INTRODUCTION: Out-of-hospital-cardiac-arrest (OHCA) is a major public health challenge and post-return-of-spontaneous-circulation (ROSC) goals have shifted from just survival to survival with intact neurology. Although post-ROSC care is crucial for survival with intact neurology, there are insufficient well-established protocols for post-resuscitation care. We aimed to evaluate post-resuscitation care in the emergency department (ED) of adult (aged ≥16 years) OHCA patients with sustained ROSC and its associated neurologically intact survival. METHODS: A retrospective review of electronic medical records was conducted for OHCA patients with sustained ROSC at the ED. Data including demographics, pre-hospital resuscitation, ED resuscitation, post-resuscitation care and eventual outcomes were analysed. RESULTS: Among 921 OHCA patients, 85 (9.2%) had sustained ROSC at the ED. Nineteen patients (19/85, 22.4%) survived, with 13 (13/85, 15.3%) having intact neurology at discharge. Electrocardiogram and chest X-ray were performed in all OHCA patients, whereas computed tomography (CT) was performed inconsistently, with CT brain being most common (74/85, 87.1%), while CT pulmonary angiogram (6/85, 7.1%), abdomen and pelvis (4/85, 4.7%) and aortogram (2/85, 2.4%) were done infrequently. Only four patients (4.7%) had all five neuroprotective goals of normoxia, normocarbia, normotension, normothermia and normoglycaemia achieved in the ED. The proportion of all five neuroprotective goals being met was significantly higher ( P = 0.01) among those with neurologically intact survival (3/13, 23.1%) than those without (1/72, 1.4%). CONCLUSION Post-resuscitation care at the ED showed great variability, indicating gaps between recommended guidelines and clinical practice. Good quality post-resuscitation care, centred around neuroprotection goals, must be initiated promptly to achieve meaningful survival with intact neurology.
Humans ; Out-of-Hospital Cardiac Arrest/mortality* ; Retrospective Studies ; Male ; Female ; Middle Aged ; Emergency Service, Hospital ; Cardiopulmonary Resuscitation/methods* ; Return of Spontaneous Circulation ; Aged ; Adult ; Treatment Outcome ; Electrocardiography ; Tomography, X-Ray Computed ; Aged, 80 and over

OBJECTIVE: To investigate the impact of early antimicrobial therapy on the prognosis of patients with suspected sepsis in emergency and outpatient settings. METHODS: A prospective cohort study was conducted. Patients with suspected sepsis admitted to the emergency department of Taizhou Hospital, Zhejiang Province, from May 1, 2022, to July 31, 2023, were enrolled. Participants were divided into an early group (0-1 hour) and a delayed group (> 1 hour) according to duration from admission to antimicrobial administration. General information, initial vital signs, laboratory parameters within 24 hours after admission, disease severity scores, vasoactive drug usage, and clinical outcomes of the patient were collected. Kaplan-Meier survival curve was used to analyze 28-day survival. Multivariate Cox proportional hazards regression was performed to identify independent risk factors for prognosis of the patients with suspected sepsis in emergency and outpatient settings. Sensitivity analyses were conducted through subgroup analyses. RESULTS: A total of 143 patients with suspected sepsis were enrolled in the analysis, with 66 patients in the early group and 77 in the delayed group. No statistically significant differences were observed in baseline characteristics (age, gender, vital signs, laboratory parameters, disease severity scores) or clinical outcomes [vasoactive drug usage rate, mechanical ventilation duration, length of intensive care unit (ICU) stay, total hospitalization duration] between the two groups. The 28-day mortality, multidrug resistance rate and sepsis confirmation rate did not differ significantly between the early group and delay group [28-day mortality: 18.2% (12/66) vs. 20.8% (16/77), multidrug resistance rate: 3.0% (2/66) vs. 2.6% (2/77), sepsis confirmation rate: 87.9% (58/66) vs. 88.3% (68/77), all P > 0.05]. Kaplan-Meier survival curve analysis showed no difference in 28-day cumulative survival between the two groups (Log-Rank test: χ² = 2.528, P = 0.112). Multivariate Cox proportional hazards regression identified vasoactive drug usage [hazard ration (HR) = 2.465, 95% confidence interval (95%CI) was 1.019-5.961, P = 0.045] and endotracheal intubation (HR = 5.516, 95%CI was 2.195-13.858, P < 0.001) as independent risk factors for 28-day death of the patients with suspected sepsis in emergency and outpatient settings. Further exploration of the impact of early antimicrobial therapy on 28-day death in different subgroups of the patients with suspected sepsis in emergency and outpatient settings was conducted through subgroup analysis. The results showed that in the patients with different ages (< 60 years old: HR = 1.214, 95%CI was 0.535-2.751, P = 0.643; ≥ 60 years old: HR = 2.085, 95%CI was 0.233-18.668, P = 0.511), sequential organ failure assessment (SOFA) scores (< 6: HR = 1.411, 95%CI was 0.482-4.128, P = 0.530; ≥ 6: HR = 0.869, 95%CI was 0.292-2.587, P = 0.801), shock indexes (< 1: HR = 1.095, 95%CI was 0.390-3.077, P = 0.863; ≥ 1: HR = 1.364, 95%CI was 0.458-4.059, P = 0.577) and whether diagnosed with sepsis or not (yes: HR = 0.943, 95%CI was 0.059-15.091, P = 0.967; no: HR = 1.207, 95%CI was 0.554-2.628, P = 0.636) subgroups, early usage of antibiotics had not shown any advantage in improving prognosis compared with delayed usage. CONCLUSION Early antimicrobial therapy does not improve the prognosis of patients with suspected sepsis in emergency and outpatient settings.
Humans ; Sepsis/drug therapy* ; Prospective Studies ; Prognosis ; Emergency Service, Hospital ; Outpatients ; Female ; Male ; Anti-Infective Agents/therapeutic use* ; Middle Aged ; Aged ; Proportional Hazards Models ; Treatment Outcome

Adult ; Humans ; Heart Arrest/therapy* ; Cardiopulmonary Resuscitation ; Emergency Service, Hospital ; Out-of-Hospital Cardiac Arrest/therapy* ; Treatment Outcome

Emergency Treatment ; Fractures, Bone/surgery* ; Hemodynamics ; Humans ; Pelvic Bones/surgery*

Humans ; COVID-19/epidemiology* ; Pandemics ; SARS-CoV-2 ; Emergency Medical Services ; Emergency Treatment ; Emergency Service, Hospital

Malaysia has one of the highest total numbers of COVID-19 infections amongst the Southeast Asian nations, which led to the enforcements of the Malaysian "Movement Control Order" to prohibit disease transmission. The overwhelming increasing amount of infections has led to a major strain on major healthcare services. This leads to shortages in hospital beds, ventilators and critical personnel protective equipment. This article focuses on the critical adaptations from a general surgery department in Malaysia which is part of a Malaysian tertiary hospital that treats COVID-19 cases. The core highlights of these strategies enforced during this pandemic are: (1) surgery ward and clinic decongestions; (2) deferment of elective surgeries; (3) restructuring of medical personnel work force; (4) utilization of online applications for tele-communication; (5) operating room (OR) adjustments and patient screening; and (6) continuing medical education and updating practices in context to COVID-19. These adaptations were important for the continuation of emergency surgery services, preventing transmission of COVID-19 amongst healthcare workers and optimization of medical personnel work force in times of a global pandemic. In addition, an early analysis on the impact of COVID-19 pandemic and lockdown measures in Malaysia towards the reduction in total number of elective/emergent/trauma surgeries performed is described in this article.
Betacoronavirus ; Coronavirus Infections ; epidemiology ; prevention & control ; Elective Surgical Procedures ; Emergency Treatment ; Humans ; Malaysia ; epidemiology ; Pandemics ; prevention & control ; Pneumonia, Viral ; epidemiology ; prevention & control ; Wounds and Injuries ; surgery

OBJECTIVE: To select and define the clinical questions and outcomes of Guideline for the Emergency Treatment of Anaphylaxis. METHODS: A draft including clinical questions, which could be divided into foreground questions and background questions, and outcomes was drawn and revised by the secretary group for the guideline referring to the present guidelines with the guidance of a panel consisting of 7 experienced clinical medicine, pharmacy and nursing experts. Foreground questions and outcomes of the draft were voted into a final version after three rounds of counsels of 22 experienced medicine, pharmacy and nursing clinical experts using Delphi method including 3 rounds of inquiry. And the background questions were directly included in the guideline after the 22 experts' thorough revising. The research was carried out under the supervision of method ologists. Active coefficient, coefficient of variation and the frequencies of each score were calculated for quality control. RESULTS: The draft of 34 foreground questions, 6 background questions and 6 outcomes was finally drawn up after thorough selecting and consulting. The 6 background questions revised by the clinical experts were all included. After three rounds of Delphi method, 28 pivotal clinical questions covering the diagnosis, preparation for the treatment, treatment and administration after the treatment, and 6 outcomes were defined and included for the guideline. The rest of the foreground questions, 4 of which were recognized as essential and 2 as important, were excluded from the guideline and left for further revising or updating. As for the outcomes, 4 of them were recognized as critical and the rest as important. The experts contributing to the research were active as the active coefficient reached 100%, and the degree of consensus was fine as the frequencies of the feedback scoring equal to or greater than 4 for all the 28 foreground questions included were greater than 75% and the result was settled in the first round. And 2 outcomes, fatality rate and severity, reached a higher degree of consensus with coefficient of variation less than 15%. CONCLUSION After thorough and rigorous selecting, the clinical questions and outcomes to be included in the Guideline for the Emergency Treatment of Anaphylaxis were finally selected and defined via Delphi method, guiding the future development of the guidelines.
Anaphylaxis/therapy* ; Consensus ; Delphi Technique ; Emergency Treatment ; Humans ; Research Design

OBJECTIVE: To investigate the effect of emergency medical service (EMS) on the prognosis of ischemic stroke patients treated with intravenous thrombolysis. METHODS: Clinical data of 2123 ischemic stroke patients treated with intravenous thrombolysis in 70 hospitals in Zhejiang province were retrospectively analyzed. There were 808 patients sent to the hospital by ambulance (EMS group) and 1315 patients by other transportations (non-EMS group). Good outcome was defined as modified Rankin Scale (mRS) ≤ 2 at 3-month. The onset to needle time (ONT), onset to door time (ODT), door to needle time (DNT) and outcome were compared between EMS group and non-EMS group. Binary logistic regression was used to explore the influencing factors for the outcome at 3-month. RESULTS: Compared with the non-EMS group, patients in the EMS group were older, with higher baseline National Institute of Health Sroke Scale (NIHSS) score, and had a higher proportion of atrial fibrillation (all <0.05), but there were no significant differences in ONT, ODT and DNT between two groups (all >0.05). Binary logistic regression showed that EMS was not independently associated with good outcome (=0.856, 95%:0.664-1.103, >0.05). CONCLUSIONS EMS had not improve the outcome of patients receiving intravenous thrombolysis in Zhejiang province.
Administration, Intravenous ; Brain Ischemia ; drug therapy ; Emergency Medical Services ; Fibrinolytic Agents ; therapeutic use ; Humans ; Prognosis ; Retrospective Studies ; Stroke ; drug therapy ; Thrombolytic Therapy ; statistics & numerical data ; Treatment Outcome

INTRODUCTION: Telestroke allows for remote determination of suitability for treatment with thrombolysis in patients with acute ischaemic stroke. However, this approach is time-dependent and most centres have yet to achieve the recommended treatment times. We describe a quality improvement initiative aimed at improving the telestroke workflow and treatment times at our centre. METHODS: A multidisciplinary workgroup comprising clinicians, stroke case managers and radiology staff was formed to oversee the initiative. A phase-by-phase review of the existing workflow was done to identify the reasons for delay. Phase-specific measures were then introduced to address these delays, and a data-monitoring system was established to track the impact of these measures. The initiatives were implemented through four Plan-Do-Study-Act cycles. The door-to-needle (DTN) times for thrombolysis and clinical outcomes before and after the interventions were compared. RESULTS: A total of 104 patients were evaluated. The median DTN time improved from 96 minutes to 78 minutes post implementation of initiatives (p = 0.003). Fewer patients had symptomatic intracranial haemorrhages (8.5% vs. 24.2%; p = 0.03), and more patients had improvements in their National Institutes of Health Stroke Scale score (47.9% vs. 25.0%; p = 0.031) after the initiatives were introduced. CONCLUSION The quality improvement initiative resulted in a reduction in median DTN time. Our approach allowed for a systematic method to resolve delays within the telestroke workflow. This initiative is part of an ongoing effort aimed at providing thrombolysis safely to eligible patients in the shortest possible time.
Adult ; Aged ; Aged, 80 and over ; Emergency Service, Hospital ; organization & administration ; Female ; Humans ; Interprofessional Relations ; Intracranial Hemorrhages ; prevention & control ; Male ; Middle Aged ; Quality Improvement ; Severity of Illness Index ; Singapore ; Stroke ; therapy ; Telemedicine ; methods ; organization & administration ; standards ; Thrombolytic Therapy ; methods ; Time ; Tissue Plasminogen Activator ; therapeutic use ; Treatment Outcome

OBJECTIVES: The aims of this study were to determine the effectiveness of local compression in patients presenting to the emergency room with intraoral bleeding and to identify when complex haemostatic measures may be required.MATERIALS AND METHODS: Five hundred forty patients who had experienced intraoral haemorrhage were retrospectively reviewed. The outcome variable was the haemostasis method used, i.e., simple (local compression with gauze) or complex (an alternative method after local compression has failed). Predictor variables were sex, age, American Society of Anesthesiologists (ASA) class, hepatic cirrhosis, bleeding disorder, use of antithrombotic agents, and site/cause of haemorrhage.RESULTS: The mean patient age was 48.9±23.9 years, 53.5% were male, 42.8% were ASA class II or higher, and 23.7% were taking antithrombotic agents. Local compression was used most often (68.1%), followed by local haemostatic agents, sutures, systemic tranexamic acid or blood products, and electrocautery. The most common site of bleeding was the gingiva (91.7%), and the most common cause was tooth extraction (45.7%). Risk factors for needing a complex haemostasis method were use of antithrombotic agents (odds ratio 2.047, P=0.009) and minor oral surgery (excluding extraction and implant procedures; odds ratio 6.081, P=0.001).CONCLUSION: A haemostasis method other than local compression may be needed in patients taking antithrombotic agents or having undergone minor oral surgery.
Anticoagulants ; Electrocoagulation ; Emergency Service, Hospital ; Emergency Treatment ; Fibrinolytic Agents ; Gingiva ; Hemorrhage ; Humans ; Liver Cirrhosis ; Male ; Methods ; Odds Ratio ; Retrospective Studies ; Risk Factors ; Surgery, Oral ; Sutures ; Tooth Extraction ; Tranexamic Acid