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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Is adrenaline misused in anaphylaxis treatment? Experience of a large, urban Emergency Department: review of 589 cases.


Objective. Acute allergic reactions are important causes of Emergency Department (ED) admissions. Although the current recommendations for treatment of patients with anaphylaxis are focused on the central role of adrenaline, evidence in support of this therapy is still scarce. We planned a retrospective analysis of all allergic and anaphylactic reactions managed in the ED, to assess adherence to current guidelines and clinical outcomes.

Methods. The study population consisted of all consecutive adult patients admitted to the ED with acute allergic reactions during the year 2013. Overall, the final study population consisted of 589 patients, i.e., 329 women and 260 men (55.9% vs. 44.1%, mean age 43±18 years, range 16-96 years).

Results. Fifty-six patients were diagnosed with anaphylaxis (9.5%), 75 with angioedema (12.7%), 363 with urticaria (61.7%), and 95 with urticaria-angioedema (16.1%). The triggers included drugs (21.9%), foods (15.0%), hymenoptera stings (9.9%), and chemicals (4.4%), whereas a specific cause could not be recognized in nearly half of the cases. Only 5 (8.9%) of 56 patients diagnosed with anaphylaxis received adrenaline and no death or Intensive Care Unit (ICU) admission occurred within one month from the acute allergic episode.

Conclusion. The results of our study suggest that anaphylaxis is widely undertreated with adrenaline in our local ED compared to guidelines and recommendations. Nevertheless, a favorable outcome was recorded for all patients included in the study, even when managed with second- and third-line treatments, as attested by the lack of deaths at 1 month and the very limited number of hospitalizations (3/589; 0.5%), related to comorbidities rather than to treatment failure. The strength of recommendations contained in current guidelines should hence be reconsidered.

Key words: allergy, anaphylaxis, urticaria, angioedema, adrenaline, epinephrine

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Chinese research status in emergency medicine journals: a bibliometric analysis based on Science Citation Index Expanded database


Background. Emergency medicine in China has undergone tremendous growth. This study was conducted to evaluate the Chinese scientific output on emergency medicine in Science Citation Index Expanded (SCIE) in the Web of Science during the period of 2000–2013.

Methods. A bibliometric analysis was applied in this study. Articles published by China in SCIE emergency medicine journals were included. They were analyzed in terms of publication outputs, document type, language of publication, journals, countries/territories, institutions, and collaboration patterns. Distributions of article titles and keywords were also studied to reveal research focuses and trends.

Results. During the period, a total of 1043 articles from China were published in SCIE emergency medicine journals. Seven documents types were found, and the journal article was the most frequently used. All articles were written in English. The Hong Kong Journal of Emergency Medicine is the most productive journal. The most productive institutes were Prince Wales Hospital, followed by Tuen Mun Hospital, Chinese University Hong Kong; USA dominated the collaborative countries. The ‘‘injury/injuries’’, ‘‘trauma’’, “acute”, “rat/rats”, “arrest”, ‘‘emergency’’, and ‘‘cardiopulmonary’’, ‘‘resuscitation’’ were the hot spots of emergency medicine research in China.

Conclusion. The results map emergency medicine (EM) development and research trends in China, and potentially guide Chinese EM physicians in evaluating and orienting their research.

Key words: emergency medicine, china, bibliometric, science citation index expanded, research

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Emergency department chest and abdominal computed tomography: impact on patients’ management


Objective. The introduction of computed tomography (CT) has had a very significant impact on patient evaluation and management decisions in the Emergency Department (ED). One of the few published studies demonstrated a positive CT yield in 67% of patients admitted to hospital. The same study demonstrated that in 25% of cases, the CT examination was able to identify a pathological process unidentified by the ED team. Only one study has focused on the evaluation of the variation in patient management that each CT examination is able to achieve. The purpose of our study is to document the impact that CT has on patient diagnosis and management in the ED, employing a large patient series.

Materials and methods. The diagnostic and therapeutic impact of CT was evaluated in a consecutive series of 300 patients who were referred to the radiology department for a chest or abdominal CT examination as requested by the emergency physician.

Results. The net impact of performing a CT was a change in planned treatment in 202 cases out of 300 (67%) and proceding with the planned treatment in the remaining 98 cases (33%). The only intention to demand a CT examination was significantly bound (p=0.015, confidence interval 0.16 and 0.38) to a change in the planned treatment before CT (as it is established with Mc Nemar test).

Discussion. Our study showed that more than 67% of CT reports were able to change the course of treatment planned before CT execution and that in 56% of these cases, the execution of a CT examination was able to generate a major variation in treatment plan.

Key words: emergency department, computed tomography, chest, abdomen, clinical impact

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The feasibility of vasopressin administration via laryngeal mask airway using a porcine model


Background. In pre-hospital situations, delay in resuscitation might carry extra risks for patients, so resuscitative measures should be rapid, easy-to use, and effective. A laryngeal mask airway (LMA) is a quickly placed supraglottic airway that may be used as a route for drug administration. Vasopressin is a vasopressor and might be absorbed well via the mucosa of the airways and alveoli. We conducted this animal study to verify the feasibility of administering vasopressin via a LMA.

Methods. Twenty-four Yorkshire pigs were anesthetized and randomly divided into four groups. The pigs in Groups Placebo and tracheal tube (TT) were intubated with a cuffed tracheal tube, and those in Groups LMA and laryngeal mask airway and a catheter (LMAC) underwent a size 4 LMA insertion. In the LMAC group, an aerosolized catheter was placed into the trachea through a LMA to deliver the drug. All pigs were able to breathe spontaneously without the assistance of a ventilator. The placebo group received 5 ml of distilled water via a tracheal tube. The other groups received 1 U/kg vasopressin, which was diluted to a total volume of 5 ml with distilled water via the varied routes. The heart rates and arterial pressures were recorded before and after drug administration.

Results. The mean arterial pressure (MAP) and diastolic arterial pressure (DAP) increased significantly and maintained a plateau from 3 to 7 min in Group TT and 2 to 29 min in Group LMAC. Group LMA and Group Placebo demonstrated only one occasional elevation in MAP and no changes in DAP. Furthermore, the heart rate decreased significantly from 2 to 29 min in Group LMAC.

Conclusions. In this porcine model, vasopressin administered via an aerosolized catheter and ventilated with a LMA demonstrated a positive and prolonged pressor effect. The results suggest that an aerosolized catheter placed through a LMA, may be a practical alternative route for vasopressin administration, and that the effective duration of vasopressin is long enough to cover the period of pre-hospital management.

Key words: laryngeal mask airway, vasopressin, airway, pre-hospital

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Are Heimlich maneuver videos on YouTube accurate and reliable?


Introductıon. First aid for airway obstruction is a life-saving maneuver that can be implemented by anyone. In this study, we determined the accuracy of Heimlich maneuver videos posted on the Internet.

Materials and methods. Heimlich maneuver videos uploaded on to YouTube were evaluated. We recorded by whom the video was uploaded, upload time, the number of viewers, and to whom it was intended. Scores from 0 to 7 were used to evaluate video suitability. Data were analyzed using SPSS 20.0 for Windows software. A p-value < 0.05 was considered to indicate significance.

Results. A total of 640 videos were evaluated; 466 (72.8%) videos were excluded because their content was primarily for entertainment purposes. In total, 174 videos met the inclusion criteria and were subjected to analysis. Of the 174 videos analyzed, 54(31%) were uploaded anonymously, the mean number of viewers was 26,814 ± 4,860, and the median video duration was 4.19 min (range, 0.06–114 min). The mean video score was 2.7 ± 1.6. Using this value as a cut-off, a significant relationship between reliability and uploading institution was detected (p ≤ 0.05), but not between the number of views and reliability (p = 0.428).

Conclusion. Our results suggest that Heimlich maneuver videos uploaded to YouTube were not particularly educational because only 13% of the videos received an above-average score.

Key words: airway obstruction, first aid, YouTube video

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