Abstract
O001
Cost-effectiveness of an accelerated diagnostic protocol incorporating heart rate n-variability versus traditional chest pain diagnostic protocol: a decision tree model-based study
Yong Loo Lin School of Medicine, Singapore
O002
Pre-hospital airway management and survival outcomes after pediatric out-of-hospital cardiac arrests
1Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
2Duke-NUS Medical School, Singapore
3Singapore General Hospital, Singapore
4Kokushikan University, Tokyo, Japan
5Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
6National Taiwan University Hospital, Taipei, Taiwan
7Hospital Pulau Pinang, Penang, Malaysia
8Rajavithi Hospital, Bangkok, Thailand
9GVK Emergency Management and Research Institute (GVK EMRI), Secunderabad, India
10Zhejiang Provincial People’s Hospital, Hangzhou, China
11National Ambulance, Abu Dhabi, United Arab Emirates
12Singapore General Hospital, Singapore
Outcomes of comparison of AAM with BVM in the overall unmatched cohort and in the propensity score matched cohort.
AAM: advanced airway management; BVM: bagged valve mask ventilation; aOR: adjusted odds ratio; CI: confidence interval; CPC: Cerebral Performance Scale; SGA: supraglottic airway; ETI: endotracheal intubation; EMS: emergency medical services; ROSC: return of spontaneous circulation.
Adjusted for age, gender, EMS transport, location of arrest, witnessed status, bystander cardiopulmonary resuscitation, pre-hospital defibrillation, pre-hospital drug administration, EMS response time (time of call to time of ambulance arriving at scene), initial arrest rhythm, cause of arrest, and pre-hospital ROSC (at scene and en route).
O003
Emergency call diversion as a solution to emergency department overcrowding: a system dynamics approach
1Health Systems and Services Research, Duke-NUS Medical School, Singapore
2Duke-NUS Medical School, Singapore
00 overall calls, about 18,000 calls to the Singapore Civil Defence Force (SCDF) Emergency Medical Services were non-emergencies, while 23,000 were life-and-death cases. Non-emergency calls can take up response capacity and delay response to life-threatening emergencies. As a result, policy makers are considering Alternate Care Service Pathways (ACSPs) for low-acuity patients. The intent is that ACSPs (Telehealth Nurses, At Scene Care, and Alternate Care Facilities) will provide care without taking the patients to the emergency department (ED). Evaluation of ACSPs is challenging, given the critical nature of ED services. Our Objective is to develop a model for in silico simulation of ACSPs.
O004
Trauma in older versus younger adults: a comparison of the characteristics and outcomes of trauma patients in the Pan-Asian Trauma Outcome Study (PATOS)
1Department of Emergency Medicine, Faculty of Medicine, Universiti Teknologi Mara (UiTM), Selangor, Malaysia
2Faculty of Medicine, Universiti Teknologi Mara (UiTM), Selangor, Malaysia
3Department of Emergency Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, South Korea
4Yale Emergency Medicine, Yale-New Haven Hospital, New Haven, CT, USA
5Department of Emergency Medicine, Seoul National University College of Medicine and Hospital, Seoul, South Korea
6Woodlands Health Campus, Singapore
Factors associated with hospital mortality using multiple logistic regression for patients age ⩾65 years old.
OR: odds ratio; CI: confidence interval; NS: not significant.
Significant (p < 0.05).
O005
Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis
Australian Catholic University, Australia
O006
NEWS2 is superior to qSOFA in predicting mortality in sepsis patients presenting to the emergency department in India
1Department of Emergency Medicine, Max Super Specialty Hospital, New Delhi, India
2Max Super Specialty Hospital, New Delhi, India
O007
Clinical impact of the injury onset to surgical time interval on survival after severe traumatic brain injury
1Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
2Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
O008
Chest radiograph screening of lung nodules by artificial intelligence algorithm enabling real-time decision support in emergency departments
1Department of Accident & Emergency, Tin Shui Wai Hospital, Tin Shui Wai, Hong Kong SAR
2Tin Shui Wai Hospital, Tin Shui Wai, Hong Kong SAR
3Tuen Mun Hospital, Tuen Mun, Hong Kong SAR
4Queen Mary Hospital, Pok Fu Lam, Hong Kong SAR
5Hospital Authority Head Office, Hi&It, Hong Kong SAR
O009
Performance of CHOSEN score on the discharge of COVID-19 patients
1Department of Emergency Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
2Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
COVID-19 is a systemic disease with SARS-CoV-2-induced acute respiratory tract involvement with variable mortality and morbidity. It is at the forefront of health center applications all over the world, which started in December 2019 and was accepted as a pandemic by the World Health Organization. Deciding hospitalization or isolation at home during a pandemic is an essential process for predicting mortality. The CHOSEN (COVID Home Safely Now) risk score has emerged because of the densities experienced in hospitals and the physicians’ decision to be discharged from patient clinics. Our aim in this study is to investigate the performance of the CHOSEN score in predicting the prognosis in COVID-19 patients.
O010
Application of heart rate variability for real-time risk stratification in acute heart failure
Medicine, Duke-NUS, Taiwan
Existing outcome-prediction scoring systems for acute heart failure (AHF) in the emergency department (ED) are reliant upon the complicated collection of numerous variables. This study aims to validate and improve a simplified triage scoring system using both common factors (e.g. vitals/clinical signs) and a novel factor: heart rate variability (HRV) to predict major adverse cardiac events (MACEs) within 30 days.
Clinically diagnosed AHF patients presenting at the Singapore General Hospital (SGH) ED from September 2019 to December 2020 were recruited. All patients undertook a 5 min electrocardiogram (ECG) recording to derive HRV parameters. They subsequently had a 30-day MACE outcomes assessment. The performance of newly developed HRV-included (HRVi) model was validated using leave-one-out cross-validation (LOOCV) analysis and compared with our previously developed model. Random forest was also applied for comparison. Due to the small size of research subjects, full data were used in both training and testing model in random forest analysis.
Out of 230 patients, 172 were included in this study, 20% of whom met the primary MACE outcomes. Comparing our new, HRVi model, to the pilot one, the HRVi model outperformed with an area under the curve (AUC) value of 0.724 (95% confidence interval (CI), 0.629–0.818) versus 0.630 (95% CI, 0.533–0.727). The six most relevant predictive variables are systolic blood pressure, pleural effusion, existing history of HF, ln(troponin), standard deviation of heart rate, and sampled entropy. After the refinement with random forest, the accuracy of the HRVi model reached 80.2%.
A triage scoring system incorporating HRV parameters may be a useful tool for predicting 30-day MACE risk in AHF patients in the ED setting. The HRVi model outperformed our pilot model. However, larger studies are required to validate these findings.
O011
Machine learning and natural language processing assisted triage for prediction of clinical disposition in emergency department
1Department of Emergency, China Medical University Hospital, Taichung, Taiwan
2National Yang Ming Chiao Tung University, Taipei, Taiwan
3China Medical University Hospital, Taichung, Taiwan
4Asia University, Taichung, Taiwan
AUC: area under curve; PPV: positive predictive value; NPV: negative predictive value; LGB: light gradient boosting; LR: logistic regression; RF: random forest classifier; ET: extra trees classifier; LR-TTAS: logistic regression—Taiwan Triage Acuity scale; EP: emergency physician.
P001
An unconscious goldsmith: acute inhalational cyanide toxicity
1Department of Emergency and Trauma, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
P002
Healthcare workers’ perception and experience toward COVID-19 nasopharyngeal swab
RIPAS Hospital, Bandar Seri Begawan, Brunei
P003
A report on 83 patients with suspected methanol poisoning from Philippine coconut wine (Lambanog) seen at East Avenue Medical Center: a case series
Emergency Medicine, East Avenue Medical Center, Quezon City, Philippines
Comparison of laboratory results with duration of ingestion.
P004
Text classification of disease syndromes from emergency department free text notes
1Group Data & Strategy Office, Tan Tock Seng Hospital, Singapore
2Tan Tock Seng Hospital, Singapore
3National Centre for Infectious Diseases, Singapore
4Ministry of Health Holdings, Singapore
This study uses an easily available, off-the-shelf open-source transformer deep neural network (TfDNN) to perform natural-language processing (NLP) of multi-label classification on EDFTN for the above four IDSs.
ARI: acute respiratory infection; GE: gastroenteritis; Acute SOB: acute febrile breathlessness; ROC: receiver operating characteristic.
P005
A girl’s downfall: acute digoxin toxicity
Department of Emergency and Trauma, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
P006
Aural foreign bodies in children—the Singapore experience: a review of 1003 cases over 4 years
KK Women’s and Children’s Hospital, Singapore
P007
Escharotomy in emergency department following 100% burn injury
Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
P008
“Potato in my heart”: an extensive hepatocellular carcinoma extending into the right heart
Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
P009
VTE risk assessment and prophylaxis in temporary lower-limb immobilization
NSW Health, St Leonards, NSW, Australia
P010
Pulmonary embolism post penile augmentation injection
Emergency and Trauma, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
P011
Where have you been—the usage of machine learning for capturing travel history
1Department of Emergency, Tan Tock Seng Hospital, Singapore
2National Centre for Infectious Diseases, Singapore
3Ministry of Health, Singapore
4Singapore Eye Research Institute, Singapore
5Tan Tock Seng Hospital, Singapore
6Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
P012
Transitioning beyond COVID-19—what lies ahead for an emergency department nurse?
1Department of Emergency, Sengkang General Hospital, Singapore
2Sengkang General Hospital, Singapore
P013
Emergency department predictors of mortality for adult patients with severe COVID-19 in a tertiary hospital: a retrospective cohort study
1Department of Emergency Medicine, St. Luke’s Medical Center-Quezon City, Quezon City, Philippines
2St. Luke’s Medical Center-Quezon City, Quezon City, Philippines
P014
Pressing problems for a primipara
Emergency Medicine, Ministry of Health Malaysia, Hospital Sultanah Bahiyah, Kedah, Malaysia
Atypical eclampsia is not an uncommon obstetrics emergency, which is characterized by mothers presenting with a new-onset seizure or coma, in the absence of hypertension and/or proteinuria. The presence of signs and symptoms of preeclampsia or laboratory abnormalities suggestive of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is sufficient to establish the diagnosis.
We herein report a case of postpartum atypical eclampsia with Posterior Reversible Encephalopathy Syndrome (PRES), in a 32-year-old primipara, presented to the emergency department at day 3 puerperium with sudden loss of vision. She reported to have multiple episodes of acephalgic migraine with scintillating blind spots. A quick check of her antenatal records revealed an uneventful pregnancy, with a 38-week-old boy born vigorously via a normal spontaneous vaginal delivery.
She was found to be normotensive and well perfused with an initial blood pressure of 129/82 mm Hg, a heart rate of 82 beats/min, in the absence of proteinuria. Within minutes, however, she had a new onset of generalized tonic-clonic seizure that lasted for 5 min, which was aborted with a loading dose of magnesium sulfate intramuscular injection. Emergent airway was secured with endotracheal intubation. Urgent laboratory investigations were reported to be within normal limits. Her electrocardiogram (ECG) and bedside point-of-care ultrasound (POCUS) were unremarkable. An urgent cranial T2-weighted magnetic resonance imaging (MRI) revealed hyperintense cortical and subcortical signals in the posterior parietal and occipital lobes, that were consistent with PRES.
Her blood pressure started rising gradually with persistently high systolic pressures of 140–150 mm Hg, and high diastolic pressures of 100–110 mm Hg, during her stay in the intensive care unit. This was controlled with intravenous labetalol infusion, which later bridged with T. amlodipine 10 mg OD. Her magnesium sulfate infusion was withheld after 24 h as she remained fit-free. Eventually, she was able to wean off ventilator support at day 5 postpartum, with a complete resolution of neurological deficits upon discharge.
Clinical vigilance must be upheld for early detection of atypical presentation of eclampsia in both expecting and postpartum mothers. Such clinical signs, once present, must warrant quick actions and timely management to improve feto-maternal outcomes.
P015
Factors associated with mortality rate in trauma patients in Luntom EMS Center, Queen Savang Vadhana Memorial Hospital
1Emergency, Queen Savang Vadhana Memorial Hospital, Si Racha, Thailand
2Queen Savang Vadhana Memorial Hospital, Si Racha, Thailand
Logistic regression correlation analysis between factors and overall hospital mortality.
Multivariable logistic regression (backward stepwise). OR: odds ratio; CI: confidence interval; SBP: systolic blood pressure; GCS: Glasgow Coma Scale; ISS: Injury Severity Score.
P016
A case report of spontaneous enterocutaneous fistula secondary to a primary transverse colon carcinoma
Emergency Medicine, East Avenue Medical Center, Quezon City, Philippines
P017
Strawberry pink blood—hypertriglyceridemia and diabetic ketoacidosis secondary to poorly controlled type II diabetes mellitus
Department of Emergency Medicine, Changi General Hospital, Singapore
A 54-year-old female with insulin-dependent Type II diabetes mellitus presented with acute shortness of breath and drowsiness on a background of polydipsia, weakness, and significant weight loss. One year prior, she had decided to stop her insulin and other medications to adopt lifestyle modifications instead. Initial emergency department (ED) blood samples appeared strawberry pink resembling a local drink “bandung.” She was eventually diagnosed with diabetic ketoacidosis (DKA) with severe hypertriglyceridemia, intubated for airway protection, and managed with fluid resuscitation and intravenous insulin to good effect.
We share an uncommon DKA presentation at the ED. History was limited as the patient was drowsy and minimally communicative. Physical examination was generally unremarkable without detection of pink skin or bright red lips. Blood investigations took up to three times the usual duration to complete as the specimens were highly lipemic and required further processing and centrifugation. This contributed initially to a paucity of information and a diagnostic challenge. When faced with abnormally colored blood in the critically ill patient, differentials include cyanide poisoning, dyshemoglobinemia (e.g. COHb, MetHb), lipemia, and drug overdose. Severe lipemia may affect the findings and accuracy of common point-of-care and laboratory tests.
P018
Rotenone Tubli: a case report
Emergency Medicine, Fatima University Medical Center, Philippines
Poison vine, known locally as Tubli in the Philippines, is used as a pesticide in both agriculture and aquaculture. Its scientific name is Derris elliptica, a member of the legume family, and contains the flavonoid rotenone in its roots and stems. Rotenone is a highly specific metabolic poison that affects cellular aerobic respiration. Reports of rotenone toxicity in humans are rare, and consequently no known specific antidote exists. This article presents a case and management options for rotenone ingestion.
A middle-aged male, presenting with 10 bouts of vomiting, restlessness, and abdominal pain, after ingesting a concoction of Tubli root, sought consultation at a highly urbanized medical center in Region 11. Diagnostic workup includes complete blood count, capillary blood glucose, bleeding parameters, renal and liver function test, serum electrolytes, arterial blood glass, urinalysis, electrocardiography, and chest radiograph. Removal of contaminated clothing, intravenous fluids, oxygen support, activated charcoal via nasogastric tube, bowel rest, intravenous famotidine, and referral to psychiatry were done. The patient was admitted, stable with no deterioration and unremarkable laboratory results. The patient opted to go home against medical advice.
PubMed was used for searching relevant literature. A total of 11 articles were reviewed. Key words searched included rotenone, Tubli, and poison vine. Short-term exposure includes irritation to eye, skin, and respiratory tract with severe drop in blood sugar. Rotenone affects cellular aerobic respiration, blocking mitochondrial electron transport by inhibiting NADH ubiquinone reductase. Death results from tissue anoxia.
Parts of the Derris plant used for solvent system extraction are the fine root, course root, and stem. Rotenone content in the root is highest. Acetone 95% (v/v) is the best solvent used for extraction of rotenone content in dried fine roots. Rotenone yield is affected by the type of solvent, part used, location, and conditions where Derris plant is obtained.
Management includes timely toxicology treatment protocol in the emergency department. Studies suggest rotenone toxicity can be prevented by the use of N-Acetylcysteine, anti-oxidants, and potassium channel openers.
P019
The unseen frontlines: perceptions and challenges of ancillary staff in the emergency department during COVID-19 pandemic
1Department of Emergency, Sengkang General Hospital, Singapore
2Sengkang General Hospital, Singapore
P020
Status epilepticus secondary to posterior reversible encephalopathy syndrome in systemic lupus erythematosus
1Department of Emergency Medicine, Philippine General Hospital, Manila, Philippines
2Philippine General Hospital, Manila, Philippines
Status epilepticus (SE) is a rare and emergent presentation of posterior reversible encephalopathy syndrome (PRES) in patients diagnosed with systemic lupus erythematosus (SLE). Common findings are headache, seizures, visual disturbance, hypertension, and altered mental status. A case of SE secondary to PRES in a lupus patient is presented in this case report. The goal is to guide the emergency department (ED) physician in the diagnosis and adequate management of this condition to avoid unnecessary costs and treatment. A 20-year-old female patient previously diagnosed with SLE with secondary end stage renal disease (ESRD) from lupus nephritis was admitted due to SE. She had acute onset headache and blurring of vision, associated with severe hypertension. Computed tomography (CT) scan revealed hypodensities in both parietal lobes and frontal corona radiata suggestive of PRES without evidence of acute intracranial hemorrhage. Strict blood pressure control and anticonvulsants were immediately started while maintaining the patient on high-dose steroids and immunosuppressants. No recurrence of seizure, improvement in sensorium, and absence of headache and blurring of vision were observed in the course of treatment. Prompt recognition and management of PRES in SLE and management of its varying complications such as seizures, SE, neurologic deficits, or coma is important. In spite of its name, reversibility may not always occur in PRES.
P021
Implication of hemodialysis indication for acute caffeine intoxication based on retrospective qualitative study of 29 cases
1Primary Care, Sapporo Tokushukai Hospital, Sapporo, Japan
2University of Michigan, Ann Arbor, MI, USA
3Sapporo Tokushukai Hospital, Sapporo, Japan
P022
Autoimmune polyendocrinopathy syndrome 2 in a pediatric patient presenting at the emergency room in thyroid storm and severe diabetic ketoacidosis: a case report
Ospital Ng Makati, Makati, Philippines
P023
A case of tetanus
Al Qassimi Hospital, Sharjah, United Arab Emirates
Tetanus is a toxin-mediated disease produced by the bacterium Clostridium tetani, characterized by generalized rigidity and muscle spasms that may lead to respiratory distress and eventually death. Tetanus typically gains access to the body through apparent or unapparent wounds, surgeries, intravenous drug abuse, bites, neonate umbilicus, piercing, tattoos, and so on. Implementation of worldwide mandatory vaccination programs has successfully reduced the prevalence of this disease. Even so, limited cases have been reported since 1980–2012 in the United Arab Emirates. We report a case of tetanus in a 38-year-old Pakistani gentleman who presented to our emergency department (ED) with a locked jaw, neck spasm, and back pain with back stiffness that started 3 days prior to his presentation. During his stay in the ED, the patient developed extrapyramidal signs with arching of the back. The patient had a history of an open wound on the left big toe 5 days earlier for which he did not seek any medical attention. His immunization history was unclear. The patient was admitted to the Intensive Care Unit, treated as tetanus, and mechanically ventilated. His hospital stay was uneventful and was discharged 1 month after his admission.
P024
Management of OHCA during COVID-19: a tale of two cities
1Department of Cardiology, National University Heart Centre, Singapore
2Emory School of Medicine, Atlanta, GA, USA
3Duke-NUS Medical School, Singapore
4Singapore General Hospital, Singapore
5Emory University, Atlanta, GA, USA
6Singapore Civil Defence Force, Singapore
7National University Hospital, Singapore
P025
Hyperbaric oxygen therapy research: an analysis of the 100 most-cited publications from 2011–2019
Linkou Chang Gung Memorial Hospital, Taiwan
P026
Epidemiology of poisoning cases presenting to the emergency department
Sengkang General Hospital, Singapore
The patient’s data were then analyzed based on demographics, type of poisoning, management, and outcome parameters. IBM SPSS statistic 21 was used for statistical analyses.
P027
Nonketotic hyperglycemic chorea—basal ganglia disease
Emergency Medicine, Meenakshi Mission Hospital and Research Institute, Madurai, India
A 70-year-old female patient with known diabetic under poor glycemic control and systemic hypertension was brought to emergency department with history of right upper-limb and lower-limb weakness, involuntary dance-like activity of left upper limb and lower limb, and giddiness and facial grimacing for 1-day duration. Her vitals are within normal limits. Neurological examination reveals weakness of power 0/5 of right upper and lower limb with facial drooping. Blood investigations shows blood glucose level 590 mg/dL with ketones negative. Arterial blood gas (ABG) shows no acidosis and normal serum osmolality. Magnetic resonance imaging (MRI) suggested T1 hyperintensities in basal ganglia with extensive periventricular leukoaraiosis and acute watershed infarct in left frontal region. The patient was managed with insulin, intravenous fluids, and other supportive measures. The patient was discharged after improvement of the chorea symptoms with strict control of glucose level. Nonketotic hyperglycemic (NKH) chorea is a special complication of diabetes mellitus characterized by elevated blood glucose without ketogenesis. In 1960, Dr Bedwell was the first author to describe the rare clinical syndrome of NKH chorea. Hyperglycemia-induced involuntary movements are uncommon manifestations of diabetes seen especially in those with poor glycemic control. Hyperglycemia impairs cerebral autoregulation. Hence, there is an activation of anaerobic metabolism with depletion of gamma aminobutyric acid (GABA) in the basal ganglia neurons whereas GABA is the main inhibitory neurotransmitter in the basal ganglia. GABA in patients with NKH is rapidly depleted due to lack of acetoacetate, so the normal activity of basal ganglia is damaged. MRI of the brain is the modality of choice for assessing possible NKH chorea and typically demonstrates signal changes (T1 hyperintensity) particularly in the putamen and/or caudate of basal ganglia. Control of blood glucose is the most important treatment in NKH chorea. Symptoms resolve with decline in blood glucose level. If there are sudden abnormal movements in patients, in addition to thinking of chorea, hepatolenticular degeneration, and other diseases, we should also pay attention to blood sugar; especially in diabetic patients with poor blood sugar control and negative ketone, we should consider the possibility of NKH chorea. NKH chorea is a special complication of diabetes.
P028
Too massive to be missed: an unusual case of acute pulmonary embolism in a young lady
Selayang Hospital, Batu Caves, Malaysia
Summary of investigations.
ECG: electrocardiogram; STE: ST-segment elevation; CXR: chest radiographs; ECHO: echocardiography; CTPA: computerized tomography pulmonary angiogram.
P029
Clinician-driven development of a personalized mobile phone application in the emergency department
1Department of Emergency Medicine, Singapore General Hospital, Singapore
2Singapore General Hospital, Singapore
P030
The racing young heart: Belhassen-type ventricular tachycardia
1Department of Emergency and Trauma, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
P031
The sewer power: acute ammonia gas inhalation toxicity
1Department of Emergency and Trauma, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
P032
Emotions of medical students in tele-simulation
1Emergency and Disaster Medicine, Hirosaki University, Hirosaki, Japan
2University of Michigan, Ann Arbor, MI, USA
3Tokyo Metropolitan Children’s Medical Center, Fuchu, Japan
4Hirosaki University, Hirosaki, Japan
Emotions perceived by medical students before, during, and after the simulation sessions.
Pos. act. emotions: positive activating emotions; Pos. deact. emotions: positive deactivating emotions; Neg. act. emotions: negative activating emotions; Neg. deact. emotions: negative deactivating emotions.
P033
Understanding of development emergency medical services in Laos emergency medicine residents
1Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
2Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
P034
“Motorcycle ambulance”: the policy to promote health and sustainable development in large cities
1Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
2Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
P035
Utility of emergency department short stay unit for adult asthma and predictive factors for unplanned inpatient transfer
1Emergency Medicine, Tan Tock Seng Hospital, Singapore
2Khoo Teck Puat Hospital, Singapore
3Tan Tock Seng Hospital, Singapore
P036
A case report for desaturated factitious disorder in emergency room
Primary Center, Sapporo Tokushukai Hospital, Sapporo, Japan
P037
Patients’ and relatives’ perspectives of observable emergency physician professionalism behavior in Thailand
1Department of Emergency, Department of Emergency Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
2King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
3Faculty of Psychology, Chulalongkorn University, Bangkok, Thailand
4Eisenhower Medical Center, Rancho Mirage, CA, USA
5Department of Emergency Medicine, University of Illinois at Chicago, Chicago, IL, USA
6Department of Emergency Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
7Institute for Population and Social Research, Mahidol University, Salaya, Thailand
P038
Interdisciplinary collaboration and computer-assisted home healthcare referral in the emergency department: an innovative model in Taiwan
Emergency Medicine, Chi Mei Medical Center, Taiwan
Comparison for ED visit and hospitalization after referral for HHC between patients with non-ED HHC and ED HHC by logistic regression analyses.
ED: emergency department; HHC: home healthcare; OR: odds ratio; CI: confidence interval.
Multiple models adjusted by sex, age, length of stay in ED, length of stay in hospitalization, expenditure in ED, expenditure in hospitalization, ED triage, trauma or non-trauma, hypertension, diabetes, dementia, cerebrovascular disease, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, iatrogenesis, bedridden, and total expenditure within 3 months.
First logistic regression.
P039
The scarred heart
1Emergency & Trauma, Keningau Hospital, Keningau, Malaysia
2Department of Emergency & Trauma, Keningau Hospital, Keningau, Malaysia
3Keningau Hospital, Keningau, Malaysia
Electrocardiogram (ECG) showed sinus rhythm with noticeably QRSf over the inferior leads.
One and half hour later, she developed a brief fitting-like episode and went into cardiac arrest. Unfortunately, she had no return of spontaneous circulation despite cardiopulmonary resuscitation (CPR). Her full blood investigation results taken earlier were all normal.
P040
Why my neck is fat?
Department of Emergency and Trauma, Keningau Hospital, Keningau, Malaysia
P041
Development and remodeling of point-of-care ultrasound education for emergency medicine residents in resource-limited countries during the COVID-19 pandemic
1Emergency Medicine, Khon Kaen University, Khon Kaen, Thailand
2Khon Kaen University, Khon Kaen, Thailand
Method: A cross-sectional 10-question survey study was conducted at Srinagarind Hospital, Department of Emergency Medicine, Thailand, from July 2019 to July 2021 to determine the experience of POCUS learning by using the 5-point Likert-type scale after first-year emergency residents finishing the ultrasound rotation.
P042
The impact of an e-learning training program on junior doctors’ confidence and knowledge of pediatric emergency management
1A&E, Khoo Teck Puat Hospital, Singapore
2Khoo Teck Puat Hospital, Singapore
P043
Rare case of necrotizing enterocolitis in adults: a case report
Department of Emergency Medicine, Philippine General Hospital, Philippines
Necrotizing enterocolitis is a common gastrointestinal emergency of infants but is an unusual occurrence in adults. Due to the rarity of the case, the study aims to provide emergency physicians with analytical clues for diagnosis and management. This is a case of a 58-year-old man with pre-existing diabetes mellitus, who presented with a 10-day history of abdominal pain, fever, and constipation. Clinical presentation, laboratory workup, and diagnostics are all consistent with the diagnosis of necrotizing enterocolitis. The etiology remains unclear but postulates may be due to bacterial infection and bowel ischemia. Treatment ranges from supportive, wide spectrum antibiotics to surgical intervention. Overall outcome depends on clinical staging and hematological parameters.
P044
Carbon monoxide poisoning: to dive or not to dive
1Department of Emergency, Hospital Tengku Ampuan Rahimah Klang, Selangor, Malaysia
2Hospital Shah Alam, Selangor, Malaysia
P045
Tangled throughout life: the rare case of pediatric ruptured arteriovenous malformation
1Department of Emergency and Trauma, Selayang Hospital, Batu Caves, Malaysia
2Universiti Teknologi Mara, Selangor, Malaysia
P046
The grisly journey of a misadventures stomach into hostile lung
1Emergency, Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
2Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
3Hospital Beaufort, Beaufort, Malaysia
P047
AED usage for cardiac arrests witnessed in the community in Singapore
1Lee Kong Chian School of Medicine, Singapore
2Tan Tock Seng Hospital, Singapore
The use of an automated external defibrillator (AED) in out-of-hospital-cardiac-arrests (OHCAs) improves outcomes for patients. Community responders sustain injuries while breaking glass to retrieve public AEDs in Singapore. This could impede their response and reduce their willingness to respond to future OHCAs.
This is the first study which surveyed local responders to understand their demographics, find out factors predictive of success in retrieving AEDs, quantify the prevalence of injuries while retrieving AEDs, and assess factors affecting responders’ willingness to respond to future OHCAs.
In Singapore, a novel crowdsourcing mobile application was introduced in 2015 by the Singapore Civil Defence Force (SCDF), to recruit volunteers to respond to OHCA cases which are within 400 m of their current location. The app includes a map of verified AED locations near them.
An e-survey was used to collect data—the investigators reached out to the MyResponder online community on Facebook, which is started by the SCDF, nationally accredited first aid training centers, as well as through word-of-mouth. Participants must have responded to an OHCA in the past 12 months. An institutional review board (IRB) was approved by the National Healthcare Group research portal.
The survey had 88 participants. The success of retrieving an AED is not impacted by occupation (p = 0.433), age (p = 0.841), or gender (p = 0.156). In addition, the success of retrieving an AED was not impacted by the time of day that retrieval was attempted (p = 0.818). Participants activated by the MyResponder app who responded to an OHCA were found to be 11.1 times more likely to successfully retrieve AEDs (95% confidence interval (CI), 2.14–57.4, p = 0.004). Being injured or losing personal items while responding to an OHCA did not make responders less willing to retrieve AEDs in future (p = 1.00).
Use of the MyResponder app was reported to increase success of retrieving AEDs in the survey. Neither gender nor not having a healthcare-related occupation of responders affected their success in retrieving AEDs. Community responders in Singapore were willing to respond even if they have been personally affected while responding to an OHCA previously.
The data table demonstrating that method of activation is significant in success of retrieving AED.
P048
The unique characteristics of shotgun injury: ballistic knowledge is key
1Department of Emergency and Trauma, Selayang Hospital, Batu Caves, Malaysia
2Universiti Teknologi Mara, Selangor, Malaysia
P049
Airbag anaphylaxis? A case of near death after being saved by the airbag
1Department of Emergency and Trauma, Selayang Hospital, Batu Caves, Malaysia
2Universiti Teknologi Mara, Selangor, Malaysia
P050
“Insensible dusky limb”: a case of scapulothoracic dissociation
1Department of Emergency and Trauma, Selayang Hospital, Batu Caves, Malaysia
2Selayang Hospital, Batu Caves, Malaysia
However, early chest radiographs are frequently not properly oriented in a true anteroposterior orientation, making the lateral displacement of the scapula difficult to detect. The lack of treatment of possibly life-threatening vascular lesions or incorrect therapy of the damaged shoulder girdle is the result of a “missed diagnosis” of scapulothoracic dissociation.
Further imaging such as CT thorax should be obtained early if this condition is suspected in the emergency department. Most studies involving patients with neurovascular damage have reported poor prognosis for these injuries.
P051
Cerebral amyloid angiopathy masquerading as recurrent transient ischemia attacks: a case report and literature review
1Hyperacute Stroke Unit, Department of Medical, Princess Royal University Hospital, King’s College Hospital NHS Foundation Trust, London, UK
2Princess Royal University Hospital, King’s College Hospital NHS Foundation Trust, London, UK
P052
Emergency care management of the sick child—observation and assessment
NHS England, Leeds, UK
P053
Redesigning emergency department for a safer surge capacity during COVID-19 pandemic
1Department of Emergency, Selayang Hospital, Batu Caves, Malaysia
2Selayang Hospital, Batu Caves, Malaysia
P054
TRAnsitional CarE strategies at local EDs (TRACES@ED Study)
1Medicine, National University of Singapore, Singapore
2National University of Singapore, Singapore
3Changi General Hospital, Singapore
Heterogeneity of CTI models for discharged elderly patients was noted. All seven EDs have CTIs which may involve (1) screening, (2) care coordination, (3) evaluation and CGA, (4) health education, and (5) telecare. Results helped to inform future strategies for CTI implementation and delivery. More research is needed to evaluate patient outcomes and cost-effectiveness of CTIs.
P055
Knowledge of drug–drug interactions among the emergency department personnel
Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
P056
Unfortunate event of vaporizing detergent: a rare case of alcohol inhalation
1Emergency, Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
2Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
His brother was pronounced dead at scene while he was rushed by the Rescue Team to the emergency department. He was intubated for airway protection. Blood gas showed decompensated metabolic acidosis with high lactate and anion gap. Creatine kinase showed markedly elevated results. The patient was given adequate fluid resuscitation and admitted to intensive care unit (ICU) for further monitoring. Subsequently, he was extubated and discharged well.
P057
Profiles and outcomes of high-acuity triage trauma patients in emergency department of a tertiary teaching hospital in Jakarta, Indonesia
Department of Emergency, Cipto Mangunkusumo Hospital and Universitas Indonesia, Jakarta, Indonesia
There was no significant correlation between response time and hospital LOS (p = 0.411). Significant mortalities were observed in GCS.
Comparison between vital sign groups and emergency room and hospital mortality.
RR: respiratory rate; CI: confidence interval.
P058
Early empirical intervention in HSV encephalitis resulting in profound clinical improvement: a case report
Hospital Duchess of Kent, Sandakan, Malaysia
Upon arrival, she appeared confused, had spontaneous eye opening but was unable to communicate properly as per her age. Her pupils were reactive and equal bilaterally. Clinically, she was in sepsis as evidenced by documented temperature 39.3°C and heart rate of 160 bpm. Her blood investigation was normal with no raise in white blood cell.
Subsequently, computed tomography (CT) brain plain was done for the patient and showed focal left temporal hypodense area that may represent focal infective changes. In correlation with her age, lesion location, and clinical history, these changes are suggestive of herpes simplex encephalitis.
However, her legal guardian refused for lumbar puncture but she was treated with 21 days course of intravenous Ceftriaxone and Acyclovir. Clinically, she improved and regained full consciousness after 2 days of medications.
Diagnosis of encephalitis hinges crucially on lumbar puncture and cerebrospinal fluid (CSF) examination. Literature shows that treatment of herpes simplex virus (HSV) encephalitis with Acyclovir dramatically improves the outcome, and the recovery will be better if Acyclovir is started early. In this particular case, the child was very fortunate that medication was started early despite lumbar puncture was not done and she fully recovered.
In conclusion, all children who presented to the emergency department with fever and neurological deficit warrant for radiological investigation as part of assessment. As reflected in this case, early radiological investigation assists in prompt diagnosis. Hence, appropriate medication was served which resulted in better outcome for patients.
P059
Scombroid poisoning: a common but frequently misdiagnosed condition
1Department of Emergency & Trauma, Hospital Duchess of Kent, Sandakan, Malaysia
2Hospital Duchess of Kent, Sandakan, Malaysia
Upon examination, she was flushed, tachycardic, had a generalized urticarial rash with mild abdominal tenderness. She revealed she usually eats mackerel but has never had hypersensitivity reaction.
A diagnosis of scombroid poisoning was made, and she was treated with intravenous fluids and anti-histamines. She was admitted for observation and discharged well the next day.
Symptoms are typically mild (widespread erythema, flushing, palpitations, vomiting, and diarrhea) but may lead to severe symptoms (bronchospasm, respiratory distress, vasodilatory shock). These findings begin within 90 min and can last till 36 h. A clinical diagnosis is usually made but it can be confirmed by measurement of histamine levels in plasma, urine, or in the spoilt food.
The manifestation can be similar to an allergic reaction, making it difficult to diagnose; however, proper history of previous allergies and the type of fish consumed is crucial. Histamine does not alter the organoleptic quality of the fish, so there will be no change in the smell or appearance of the consumed food. Histamine is heat stable, and remains present after cooking, freezing, or canning. In scombroid poisoning, more than one person, often with no history of food allergies, may be affected.
Most cases of scombroid poisoning are usually self-limiting, but if the patient requires treatment, rapid acting anti-histamines along with supportive care is given, tailored to the signs and symptoms. Adrenaline, although uncommon, may be required. Corticosteroids are generally not indicated.
To prevent further instances of poisoning, proper patient education regarding storage of raw fish and notification to public health authorities to investigate the source are recommended.
P060
Sinister chronic headache caused by giant arachnoid cyst: a case report
Hospital Duchess of Kent, Sandakan, Malaysia
On assessment, he was alert with normal vital signs and neurological findings. Computed tomography (CT) brain showed large right fronto-temporal extra-axial CSF attenuating hypodense cystic lesion compressing the right frontal and temporal lobe causing midline shift to the left with subfalcine herniation in keeping with type III AC. Presences of adjacent bone remodeling was found and no intracranial bleed (ICB). He was subsequently admitted for observation. Elective operation was performed by creating a cysto-peritoneal shunt.
P061
Consistency in the treatment of patients who misuse opiates in Leeds: a clinical audit-cum-service evaluation
University of Leeds, Leeds, UK
P062
Serum electrolytes—are we undermining this potential prognostic marker for predicting major adverse cardiac events in STEMI?
1Department of Emergency, PRS Hospital, Trivandrum, India
2PRS Hospital, Trivandrum, India
3Sheikh Khalifa Medical City, Abudhabi, United Arab Emirates
4
P063
The sensitivity of a positive HINTS examination in identifying posterior circulation stroke
1Department of Emergency, PRS Hospital, Trivandrum, India
2PRS Hospital, Trivandrum, India
3Sheikh Khalifa Medical City, Abudhabi, United Arab Emirates
4
Misdiagnosis of posterior circulation stroke in ED is frequent, and with the occasional false negative neuroimaging, there is dire need for a reliable and accurate bedside evaluation in acute vestibular syndrome. HINTS examination—a battery of bedside clinical tests—is aimed at identifying posterior circulation stroke in patients presenting with AVS.
HINTS comprises Head Impulse, Nystagmus, and Test of Skew. The HINTS examination has been shown to have greater sensitivity than neuroimaging in ruling out stroke in patients presenting with acute vertigo.
In our study, we aimed to evaluate the accuracy of positive HINTS score in identifying posterior circulation stroke in AVS patients.
P064
Altered sensorium caused by fat embolism syndrome: a case report
Department of Emergency and Trauma, Hospital Duchess of Kent, Sandakan, Malaysia
P065
Pre-hospital thrombolysis in ST-segment elevation myocardial infarction: a remote Borneo island experience
1Emergency and Trauma, Labuan Hospital, Labuan, Malaysia
2Labuan Hospital, Labuan, Malaysia
P066
Characteristics of patients with confirmed COVID-19 transported by emergency medical services (EMS) in Labuan Island, Borneo, Malaysia
1Emergency and Trauma, Labuan Hospital, Labuan, Malaysia
2Labuan Hospital, Labuan, Malaysia
Common clinical symptoms noted in confirmed COVID-19 cases included fever (64.9%), cough (53.5%), lethargy (57.3%), dyspnea (59.4%), sore throat (48.1%), and less commonly abdominal pain (1.9%), nausea/vomiting (4.5%), and diarrhea (1.7%).
There was no significant association between gender, age, nationality, and time of ambulance call between the patients who were confirmed with COVID-19 and those who were not (p > 0.05).
The presence of respiratory tract symptoms, fever, and lethargy represents a statistically significant difference in confirmed COVID-19 patients (p < 0.05)
Symptoms such as abdominal pain, nausea/vomiting, and diarrhea did not represent a statistically significant difference in the ultimate COVID-19 diagnosis (p > 0.05)
P067
Rapid thrombolysis protocol—results from a before and after study
Emergency Medicine, Max Hospital, Patparganj, India
P068
Effect of implementation of multi-tier response system and prolonged on-scene resuscitation for out-of-hospital cardiac arrest
Chonnam National University Hospital, Gwangju, South Korea
P069
Interaction effect between mechanical chest compression device use and post–cardiac arrest care on survival outcomes after out-of-hospital cardiac arrest
Chonnam National University Hospital, Gwangju, South Korea
P070
Mechanical chest compression devices during transport after out-of-hospital cardiac arrest in Korea: a national observational study from 2014 to 2016
Chonnam National University Hospital, Gwangju, South Korea
P071
Cardiac arrest while exercising in national or provincial parks on mountains: a national observational study from 2012 to 2018
Chonnam National University Hospital, Gwangju, South Korea
P072
Accuracy of computed tomography (CT) of the chest as a diagnostic tool for COVID-19 patients in emergency department
Emergency Medicine, Max Superspeciality Hospital, Patparganj, India
P073
Hemodialysis-induced cerebral arterial gas embolism (CAGE) treated with hyperbaric oxygen therapy
AED, PYNEH, Chai Wan, Hong Kong SAR
Two sessions of HBOT were performed with US Navy Treatment Table 6 with a maximum pressure of up to 2.8 ATA. After the treatments, a CT of the brain was performed again and right parietotemporal infarction and high right frontal infarction with cerebral edema over his right cerebrum were noted. The patient was extubated the next day with normal Glasgow Coma Scale (GCS). However, residual hemiplegia remained. The patient rehabilitated for around 1 month and was discharged with mild left hemiplegia and around 4/5 of limb strength.
As soon as CAGE is suspected, the patient should start receiving 100% high-flow oxygen and should lie flat. HBOT using 100% oxygen is the definitive treatment for CAGE. A retrospective review at that time in receipt of HBOT was the only statistically significant factor predictive of a good outcome with a mean of 8.8 h. Even if a higher probability of good outcomes is associated with shorter timeframes between embolism and HBOT, responses can still be observed even if the treatment commences after 24 h.
Arterial gas embolism presents in highly variable ways with no pathognomonic signs or symptoms. While it is uncommon to achieve a consensus on the diagnosis, it is a common practice to err on the side of caution.
Multiple branching gas density noted in the right frontal and parietal lobe as indicated by red arrows.
P074
Multilingual emergency care: the ethics of medical interpretation
1Faculty of Medical and Health Science, Universiti Sains Islam Malaysia, Nilai, Malaysia
2Universiti Teknologi Mara, Selangor, Malaysia
3Ampang Hospital, Selangor, Malaysia
Occasionally, patients and physicians do not speak the same language. Failure of the physicians to provide interpretation undermines the patient’s autonomy and hinders informed decision-making. This study aims to identify the methods available in clinical practice that are used for medical interpretation and from these methods, to examine its application in emergency department. Systematic review was conducted using SCOPUS and PubMed with the following keywords: (“medical interpretation” OR “medical translation”) AND (“emergency” OR “physician” OR “doctor” OR “healthcare worker OR professional”). It was conducted from August to September 2020. Articles retrieved include abstracts, conference papers, reports, and opinion papers. Duplication and non-English articles were excluded. All articles regarding methods of interpretation were identified, and the methods that are applicable in emergency department are analyzed to answer the objectives. Effective interpretation has been shown to improve patient’s satisfaction, optimize resources, reduce length of stay, and lead to good clinical outcome. There are four interpretation methods identified: (1) professional or trained, (2) ad hoc or non-professional, (3) patients’ relatives, and (4) interpretation devices. Professional interpretation method is accepted as the gold standard. Providing a professional interpreter is time-consuming and costly, and the differing standardization of the training may pose issues to providers. In comparison with the other three methods, this method is the least readily available method of interpretation. Another method is ad hoc interpreter that includes multilingual available staff. The interpreters are not trained, and thus, it risks breach in the patient’s confidentiality. Multilingual relative is a method most used in emergency situations. The patient may not want certain sensitive medical condition to be revealed to their relatives. The role of relatives as caretaker can have some degree of bias leading to misinterpretation. Interpretation device is another method; however, there is no validated medical device available. The interpretation may be imprecise since most of the devices are meant for translation. Devices also deprive of human connection and of advocating patients’ needs. Choosing the best method is crucial for emergency physician. The right choice would depend on the level of urgency, the sensitivity of the conversation, and the availability of the preexisting method in the institution.
P075
Risk of traumatic delayed intracerebral hemorrhage in patients with oral anticoagulants after head injury
1School of Medicine, College of Medicine, China Medical University, Taiwan
2Department of Emergency Medicine, China Medical University Hospital, Taiwan, Taiwan
3Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
4Center for Artificial Intelligence in Precision Medicine, Asia University, Taichung, Taiwan
P076
Global pandemic: sharing story of our darkest day, an integrated clinical support in hospital disaster management
1Emergency, Hospital Tengku Ampuan Rahimah Klang, Selangor, Malaysia
2Hospital Tengku Ampuan Rahimah Hospital Tengku Ampuan, Malaysia
P077
Music improves respiratory function and acute mountain sickness symptoms in simulated high-altitude environment
1Emergency, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
2Universiti Teknologi Mara, Selangor, Malaysia
P078
Early conversion to shockable rhythm is a predictor of favorable outcome among patients with out-of-hospital cardiac arrest
1Department of Emergency, China Medical University Hospital, Taichung, Taiwan
2China Medical University Hospital, Taichung, Taiwan
Comparison of demographic data and outcomes of resuscitation between early convert group, late convert group, and non-shockable group.
CPR: cardiopulmonary resuscitation; CPC: cerebral performance category.
P079
Lucio’s phenomenon: a rare manifestation of leprosy in Selangor, Malaysia
Emergency Medicine, Hospital Selayang, Selangor, Malaysia
Leprosy is a chronic infectious disease caused by Mycobacterium leprae, predominantly affecting the skin and peripheral nerves. Lucio’s phenomenon is a rare reactional state presenting in patient with lepromatous leprosy and described as acute cutaneous necrotizing vasculitis. We discussed the case of a 38-year-old male patient presenting with edematous and dusky discoloration of bilateral hands and feet associated with diffuse facial involvement. His skin condition gradually worsened to form multiple ulcers with bizarre-shaped purpuric lesion over bilateral upper and lower limbs, trunk, and face. Histopathological examination of the skin biopsy showed multiple acid fast bacilli, and diagnosis of Lucio’s phenomenon was made in the background of lepromatous leprosy. He was treated with multi-drug therapy (MDT) as recommended by the World Health Organization guidelines. A better understanding of rarer manifestation of this illness is important for early diagnosis and to prevent significant morbidity and disability associated with it.
P080
A lady with a blue tongue
1Emergency Medicine, Hospital Raja Perempuan Zainab II, Kota Bharu, Malaysia
2Hospital Raja Perempuan Zainab II, Kota Bharu, Malaysia
Clinical examination revealed a huge lingual hematoma with multiple bruises over the upper and lower limbs and abdomen. The tongue was swollen and contused with reduced mobility and pain on movement. She was otherwise normotensive, afebrile, and had no breathing difficulties. Laboratory findings showed an isolated prolonged activated partial thromboplastin time (>180 s) with a normal international normalized ratio (INR) and prothrombin time consistent with heparin exposure from hemodialysis.
She was seen by the otorhinolaryngology team and a fiberoptic laryngoscope was done which excluded potential airway obstruction. She was then treated with 50 mg of protamine sulfate to reverse the effects of heparin and was admitted to the intensive care unit for close observation. She was discharged home after 4 days during which the hematoma had started to resolve and completely healed after 2 weeks.
P081
Mistaken identity: paying the price of shyness
1Emergency Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
Abdominal X-ray showed a dilated small bowel. He was initially treated with infective gastroenteritis. The white cell was 21 × 103 mm. He was reassessed while being observed in the emergency department. Upon further questioning, he finally admitted that he did have a swollen scrotum. Examination revealed irreducible inguinal hernia. Diagnosis was revised to strangulated inguinal hernia. Surgical team was referred and the patient was taken to the operation theater. Small bowel resection with primary anastomosis and right hernioplasty was performed.
P082
A study to investigate the accuracy of hemoglobin concentration between capillary blood and venous blood when assayed by HemoCue 201DM in accident and emergency department of Tuen Mun Hospital and Pok Oi Hospital
1Tuen Mun Hospital, Tuen Mun, Hong Kong SAR
2Pok Oi Hospital, Au Tau, Hong Kong SAR
A person’s hemoglobin (Hb) concentration indicates the amount of Hb present in blood. Nowadays, HemoCue is a widely accepted and commonly used device in Hong Kong accident and emergency (A&E) department. It is a portable electronic quantitative haemoglobinometer that can provide Hb concentration in a rapid and cost-effective way. A prompt testing of Hb concentration can facilitate healthcare providers on planning patients’ future management and nursing care. The reliability of HemoCue Results is important. From 2018 to 2019, in Tuen Mun hospital and Pok Oi Hospital A&E, there are a total of 12 HemoCue-related incidents being reported. Eleven incidents were related to capillary samples and one incident was related to venous sample. This study would like to investigate whether the capillary or venous blood samplings will affect the HemoCue results.
This is a prospective and correlation study. The study was started on October 2019 and finished on January 2021.
The data collected were analyzed by Pearson’s correlation coefficient and Bland–Altman plot with MedCalc software (version 19.1.3). Significance and confidence interval will be set at 0.05% and 95%, respectively. Under the analysis of Pearson’s correlation coefficient (Figure 3), positive and strong correlation among both capillary (r = 0.9797, p < 0.0001) and venous (r = 0.9917, p < 0.0001) versus laboratory results (Lab) were observed. With the use of Bland–Altman Plot (Figure 4), both capillary and venous and Lab illustrated a negative mean difference.
From the comparison between the literature and the results of this study, a good correlation was found between the capillary versus Lab and the venous versus Lab. From the study results, a negative mean difference was found in the comparison between capillary versus Lab and venous versus Lab; this implied an underestimation. Although the venous versus Lab had a better agreement in the study, both the capillary and venous were reliable clinically.
To conclude, HemoCue provides rapid, convenient, and reliable hemoglobin results. From the study, it was found that it showed a good correlation between capillary to laboratory results and venous to laboratory results. Both capillary and venous HemoCue Results are accurate and reliable for decision-making in emergency situations.
P083
Awoken from death: a case study of OSA self-asphyxiation
1Department of Emergency and Trauma, Hospital Bintulu, Bintulu, Malaysia
2Hospital Umum Sarawak, Kuching, Malaysia
In the emergency department, the patient was noted to have a bilateral subconjunctival hemorrhage. His vital signs, systemic examination, and blood investigations were unremarkable for hypertension or systemic coagulopathies. With a Stop-Bang score of 6 and Epworth Sleepiness Scale of 19, he was referred to the Ear, Nose, and Throat (ENT) team for severe obstructive sleep apnea (OSA).
A flexible scope noted 75% adenoid hypertrophy, left-sided nasal septum deviation, and moderate bilateral hypertrophy of inferior turbinates. Muller’s test revealed that retropalatine and retrolingual were 100% collapsible. However, the upper airway was seen to be patent. The sleep study has been performed, and the patient was discharged well to continue continuous positive airway pressure (CPAP) at home and advice for weight reduction.
P084
Impact of COVID-19 on the morale of healthcare professionals who cared for the migrant workers in Singapore: a qualitative approach
Sengkang General Hospital, Singapore
Motivators included HCPs’ professional obligation to help others and gain personal experience. Altruism was also a key motivator. HCPs faced difficulties interacting with the migrant workers, feared contagion, and struggled with rapidly changing workflows. Many expressed empathy for the migrant workers’ predicament. Peer and social support, and effective leadership were morale boosters and might have cushioned any negative experiences, as all HCPs had overall high morale despite the numerous challenges they faced.
P085
Anesthetic methods in the emergency care setting for the closed reduction of pediatric forearm fractures: a systematic review of randomized controlled trials
1National University of Singapore and Yong Loo Lin School of Medicine, Singapore
2Department of Emergency Medicine, Singapore General Hospital, Singapore
3Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
4Pre-Hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore
P086
A survey study on the role of Chinese medicine practitioner in Hong Kong emergency medicine
Hong Kong Baptist University, Kowloon Tong, Hong Kong SAR
P087
Death by dog: a case of rabies encephalitis by unorthodox transmission
1Emergency and Trauma, Sarawak General Hospital, Kuching, Malaysia
2Sarawak General Hospital, Kuching, Malaysia
Further history elucidated that he was in contact with a dog 7 months prior: the dog had bitten his wife, after which he killed the dog. He had not been bitten or scratched by the offending animal, but had an open, uncovered wound prior to disposing of the dog. His wife was subsequently vaccinated for rabies and was asymptomatic.
Magnetic resonance imaging (MRI) of the brain/spine of the man showed features suggestive of rabies encephalitis.
He did not recover from the disease.
Although rabies is conventionally transmitted via a bite or scratch by an infected animal, there are other less common methods of transmission that the clinician must be mindful of. As such, public education must be reemphasized to promote early healthcare-seeking behavior.
P088
Cardiac tamponade: the dangerous 6 mL of blood clot
1Department of Emergency and Trauma, Sarawak General Hospital, Kuching, Malaysia
2Sarawak General Hospital, Kuching, Malaysia
Post-traumatic cardiac tamponade is a dying emergency if not treated promptly. We herein report a cardiac tamponade case that required an urgent pericardiocentesis. A 50-year-old gentleman presented to the emergency department with chest pain after a road traffic accident. The patient was triaged to the critical zone immediately in view of hypotension and fluctuating conscious level. Electrocardiogram (ECG) showed generalized ST depression with ST elevation over V1 and AVR. Bedside echocardiography (ECHO) showed pericardial effusion with blood clot and left ventricular hypertrophy with right ventricle collapsed during diastole. Other cardiac structures were otherwise normal. In view of persistent low blood pressure despite fluid resuscitation, ultrasound-guided pericardiocentesis was done using parasternal approach. Six milliliters of blood clot was aspirated until the resistance was met. The patient showed significant hemodynamic improvement after the procedure. Repeated bedside ECHO showed there was circumferential pericardial effusion with no right atrium and ventricle collapsed during diastole. In addition, all chambers were grossly intact. ECG also showed resolved generalized ST depression. Subsequently, the patient underwent an urgent contrast-enhanced computed tomography (CECT) of the thorax that showed the presence of pericardial hematoma with thickness up to 1.4 cm at left ventricle. Cardiac tamponade due to blunt trauma usually involves cardiac chamber rupture, which is typically fatal before patients can be brought for treatment. However, in our case, it was a blunt trauma without obvious cardiac chamber rupture. The rapid accumulation of a little amount of fluid which is quicker than it can be absorbed can cause a considerable increase in pericardial pressure and, eventually, cardiac tamponade. Failure to aspirate blood does not exclude the diagnosis because fresh blood in the pericardium is often clotted. As illustrated in our case, the hemodynamic instability was significantly improved after aspiration of as little of 6 mL of blood clot. In emergency setting, bedside ECHO can facilitate the assessment of cardiac compromise before and after the procedure.
P089
The flood aftermath of a blast: a case of an abnormal presentation of ruptured ovarian cyst
Department of Emergency and Trauma, Hospital Bintulu, Bintulu, Malaysia
An abnormal presentation of ruptured ovarian cyst
Department of Emergency and Trauma, Hospital Bintulu, Bintulu, Malaysia
P090
Management and outcomes of animal bites from a pediatric emergency department’s perspective
1Children Emergency, KK Women’s and Children’s Hospital, Singapore
2KK Women’s and Children’s Hospital, Singapore
P091
A 1-year longitudinal study: change in mental health outcomes of frontline emergency department healthcare workers in this COVID-19 pandemic
1A&E, Khoo Teck Puat Hospital, Singapore
2Khoo Teck Puat Hospital, Singapore
3Health Services & Outcomes Research, NHG, Singapore
MHO scores among all HCWs and its subgroups of doctors and nursing staff.
HCWs: Healthcare workers; IQR: interquartile range.
P092
A systematic review and meta-analysis of the long-term outcomes of out-of-hospital cardiac arrest patients
1Medicine, Yong Loo Lin School of Medicine, Singapore
2Yong Loo Lin School of Medicine, Singapore
3Singapore General Hospital, Singapore
4Nus Saw Swee Hock School of Public Health, Singapore
5Duke-NUS Medical School, Singapore
Influence of region on survival and neurological outcomes.
CI: confidence interval.
P093
Trends in bystander CPR and dispatcher-assisted CPR rates for out-of-hospital cardiac arrest in Asia (PAROS participating sites)
National University of Singapore, Singapore
There are significant variations in bystander cardiopulmonary resuscitation (BCPR) and dispatcher-assisted (DA)-CPR implementation between countries across Asia. While the Pan Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network (CRN) found variable BCPR rates between countries in Asia, the trends of BCPR and DA-CPR after DA-CPR implementation are unclear. We analyzed the year-on-year bystander CPR and DA-CPR rates of selected PAROS participating sites.
This is a retrospective, multicenter cohort study of BCPR and DA-CPR rates of out-of-hospital cardiac arrest (OHCA) cases across the Asia-Pacific using the PAROS database. All complete years of OHCA cases conveyed by emergency medical services (EMS) or presenting at emergency departments during the study period were captured. OHCAs witnessed by EMS or ambulance crew, traumatic arrests, or resuscitation not attempted or unknown were excluded. Participating sites with less than four consecutive full years of OHCA cases captured in the PAROS database were excluded.
In all, 156,889 OHCAs met our inclusion criteria from six countries. Of the six participating sites shortlisted, 66 OHCAs were from incomplete years and were excluded. Across the six sites, the mean age of OHCAs varied from 53.6 to 71.1 years. The proportion of males ranged from 57.5% to 72.7%. The proportion of unwitnessed arrest ranged from 18.5% to 62.0%. Overall, BCPR rates are improving in Seoul and Singapore. However, no clear BCPR trend is seen in Bangkok, Hangzhou, Kuala Lumpur, and Osaka. This trend is similar for rate of return of spontaneous circulation across the six participating sites. DA-CPR rates are improving in all included participating sites where a DA-CPR package was implemented, except for Kuala Lumpur.
Trends of BCPR and DA-CPR vary across PAROS participating sites, and this might be related to differences in implementation of DA-CPR and public education between sites.
P094
A rare case of combined purulent meningoencephalitis and infective endocarditis
Woodlands Health Campus, Singapore
During the current visit to the emergency department, computed tomography (CT) scan of the brain showed hyperdensities in the subarachnoid spaces along both frontal convexities and a small focus of hyperdensity in the extra-axial part of the left cerebellum. Given the lack of trauma and history of fever, he was diagnosed to have purulent leptomeningitis complicated by subdural empyema. He was commenced on antibiotics and admitted under internal medicine. Repeat CT of the brain 2 days later showed thromboembolic ischemic infarct/septic emboli in the right parieto-occipital region and interval development of a subarachnoid hemorrhage secondary to a ruptured mycotic aneurysm (Figure 1). Blood cultures and TTE established the diagnosis of S. aureus infective endocarditis. In view of poor premorbid, he was treated conservatively without surgical intervention.
P095
Role of electrocardiogram findings in predicting 48-h mortality in patients with traumatic brain injury
1Emergency Medicine, Chonnam National University Hospital, Gwangju, South Korea
2Chonnam National University Hospital, Gwangju, South Korea
Multivariate logistic regression analysis for predicting in-hospital mortality in patients with TBI.
TBI: traumatic brain injury; OR: odds ratio; CI: confidence interval; ECG: electrocardiogram; STE: ST-segment elevation; STD: ST-segment depression.
P096
The association between disseminated intravascular coagulation profiles and in-hospital mortality in patients with traumatic brain injury
Emergency Medicine, Chonnam National University Hospital, Gwangju, South Korea
P097
A pilot eICU teleconsultation model for critically ill patients enabling conjoint resuscitation between emergency physicians and intensivists in a district hospital
1Accident & Emergency, Tin Shui Wai Hospital, Tin Shui Wai, Hong Kong SAR
2Tin Shui Wai Hospital, Tin Shui Wai, Hong Kong SAR
3Pok Oi Hospital, Au Tau, Hong Kong SAR
P098
Contact-precaution-compatible and programmable magnetic tourniquet alarm system to prevent tourniquet retention in resuscitation room
1Tuen Mun Hospital, Tuen Mun, Hong Kong SAR
2Department of Quality and Safety, Tuen Mun Hospital, Tuen Mun, Hong Kong SAR
P099
Emergency bougie-assisted cricothyroidotomy—a teleconference success story for failed airway in rural setting
Department of Emergency and Trauma, Hospital Semporna, Semporna, Malaysia
Cricothyroidotomy remains the final option for rapid resolution of securing airway in “cannot intubate, cannot oxygenate” (CICO) scenario. In the hands of inexperienced clinician, performing this technique can be daunting, especially in rural hospital where no senior doctor or specialist is available. We share a case where a patient had successful bougie-assisted cricothyroidotomy (BAC) performed by junior doctors after teleconferencing with an emergency physician located 108 km away.
A 50-year-old gentleman with multiple comorbidities presented with shortness of breath. He was treated for decompensated heart failure, precipitated by septic shock and pneumonia. After a period of non-invasive positive pressure ventilation, he underwent endotracheal intubation due to worsening type 2 respiratory failure, when CICO occurred. Teleconference with the emergency physician from a tertiary hospital was done, and step-by-step instructions on how to perform BAC were given. The cricothyroid membrane (CTM) was identified and marked by inserting a needle and incision then made. Bougie was inserted through the opening, and size 6 endotracheal tube (ETT) was railroaded through the bougie. The ETT was secured, saturation improved, and the patient was transferred to the tertiary hospital for further care.
Challenges faced while working in rural hospital include junior doctors with limited experience and equipment to deal with highly complex and difficult clinical scenarios such as CICO. At the time of critical situation like this, video teleconferencing is a reliable way to quickly reach a decision and it can even be used to teach how to perform BAC. BAC requires minimal equipment that are commonly available in the rural setting. While the technique is in theory quite straightforward, it takes courage for an inexperienced doctor to perform it, especially the step where CTM needs to be identified and incision made.
BAC is a relatively easy technique, and can be quickly taught and successfully performed even by an inexperienced doctor. In addition, video teleconferencing is still a reliable and relevant way to discuss and manage difficult cases when expertise is not available to the rural setting.
P100
Characteristics of patients with carbon monoxide poisoning due to smoke inhalation and pre-hospital factors related to intensive care unit admission of these patients: a nationwide observational study
Emergency Medicine, Chonnam National University Hospital, Gwangju, South Korea
This study aimed to investigate the pre-hospital clinical status of patients with carbon monoxide (CO) poisoning by smoke inhalation and the pre-hospital factors associated with these patients’ admission to the intensive care unit (ICU). In this observational study from January 2016 to December 2018, the National Fire Agency’s first aid activity log on patients with smoke inhalation was matched with National Emergency Department Information System’s patient data with CO poisoning and further analyzed retrospectively. Multiple logistic regression analysis was conducted to identify the relevant pre-hospital associative factors for the decision to admit a patient with CO poisoning to the ICU. Of the 4422 patients with CO poisoning included in the study, 358 (8.09%) were admitted to the ICU. In such patients transported by pre-hospital emergency medical services, age (odds ratio (OR), 1.020; 95% confidence interval (CI), 1.010–1.029), verbal skills (OR, 3.564; 95% CI, 2.390–5.315), pain (OR, 4.011; 95% CI, 2.661–6.045), unconsciousness (OR, 5.728; 95% CI, 2.708–12.113), systolic blood pressure (SBP) (OR, 0.979; 95% CI, 0.969–0.989), heart rate (HR) (OR, 1.011; 95% CI, 1.004–1.018), SpO2 (OR, 0.965; 95% CI, 0.946–0.985), O2 supply (OR, 1.725; 95% CI, 1.143–2.603), use of nasal prongs (OR, 0.504; 95% CI, 0.281–0.905), and intentional inhalation (OR, 2.282; 95% CI, 1.659–3.139) were independently associated with ICU admission. Our study demonstrated that age, mental change, SBP, HR, SPO2, O2 supply, use of nasal prongs, and intentional inhalation in patients with CO poisoning were associated with their ICU admission.
P101
Fibrinogen is an independent predictor of massive transfusion in patients with unstable esophageal variceal hemorrhage
1Emergency Medicine, Chonnam National University Hospital, Gwangju, South Korea
2Chonnam National University Hospital, Gwangju, South Korea
P102
Trauma in females, a descriptive analysis from real-world data
1Faculty of Medicine, Universiti Teknologi Mara, Selangor, Malaysia
2Department of Mathematical Sciences, Faculty of Science, Universiti Teknologi Malaysia, Johor Bahru, Malaysia
3Centre for Industrial and Applied Mathematics, Universiti Teknologi Mara, Selangor, Malaysia
Patient characteristic by gender.
RTS: revised trauma score; ISS: injury severity score; GCS: Glasgow Coma Scale.
P103
The hole of dome
Department of Emergency and Trauma, Keningau Hospital, Keningau, Malaysia
P104
Effects of first-wave COVID-19 outbreak on emergency department utilization in hybrid hospitals in Malaysia
1Department of Emergency Medicine, Universiti Teknologi Mara, Selangor, Malaysia
2Universiti Teknologi Mara, Selangor, Malaysia
P105
Hemichorea induced by non-ketotic hyperglycemia
1Department of Emergency and Trauma, Hospital Ampang, Ampang, Malaysia
2Hospital Ampang, Ampang, Malaysia
Head CT scan showed chronic multifocal infarct with underlying cerebral atrophy. The patient was treated with insulin and subsequently symptoms resolved and was discharged home well.
P106
Knowledge and compliance to personal protective equipment in emergency department during COVID-19 pandemic in Malaysia: a cross-sectional questionnaire study
1Department of Emergency Medicine, Universiti Teknologi Mara, Selangor, Malaysia
2Universiti Tunku Abdul Rahman, Malaysia
3Universiti Teknologi Mara, Selangor, Malaysia
4Universiti Kebangsaan Malaysia, Bangi, Malaysia
5Universiti Pertahanan National Malaysia, Kuala Lumpur, Malaysia
6Hospital Selayang, Selangor, Malaysia
P107
Secondary exposure to organophosphate in the emergency department: incident analysis
1Emergency, Sengkang General Hospital, Singapore
2Sengkang General Hospital, Singapore
P108
A peculiar presentation of stroke in young patients
1Emergency Medicine, Yashoda Superspeciality Hospitals, Malakpet, India
2Yashoda Superspeciality Hospitals, Malakpet, India
P109
Utility of monocyte distribution width in acute appendicitis
China Medical University & Hospital, Taiwan
P110
The new normal: effectiveness of hybrid basic life support renewal course among healthcare workers in an academic hospital
Universiti Teknologi Mara, Selangor, Malaysia
P111
Lightning strike–induced multiorgan failure—a multidisciplinary approach
1Emergency Medicine, Meenakshi Mission Hospital and Research Institute, Madurai, India
2Meenakshi Mission Hospital and Research Institute, Madurai, India
Lightning strike injuries are rare presentations in emergency departments. Nonetheless, they represent the most common environmental cause of sudden cardiac death. Lightning strikes can be associated with multiorgan injuries, leading to cutaneous, cardiac, renal, and neuropsychological complications. A 32-year-old male patient with no known co-morbidities was brought to emergency with alleged history of lightning struck in the vicinity while sitting in a stationary two wheeler. He had loss of consciousness lasting for 2 min and multiple first-degree burns present over the right groin region. On examination, Glasgow Coma Scale (GCS) was E3V3M5 (11/15) and bilateral pupils were 2.5 mm reacting to light. He was moving all four limbs with right hemiparesis of grade 3/5 in both UL and LL with diminished deep tendon reflexes. Computed tomography (CT) imaging was suggestive of petechial hemorrhage in right basal ganglia and left frontal lobe; bleed was seen in the right mastoid air cells. Electrocardiogram (ECG) showed sinus tachycardia, and echocardiogram (ECHO) revealed moderate left ventricular (LV) dysfunction and elevated cardiac enzymes which were treated accordingly for lightning-induced myocarditis. The patient developed acute kidney injury with rhabdomyolysis for which he was managed with intarvenous (IV) fluids, antibiotics, and other supportive measures. The patient went into respiratory distress, hence intubated and put on mechanical ventilation. Magnetic resonance imaging (MRI) of the spine suggested prevertebral hematoma in the entire cervical region. During the course in hospital, the patient developed quadriparesis without GCS drop for which nerve conduction study was done, which turned out to be normal. Tracheostomy was done for tracheal toileting purpose and regular neuro-rehabilitation done. The patient was diagnosed as having post-lightning polyneuropathy with myocarditis and rhabdomyolysis. During the rehabilitation period, the patient had gradual improvement in motor power with spasticity in both UL and LL. The patient was gradually weaned off and maintained with oxygen support. After 28 days, tracheostomy was decannulated, and the patient’s condition improved and was discharged. Lightning strike patients may present with multiple organ injury. So, multidisciplinary management is of paramount importance, and the psychological impact of a lightning strike needs to be assessed early.
P112
A twitch, a twirl and I can’t stop dancing! A rare case of localized tetanus
1Emergency and Trauma, Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
2Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
Tetanus is a deadly disease of the nervous system caused by the bacterium Clostridium tetani. Generalized tetanus albeit being the most common form, other unusual variety has been reported. In this case report, we present this rare occurrence—an adult male presenting with localized tetanus after a traumatic event.
Mr V is a 19-year-old gentleman, who presented to the emergency department (ED) with acutely painful left calf with cramping after waking up from sleep. He recalled a history of trauma 6 weeks prior, with the left heel hitting the trolley at a supermarket, resulting in a small deep wound with active bleeding. He was only treated by general practitioner (GP) with analgesic and anesthetic cream; no tetanus vaccine given. Examination revealed swollen, tender left calf with intermittent spasms. The patient was given muscle relaxant and intramuscular human tetanus immunoglobulin (HTIG) 1000 units and intramuscular anti-tetanus toxoid (ATT) 0.5 mL injection opposite to the tetanus immunoglobulin site, after which the cramping improved and resolved.
C. tetani is an anaerobic bacterium found in contaminated surfaces that produces neurotoxins called tetanospasmin, which causes acute, uncontrolled spasms by blocking the release of γ-aminobutyric acid, an inhibitory neurotransmitter acting on motor neurons. Localized tetanus is unique because besides having atypical presentation that may mimic other joint and muscle disorders, it usually involves only the affected muscle group at the site of puncture. In localized tetanus, the neurotoxins enter the adjacent nerve supplying the specific muscle group compared to in the generalized form, where multiple nerve endings are reached through blood and lymphatics. Rapid administration of tetanus immunoglobulin coupled with antibiotics such as metronidazole helps prevent toxin spread and improves mortality. Tetanus immunization should be given at presentation and at discharge, followed by 4 weeks later for a more sustained immunity.
Prompt clinical diagnosis and treatment of localized tetanus in ED are paramount to prevent progression into a more deadly form of generalized tetanus, as it is a great mimicker of other musculoskeletal diseases.
P113
Prevalence of herbal usage in Thai elderly patient visited at emergency department of an urban teaching hospital in Bangkok: a cross-sectional survey
1Emergency Medicine, Thailand
2Emergency Medicine, Vajira Hospital, Bangkok, Thailand
P114
The deadly fish
1Department of Emergency, Hospital Tengku Ampuan Rahimah Klang, Selangor, Malaysia
2Hospital Shah Alam, Selangor, Malaysia
On arrival, he was hemodynamically stable with intact neurological examinations. Supportive treatment was initiated; however, within 2 h of observation, he developed sudden respiratory distress and went into cardiac arrest. Cardiopulmonary resuscitation was initiated as per protocol and definitive airway via crash intubation was in place. Fortunately, he had return of spontaneous circulation after 10 min of resuscitative efforts and remained stable subsequently. Blood parameters, electrocardiogram (ECG), and computed tomography (CT) of the brain done in ED were unremarkable. The patient was nursed in intensive care unit (ICU) and was weaned off ventilator support within 2 days of admission. He was discharged well on day 7 with no neurological sequelae.
P115
Devastating biventricular thrombi with dilated cardiomyopathy
Hospital Bintulu, Bintulu, Malaysia
As right-sided ventricular thrombus can cause pulmonary embolism, left-sided ventricular thrombus causes systemic thromboembolism, multiorgan infarction, and failure. Besides, biventricular thrombi are related to diastolic dysfunction, which worsens cardiac function. Biventricular thrombosis can be managed with an oral vitamin K antagonist for 3–6 months, with growing evidence advocating the use of direct oral anticoagulants. Other interventions such as catheter-directed thrombolysis, percutaneous thrombus aspiration, or surgical removal of the thrombus can be considered in thrombi enlargement or symptoms of systemic or pulmonary embolism despite adequate anticoagulation.
P116
Accessory climbing routes were associated with more rescue operations than main climbing route: a retrospective 12-year report of Yu-Shan National Park
China Medical University Hospital, Taichung, Taiwan
P117
Kounis syndrome precipitated by bee sting: a case report
1Emergency, Duchess of Kent Hospital, Sandakan, Malaysia
2Duchess of Kent Hospital, Sandakan, Malaysia
Upon arrival, his Glasgow Coma Scale (GCS) was E1V1M1 and hypotensive, with blood pressure of 86/54 mm Hg. There was no urticaria rash noted and no laryngeal edema seen during intubation. He was ventilated and started on vasopressor.
Initial electrocardiogram (ECG) showed ST elevation in V1V3 with prolonged QT interval. Troponin T was raised (199 ng/L). Subsequent ECGs showed normalization of the ST segment.
Echocardiogram showed preserved left ventricle systolic function, and coronary angiogram showed normal coronary arteries. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain were normal.
He was administered aspirin, statin, and beta blocker. His condition improved and was discharged well. Further history from patient when he regained consciousness noted that he actually suffered from chest pain and dyspnea after being stung by a bee.
Therefore, the diagnosis made was type 1 KS.
The manifestation is similar to actual acute coronary syndrome (ACS), making it difficult to diagnose; however, identifying allergic history is crucial. The most common triggers of KS were antibiotics (27.4%), followed by insect bites (23.4%).
Treatment is challenging, targeted on both cardiac and allergic symptoms. This includes antiplatelets, antihistamines, and vasodilators. Morphine in contrary is avoided as it may induce further histamine release. Patients with the type I variant may benefit from the treatment of the allergic reaction. Nitroglycerin should be used with caution as it may worsen hypotension and tachycardia. Epinephrine can also aggravate ischemia and worsen coronary spasm.
The prognosis of KS is better than atherosclerotic ACS as serious complications such as cardiogenic shock and cardiac arrest are rare.
P118
Starvation ketoacidosis, the forgotten acidosis
Hospital Kuala Lipis, Kuala Lipis, Malaysia
Starvation ketoacidosis (SKA) is an uncommon, often overlooked, and potentially life-threatening event that may develop following a prolonged period of reduced carbohydrate intake. The pathophysiology involves an increase in the production of ketone bodies as alternative fuel in response to carbohydrate depletion. The cause can be multifactorial, which includes pregnancy, sepsis, gastrointestinal tract pathology, and so on. We report a case of 23-year-old lady who developed life-threatening high anion gap metabolic acidosis (HAGMA) probably due to SKA following a period of reduced carbohydrate intake attributed to her cultural belief following childbirth. She had an initial venous pH of 7.37, bicarbonate level of 11.4 mmol/L, anion gap of 24.2 mmol/L, and serum ketone of 3.9 mmol/L with normal lactate and glucose levels. History and other laboratory parameters did not suggest other causes of HAGMA. Intravenous fluid and dextrose solution were administered, followed by rapid resolution of acidosis in a matter of hours in our emergency department. Subsequently she was discharged well following a short and uncomplicated admission to medical floor. We wish to highlight the importance of recognition and timely interventions to prevent significant morbidity and mortality from severe SKA.
P119
Coffee in acute exacerbation of asthma: a randomized controlled study
1Department of Emergency, Hospital Kajang, Kajang, Malaysia
2University of Malaya, Kuala Lumpur, Malaysia
3University Putra Malaysia, Seri Kembangan, Malaysia
P120
Air hunger child
1Emergency and Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
2Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
The airway of children has a unique anatomy and physiology compared to adults. The upper airway of the children is smaller than adult and easily compromised. Therefore, when there is stertor or stridor which is pathognomonic of upper airway obstruction, it should alarm the likelihood of the difficult airway as it poses serious challenges in this age group.
This is a case of upper airway obstruction secondary to retropharyngeal abscess. An 11-month old Pakistani boy unsure of vaccination status was brought by his parents to emergency department for noisy breathing for the past 2 days, associated with fever, cough, coryza, and left neck swelling for 4 days. Upon examination, he was in right lateral position, drooling of saliva with hyperextension of his neck. There was a mass of size 4 × 3 cm, firm, warm, and tender at left lateral neck. There was also stertor, and suprasternal and subcostal recessions; he looked ill. Flexible scope was done, noted to be bulging over the posterior pharyngeal wall of oropharynx, obscuring the view of bilateral arythenoid, unable to visualize vocal cords. He was transferred to the operation theater immediately after scope for intubation by the anesthesiology team. Computed tomography of the neck was done post intubation and retropharyngeal and parapharyngeal abscess was noted. He was treated with intravenous cloxacillin; at the same time, transcervical incision and drainage of the abscess was done. He recovered well.
Acute upper airway obstruction is a pediatric airway emergency; it should be addressed early, and the priority is to secure airway in a controlled manner under controlled environment.
P121
N-acetylcystine may prevent the delayed neuropsychiatric sequelae caused by carbon monoxide poisoning in patients with lactic acidosis
1Emergency, China Medical University Hospital, Taichung, Taiwan
2China Medical University Hospital, Taichung, Taiwan
P122
The problem with tramadol—a literature review
Emergency Medicine, Zayed Military Hospital, Abu Dhabi, United Arab Emirates
P123
Prehospital profile of critically ill heat stroke among hikers in Hong Kong
1Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR
2LKS Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR
3Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR
4Government Flying Service, Hong Kong SAR
P124
Desaturating neonatal medevac: to fly or not to fly
1Emergency and Trauma, Sabah Women and Children’s Hospital, Kota Kinabalu, Malaysia
2Sabah Women and Children’s Hospital, Kota Kinabalu, Malaysia
P125
To find the steady state again: the strategy of selection, adaptation, and integration of multitasking female physician during the COVID pandemic, a qualitative study
Department of Emergency, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
Through fusion of horizons, those themes were further unified into three coping models including selection, adaptation, and integration. By the SAI model, multitasking women physicians coped with the difficulties arising during pandemics and found the steady state of life and work again.
P126
Eye tracking technology to enhance learning experience in simulation training for COVID-19 pandemic
1Department of Accident and Emergency, Urgent Care Center, Hong Kong Adventist Hospital–Tsuen Wan, Tsuen Wan, Hong Kong SAR
2Intensive Care Unit, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR
3Nethersole Clinical Simulation Training Center, Hospital Authority, Hong Kong SAR
All participants filled in six questions concerning the use of eye-tracking device at the end of the course. Written comment about the course was entered as free text.
Thirteen (11.9%) out of 109 written comments related to eye-tracking technique were received with examples:
The eye-tracing technology is a really good learning experience. More could be elaborated.
I would recommend eye-tracking to improve the training.
Eye-tracking is very useful and would like it to be tried more by other teammates.
G001
Sure-shot silver bullet for lower limb analgesia
Department of Emergency Medicine, Christian Medical College and Hospital, India
G002
Minimally invasive chest drain insertion for primary spontaneous pneumothorax
1Department of Accident & Emergency, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong SAR
2Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong SAR
Since no blunt dissection is required, this procedure is less traumatic. Risk of internal organ injuries is minimal as a protective central tip would spring out from the insufflation needle after the needle-sleeve assembly is passed through the chest wall.
G003
The “Suit. Pro.”
1Department of Emergency Medicine, Linkou Chang Gung Memorial Hospital, Keelung, Taiwan
2Linkou Chang Gung Memorial Hospital, Keelung, Taiwan
3Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
Widen the leg opening of PPE;
Widen the opening of the shoe cover and use a cord lock and a cord to tighten it up instead of an elastic band;
Shorten the pants to about 15 cm below the knee and lengthen the shoe cover to about 5 cm below the knee to make an adequate overlap without redundant length.
These adjustments speed up the wearing process and will not compromise the effectiveness of protection.
G004
Thoracent pump
Narayana Hrudayalaya, Bangalore, India
A needle is introduced into the pleural cavity and connected to a three-way valve and is followed by aspiration. Aspiration of the pleural fluid with the help of the syringe, which usually does not require much force in the beginning, tends to get challenging as the volume of the fluid removed increases. All of these can cause the cannula to get displaced and leads to multiple punctures for the patient.
In cases with massive pleural effusion where the volume of the fluid to be drained is large, the individual performing thoracocentesis could get fatigued, which again can lead to the cannula or the needle being displaced.
The three-chamber system as well as the one-way valve ensures that it is a one-way circuit, and no air enters the pleural cavity.
This reduces the error that could occur, leading to needle displacement as there is less fiddling with the circuit. The volume of fluid that is drained can also be controlled by placing sensors in chamber 1; that would switch off the pump as soon as the fixed volume of fluid is drained.
We have performed a simulation study to evaluate the concept and found that it was useful and can reduce the chances of needle/cannula displacement with better patient compliance.
G005
Protecting healthcare workers against COVID-19: a fast-track ventilation system for hospitals
1Department of Mechanical Engineering, City University of Hong Kong, Kowloon, Hong Kong SAR
2City University of Hong Kong, Kowloon, Hong Kong SAR
Hence, we develop an ultra-fast-track and effective technology utilizing vented enclosures for individual patients to protect HCWs.
Our system mainly consists of transparent hood, polyvinyl chloride (PVC) pipes, pump, filter, and antiviral materials. When negative pressure is introduced by the pump, the suction at several extraction ports is induced. The contaminated air is conveyed through an exit port at the base of the hood. The extracted contaminated air is cleaned by high-efficiency particulate air (HEPA) filters and UVC light, and then released back into the ward. Besides, the hood is coated by anti-viral and anti-bacterial coating.
G006
Use of drones (unmanned aerial vehicles) for supporting emergency medical services and out-of-hospital cardiopulmonary arrest
Emergency Medicine, Apollo Hospitals, India
Drone as First Response in Disaster: The drone was able to fly unhindered, hover over the accident location, and relay details of the crash site.
Supervision of Patient Transfers in Disaster: The drone was able to send live video feed continuously as each patient was being evacuated.
Cordoning the Disaster Site: Based on the drone video feed, the ingress/egress routes for the ambulance vehicles were identified and secured.
Basic Life Support: The drone was able to provide live views of arrest scenarios to co-pilot and helped in guiding the first responder for cardiopulmonary resuscitation (CPR).
Transport of Samples: The drone was able to transport blood samples for the stroke patient from the emergency room to the laboratory in the hospital.
Intrahospital Transport of Medicines: The drone was also able to carry medicines from the in-patient pharmacy to the wards.
The Directorate General of Civil Aviation (DGCA) and other authorities should facilitate utilization of drones and unmanned aerial vehicles (UAVs) for supporting emergency medical personnel.