the mRS at 90 days post thrombolysis for AIS. Higher baseline NIHSS scores and diabetes mellitus were associated with poorer functional outcomes after thrombolysis.

Iced towel - a novel method to revert supraventricular tachycardia in a paediatric patient.

Supraventricular tachycardia (SVT) is the commonest tachyarrhythmia among paediatric age group. Modified Valsalva manoeuvre can be attempted in a stable child. We discuss here a case of a 6-year-old boy who presented with stable SVT and iced towel was applied to his face to revert the tachyarrhythmia. This method was well tolerated by the child without any complications. The SVT was successfully reverted, and pictures were taken to capture the simple but effective method.

Elephant attack - A rare case of survival.

Conflict of human-wild elephant is not uncommon in Malaysia. Most of the human victims usually succumb to death due to internal organ injuries. Here we report a case of a woman who was the victim of an elephant attack and successfully survived to share our experience in managing this type of polytrauma.

Acute compartment syndrome of the forearm: A case report of radius fracture with concomitant brachial artery transaction.

Acute compartment syndrome (ACS) is a surgical emergency that requires timely recognition and early management for a good outcome. We report a case of a 71- year-old male seen at the Emergency Department of Universiti Sains Malaysia (USM), Malaysia, on anticoagulant therapy for valvular atrial fibrillation, who had sustained a closed fracture of the left distal end radius following a fall. Examination of the left upper limb showed deformity and tenderness over the left wrist, associated with swelling and a tense anterior compartment with blisters formation and rapid expansion of hematoma at the cubital fossa away from the fracture site. Both radial and brachial pulses were absent and confirmed with the absence of a doppler signal over the brachial and radial artery and CT angiography of the left upper limb showed there was a vascular injury of the brachial artery. Fasciotomy of the left upper limb and revascularization of the left brachial artery was done. Intraoperative findings showed a tight anterior compartment with muscle bulging upon compartment release with a complete cut of the left distal brachial artery. The primary end-to-end vascular anastomosis was done and distal circulation was restored. The distal end radius fracture was treated conservatively. The patient underwent split skin grafting of the left forearm after 6 weeks post-injury and went home well. It is critical to recognize a concomitant vascular injury in fracture-related ACS as the clinical feature may overlap. Failure in detection of concomitant vascular injury may lead to emergency fasciotomy without vascular exploration and repair.

Hyperkalemia measurement between Blood Gas Analyser and Main Laboratory Biochemistry Analyser.

INTRODUCTION: Potassium level is measured for patients with high risk of hyperkalemia in the emergency department (ED) using both blood gas analyser (BGA) and biochemistry analyser (BCA). The study was conducted to evaluate the correlation and agreement of potassium measurement between BGA and BCA. MATERIALS AND METHODS: This is a prospective cross-sectional study on the data obtained from Hospital Universiti Sains Malaysia (Hospital USM) from Jun 2018 until May 2019. Blood samples were taken via a single prick from venous blood and sent separately using 1ml heparinised syringe and were analysed immediately in ED using BGA (Radiometer, ABL800 FLEX, Denmark) and another sample was sent to the central laboratory of Hospital USM and analysed by BCA (Architect, C8000, USA). Only patients who had potassium levels ≥5.0mmol/L on blood gas results were included. A total of 173 sample pairs were included. The correlation and agreement were evaluated using Passing and Bablok regression, Linear Regression and Bland-Altman test. RESULT: Of the 173 sample pairs, the median of potassium level based on BGA and BCA were 5.50mmol/L (IQR: 1.00) and 5.90mmol/L (IQR: 0.95) respectively. There was significant correlation between two measurements (p<0.001, r: 0.36). The agreement between the two measurements showed within acceptable mean difference which was 0.27 mmol/L with 95% limit of agreement were 1.21mmol/L to 1.73mmol/L. CONCLUSION: The result of blood gas can be used as a guide for initial treatment of hyperkalaemia in critical cases where time is of the essence. However, BCA result is still the definitive value.

Ultrasound findings of plasma leakage as imaging adjunct in clinical management of dengue fever without warning signs.

INTRODUCTION: Plasma leakage is a major cause of morbidity and mortality in dengue fever. Few studies have shown the sensitivity of thoracoabdominal ultrasound in detecting plasma leakage in severe dengue, however its sensitivity in the early presentation of dengue fever without warning signs remains unknown. This study is aimed to determine the role of serial ultrasound in order to detect plasma leakage in dengue fever without warning signs. METHODS: This prospective cohort study was conducted at Hospital Universiti Sains Malaysia (USM) from 1st October 2016 to 30th November 2017. Serial bedside ultrasound procedures were performed for 83 patients who were diagnosed as having dengue fever without warning signs and were initially treated as outpatients. Ultrasonography evidence of plasma leakage either pleural effusion, thickened gallbladder wall, ascites or pericardial effusion were compared with clinical findings and laboratory parameters for plasma leakage. RESULTS: Of the 83 dengue patients, eventually 72.3% had dengue fever with warning signs and 6.0% had severe dengue fever. There were 38 patients who had subclinical plasma leakage at initial presentation, 84.2% and 7.9% of them then progressed to dengue fever with warning signs and severe dengue respectively. There was a minimal agreement between serial bedside ultrasound and haematocrit level in the detection of plasma leakage (observed kappa 0.135). CONCLUSIONS: Serial bedside ultrasound is an adjunct procedure to physical examination and may detect plasma leakage earlier compared to haemoconcentration. The early usage of serial ultrasound is of paramount importance in detecting dengue patients who are at risk of progressing to severe dengue.

Study on the incidence of adverse events during intra-hospital transfer of critical care patients from emergency department.

INTRODUCTION: Emergency department (ED) plays a main role in the initial management of patients who are critically ill. These patients require intra-hospital transfer for continuation of care. Adverse events can occur during this short duration and the distance of intra -hospital transfer. The aims of this study were to determine the incidence of adverse events during intrahospital transfer from ED and to determine the factors associated. METHODOLOGY: This was a cross-sectional observational study done from November 2017 until December 2017 at ED Hospital Sultan Abdul Halim (HSAH), a 650-bedded tertiary hospital in the state of Kedah. All patients that were triaged to red zone, age 18 years and above, and involved in intra-hospital transfer to critical coronary unit, intensive care unit and wards were included. All cases were documented in proforma by the accompanying staff. RESULTS: Among the 170 critically ill patients, only 29 patients (17.1%) experienced adverse events during intra-hospital transfer. The adverse events seen were hypotension (12.4%), desaturation (3.5%) and dislodged peripheral line (2.4%). Cardiorespiratory related diagnosis was the commonest presentation. Intra-hospital transfer during morning shift and evening shift has 79.5% (b=-1.59, OR=0.21, 95% CI: 0.06, 0.69, p=0.011) and 75.6% ((b=-1.41, OR=0.24, 95% CI: 0.08, 0.73, p=0.012) lesser odds of experiencing adverse events compare to night shift. Patients with vasopressor/inotropes had 9 times higher odds of experiencing adverse events during transportation, compared to patients with no vasopressor/inotropes (b=2.27, OR=9.70, 95% CI: 3.39, 27.72, p<0.001). CONCLUSIONS: Critical care patients who are involved in intrahospital transfer were at risk of adverse events such as hypotension, desaturation and dislodge peripheral line. Risk identification and maintaining level of care is important to minimize the adverse events during transfer. Patients had higher rates of adverse events if they were transferred during night shifts and on inotropic/vasopressor support.