Editor’s note: Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals, and are not peer reviewed or edited by Hong Kong Journal of Emergency Medicine.
The burden of intentional self-poisoning on a district-level public Hospital in Cape Town, South Africa
Van Hoving DJ, Hunter LD, Gerber RJ, Lategan HJ, Marks CJ
Afr J Emerg Med 2018;8(3):79-83 https://doi.org/10.1016/j.afjem.2018.03.002
Introduction: Intentional self-poisoning is a significant part of the toxicological burden experienced by emergency centres. The aim of this study was to describe all adults presenting with intentional self-poisoning over a six-month period to the resuscitation unit of Khayelitsha Hospital, Cape Town.
Methods: Adult patients with a diagnosis of intentional self-poisoning between 1 November 2014 and 30 April 2015 were retrospectively analysed after eligible patients were obtained from the Khayelitsha Hospital Emergency Centre database. Missing data and variables not initially captured in the database were retrospectively collected by means of a chart review. Summary statistics were used to describe all variables.
Results: A total of 192 patients were included in the analysis. The mean age was 27.3 years with the majority being female (n = 132, 68.8%). HIV-infection was a comorbidity in 39 (20.3%) patients, while 13 (6.8%) previously attempted suicide. Presentations per day of the week were almost equally distributed while most patients presented after conventional office hours (n = 152, 79.2%), were transported from home (n = 124, 64.6%) and arrived by ambulance (n = 126, 65.6%). Patients spend a median time of 3h37m in the resuscitation unit (interquartile range 1 h 45 m–7 h 00 m; maximum 65 h 49 m). Patient acuity on admission was mostly low according to both the Triage Early Warning Score (non-urgent n = 100, 52.1%) and the Poison Severity Score (minor severity n = 107, 55.7%). Pharmaceuticals were the most common type of toxin ingested (261/343, 76.1%), with paracetamol the most frequently ingested toxin (n = 48, 25.0%). Eleven patients (5.7%) were intubated, 27 (14.1%) received N-acetylcysteine, and 18 (9.4%) received benzodiazepines. Fourteen (7.3%) patients were transferred to a higher level of care and four deaths (2%) were reported.
Discussion: Intentional self-poisoning patients place a significant burden on emergency centres. The high percentage of low-grade acuity patients managed in a high-acuity area is of concern and should be investigated further.
Annals of Emergency Medicine
(The print version of this article has been scheduled for March 2019)
Oral Ondansetron Administration to Nondehydrated Children With Diarrhea and Associated Vomiting in Emergency Departments in Pakistan: A Randomized Controlled Trial
Stephen B. Freedman, Sajid B. Soofi, Andrew R. Willan, Sarah Williamson-Urquhart, Noshad Ali, Jianling Xie, Fady Dawoud, Zulfiqar A. Bhutta
Study objective: We determine whether single-dose oral ondansetron administration to children with vomiting as a result of acute gastroenteritis without dehydration reduces administration of intravenous fluid rehydration.
Methods: In this 2-hospital, double-blind, placebo-controlled, emergency department–based, randomized trial conducted in Karachi Pakistan, we recruited children aged 0.5 to 5.0 years, without dehydration, who had diarrhea and greater than or equal to 1 episode of vomiting within 4 hours of arrival. Patients were randomly assigned (1:1), through an Internet-based randomization service using a stratified variable-block randomization scheme, to single-dose oral ondansetron or placebo. The primary endpoint was intravenous rehydration (administration of ≥20 mL/kg of an isotonic fluid during 4 hours) within 72 hours of randomization.
Results: Participant median age was 15 months (interquartile range 10 to 26) and 59.4% (372/626) were male patients. Intravenous rehydration use was 12.1% (38/314) and 11.9% (37/312) in the placebo and ondansetron groups, respectively (odds ratio 0.98; 95% confidence interval [CI] 0.60 to 1.61; difference 0.2%; 95% CI of the difference −4.9% to 5.4%). Bolus fluid administration occurred within 72 hours of randomization in 10.8% (34/314) and 10.3% (27/312) of children administered placebo and ondansetron, respectively (odds ratio 0.95; 95% CI 0.56 to 1.59). A multivariable regression model fitted with treatment group and adjusted for antiemetic administration, antibiotics, zinc prerandomization, and vomiting frequency prerandomization yielded similar results (odds ratio 0.91; 95% CI 0.55 to 1.53). There was no interaction between treatment group and age, greater than or equal to 3 stools in the preceding 24 hours, or greater than or equal to 3 vomiting episodes in the preceding 24 hours.
Conclusion: Oral administration of a single dose of ondansetron did not result in a reduction in intravenous rehydration use. In children without dehydration, ondansetron does not improve clinical outcomes.
Sex-specific high-sensitivity cardiac Troponin T cut-off concentrations for ruling out acute myocardial infarction with a single measurement
Andrew McRae MD, PhD, FRCPC, Michelle Graham MD, MSc, FRCPC, Tasnima Abedin MSc1, Yunqi Ji PhD, Hong Yang MSc, Dongmei Wang MSc, Danielle Southern MSc, James Andruchow MD, MSC, FRCPC, Eddy Lang MD, CCFP(EM), Grant Innes MD, MSc, FRCPC, Isolde Seiden-Long PhD, Lawrence DeKoning PhD, Peter Kavsak PhD
CJEM 2019, 21(1), 26-33
doi.org/10.1017/cem.2018.435
Abstract
Background: Sex-specific diagnostic cutoffs may improve the test characteristics of high-sensitivity troponin assays for the diagnosis of myocardial infarction (MI). The objective of this study was to quantify test characteristics of sex-specific cutoffs of a single hs-cTnT assay for 7-day MI in patients with chest pain.
Methods: This observational cohort study included consecutive ED patients with suspected cardiac chest pain from four Canadian EDs who had a hs-cTnT assay performed within 60 minutes of ED arrival. The primary outcome was MI at 7 days. We quantified test characteristics (sensitivity, negative predictive value, likelihood ratios and proportion of patients ruled out) for multiple combinations of sex-specific rule-out cutoffs. We calculated the net reclassification index compared to universal rule-out cutoffs.
Results: In 7130 patients (3931 men and 3199 women), the 7-day MI incidence was 7.38% among men and 3.78% among women. Optimal sex-specific cutoffs (<8g/L for men and <7ng/L for women) were 98.5% sensitive for MI and ruled out MI in 55.8% of patients. This would enable an absolute increase in the proportion of patients able to be ruled out with a single hs-cTnT of 13.2-22.2%, depending on the universal rule-out concentration used as a comparator.
Conclusions: Sex-specific hs-cTnT cutoffs for ruling out MI at ED arrival may improve classification performance, enabling more patients to be safely ruled out at ED arrival. However, differences between sex-specific and universal cutoff concentrations are within the variation of the assay, limiting the clinical utility of this approach. These findings should be confirmed in other datasets.
Patients with acute heart failure discharged from the emergency department and classified as low risk by the MEESSI score (multiple risk estimate based on the Spanish emergency department scale): prevalence of adverse events and predictability
Òscar Miró, Víctor Gil, Xavier Rosselló, Francisco Javier Martín-Sánchez, Pere Llorens, Javier Jacob,Pablo Herrero, Sergio Herrera Mateo, Fernando Richard, Rosa Escoda, Marta Fuentes, Enrique Martín Mojarro, Lluís Llauger, Héctor Bueno, Stuart Pocock, en representación del grupo ICA-SEMES
Cited: Miró O, Gil V, Rosselló X, Martín-Sánchez FJ, Llorens P, Jacob J, et al. Patients with acute heart failure discharged from the emergency department and classified as low risk by the MEESSI score: prevalence of adverse events and predictability Emergencias. 2019;31:5-14.
http://emergencias.portalsemes.org/descargar/eventos-adversos-en-pacientes-con-insuficiencia-cardiaca-aguda-clasificados-de-bajo-riesgo-por-la-escala-meessi-y-dados-de-alta-desde-urgencias-cuantificacin-y-predictibilidad/
Objective. To determine the rate of adverse events in patients with acute heart failure (AHF) who were discharged from the emergency department (ED) after classification as low risk according to MEESSI score (multiple risk estimate based on the Spanish ED scale), to analyze the ability of the score to predict events, and to explore variables associated with adverse events.
Methods. Patients in the EAHFE registry (Epidemiology of Acute Heart Failure in EDs) were stratified according to risk indicated by MEESSI score in order to identify those considered at low risk on discharge. All-cause 30-day mortality and revisits related to AHF within 7 days and 30 days were recorded. The area under the receiver operating characteristic curve (AUC) was calculated for the MEESSI score’s ability to predict these events. Associations between 42 variables and 7-day and 30-day revisits to the ED were analyzed by multivariable logistic regression.
Results. A total of 1028 patients were included. The 30-day mortality rate was 1.6% (95% CI, 0.9%–2.5%). The 7-day and 30-day revisit rates were 8.0% (95% CI, 6.4%–9.8%) and 24.7% (95% CI, 22.1%–25.7%), respectively. The AUCs for MEESSI score discrimination between patients with and without these outcomes were as follows: 30-day mortality, 0.69 (95% CI, 0.58–0.80); 7-day revisiting, 0.56 (95% CI, 0.49–0.63); and 30-day revisiting, 0.54 (95% CI, 0.50–0.59). Variables associated with 7-day revisits were long-term diuretic treatment (odds ratio [OR], 2.45; 95% CI, 1.01–5.98), hemoglobin concentration less than 110 g/L (OR, 1.68; 95% CI, 1.02–2.75), and intravenous diuretic treatment in the ED (OR, 0.53; 95% CI, 0.31–0.90). Variables associated with 30-day revisits were peripheral artery disease (OR, 1.74; 95% CI, 1.01–3.00), prior history of an AHF episode (OR, 1.42; 95% CI, 1.02–1.98), long-term mineralocorticoid receptor antagonist treatment (OR, 1.71; 95% CI, 1.09–2.67), Barthel index less than 90 points in the ED (OR, 1.48; 95% CI, 1.07–2.06), and intravenous diuretic treatment in the ED (OR, 0.58; 95% CI, 0.40–0.84).
Conclusions. Patients with AHF who are at low risk for adverse events on discharge from our EDs have event rates that are near internationally recommended targets. The MEESSI score, which was designed to predict 30-day mortality, is a poor predictor of 7-day or 30-day revisiting in these low-risk patients. We identified other factors related to these events.
A simple clinical assessment is superior to systematic triage in prediction of mortality in the emergency department
Anne Kristine Servais Iversen,1 Michael Kristensen,2 Rebecca Monett Ostervig,3
Lars Kober,4 Gyorgy Soletormos,5 Jakob Lundager Forberg,6 Jesper Eugen-Olsen,7
Lars Simon Rasmussen,3 Morten Schou,8 Kasper Karmark Iversen
Emerg Med J
doi:10.1136/emermed-2016-206382
Abstract
Objective To compare the Danish Emergency Process Triage (DEPT) with a quick clinical assessment (Eyeball triage) as predictors of short-term mortality in patients in the emergency department (ED).
Methods The investigation was designed as a prospective cohort study conducted at North Zealand University Hospital. All patient visits to the ED from September 2013 to December 2013 except minor injuries were included. DEPT was performed by nurses. Eyeball triage was a quick non-systematic clinical assessment based on patient appearance performed by phlebotomists. Both triage methods categorized patients as green (not urgent), yellow, orange or red (most urgent). Primary analysis assessed the association between triage level and 30-day mortality for each triage method. Secondary analyses investigated the relation between triage level and 48-hour mortality as well as the agreement between DEPT and Eyeball triage.
Results A total of 6383 patient visits were included. DEPT was performed for 6290 (98.5%) and Eyeball triage for 6382 (~100%) of the patient visits. Only patients with both triage assessments were included. The hazard ratio (HR) for 48-hour mortality for patients categorised as yellow was 0.9 (95% CI 0.4 to 1.9) for DEPT compared with 4.2 (95% CI 1.2 to 14.6) for Eyeball triage (green is reference). For orange the HR for DEPT was 2.2 (95% CI 1.1 to 4.4) and 17.1 (95% CI 5.1 to 57.1) for Eyeball triage. For red the HR was 30.9 (95% CI 12.3 to 77.4) for DEPT and 128.7 (95% CI 37.9 to 436.8) for Eyeball triage. For 30-day mortality the HR for patients categorised as yellow was 1.7 (95% CI 1.2 to 2.4) for DEPT and 2.4 (95% CI 1.6 to 3.5) for Eyeball triage. For orange the HR was 2.6 (95% CI 1.8 to 3.6) for DEPT and 7.6 (95% CI 5.1 to 11.2) for Eyeball triage, and for red the HR was 19.1 (95% CI 10.4 to 35.2) for DEPT and 27.1 (95% CI 16.9 to 43.5) for Eyeball triage. Agreement between the two systems was poor (kappa 0.05).
Conclusion Agreement between formalised triage and clinical assessment is poor. A simple clinical assessment by phlebotomists is superior to a formalised triage system to predict short-term mortality in ED patients.
