Naja species Bite Injury- Pathophysiology of Envenomation and Multidisciplinary Approach in Management

@#Cobra bite envenomation is one of the commonest causes of snake related injuries in Malaysia. Local tissue injury following a cobra bite is a complex sequalae of envenomation that is attributed to various peptides and enzymes including cytotoxin, metalloproteases, phospholipase A2 and hyaluronidase. This case involves a young construction worker who was bitten by an unidentified snake on the dorsum of his left foot. He presented with typical features of local and systemic envenomation of a Naja species. Remote Envenomation Consultancy Services was consulted and the appropriate antivenom was administered. The patient underwent wound debridement and subsequent skin grafting. Follow up at outpatient clinic showed good skin graft uptake and recovery. Managing a significant Naja species bite envenomation can be a lengthy process requiring expertise from various subspecialties. Timely and seamless multidisciplinary approach in managing a Naja species envenomation ensures a favorable outcome with minimal complication..

The Prevalence of Hypersensitivity Reactions to Snake Antivenoms Administered in Sultanah Nur Zahirah Hospital From 2013 To 2016

@#Introduction: Snakebite is an important medical emergency. Antivenoms remain the only proven treatment for snake envenoming. However, the use of antivenom is associated with hypersensitivity reactions. The aims of this study were to determine the prevalence and types of hypersensitivity reactions and types and outcomes of pharmacological and non-pharmacological treatments for antivenom reactions among snakebite patients that received antivenoms. Methods: This was a 4-year cross-sectional study of snakebite patients from January 2013 to December 2016 in Hospital Sultanah Nur Zahirah (HSNZ), Terengganu. Data was extracted from the Pharmacy Record on the usage of antivenom and patients of snakebites treated with antivenom were identified. Data of patients were then obtained from the electronic medical records.’ Demographic details, clinical features and characteristics of antivenom reactions of patients were recorded in standardized data collection forms and analyzed using chi-square or MannWhitney U tests. Results: Of the 44 patients who received antivenom, 24 (54.5%) developed hypersensitivity reaction. All patients developed reaction early. No patient developed delayed (serum-sickness) reaction. Of the 24 patients, 14 (58.3%) had moderate to severe hypersensitivity reaction and 9 (37.5%) patients had mild reactions. Only one (4.2%) patient presented with bradycardia. Conclusion: The prevalence of early hypersensitivity reaction to snake antivenom in HSNZ was relatively high. Healthcare providers should be aware of the appropriate method of preparing and administering antivenom, and the management for acute hypersensitivity reactions. This will optimize the management of snakebite and ensure patient safety

A case of cough induced rib fracture with subcutaneous emphysema and pneumothorax

@#Coughing is an important reflex mechanism which enhances the clearance of secretions and particulates from the airways, however repetitive muscle strain due to prolonged coughing may cause the uncommon complication of stress fracture of the ribs. The following is an unusual case of cough induced multiple rib fractures associated with subcutaneous emphysema and pneumothorax which was missed in the emergency setting. Delayed diagnosis and treatment would have been avoided if this uncommon condition was considered as a possibility

The Effectiveness of a Navigation System for Ambulance Service in Kuala Lumpur, Malaysia

The response and transport intervals of an ambulance dispatch are affected by various factors. The present ambulance system relies on the driver’s experience, knowledge of local road map and estimations of directions. These may contribute to delays, misdirection and inefficient utilization of resources. The objectives of this study were to assess the effects of GPS navigation device on the response and transport time intervals of an ambulance service operating in urban setting. This was a three-month experimental study involving simulated ambulance dispatch based in a hospital. A total of 50 simulated cycles were constructed. Travel time, arrival time and distance were documented from each cycle. The median actual response time using map and GPS navigation device was 11.82 min and 10.47 min respectively. The median actual transport time using map and GPS navigation device was 11.00 min and 10.74 min respectively. The differences in response time and transport time between map and GPS navigation were not statistically significant (p= 0.215 and p=0.710). The application of GPS reduced the error value between estimated and actual response time by 8.73%. It also reduced the mean error value between estimated and actual transport time by 1.42%. The result shows that the GPS navigation device allowed for more accurate travel time estimation and its application in an urban setting such as Kuala Lumpur has the potential to reduce ambulance response time.

The Effectiveness Of A Navigation System For Ambulance Service In Kuala Lumpur, Malaysia

@#The response and transport intervals of an ambulance dispatch are affected by various factors. The present ambulance system relies on the driver’s experience, knowledge of local road map and estimations of directions. These may contribute to delays, misdirection and inefficient utilization of resources. The objectives of this study were to assess the effects of GPS navigation device on the response and transport time intervals of an ambulance service operating in urban setting. This was a three-month experimental study involving simulated ambulance dispatch based in a hospital. A total of 50 simulated cycles were constructed. Travel time, arrival time and distance were documented from each cycle. The median actual response time using map and GPS navigation device was 11.82 min and 10.47 min respectively. The median actual transport time using map and GPS navigation device was 11.00 min and 10.74 min respectively. The differences in response time and transport time between map and GPS navigation were not statistically significant (p= 0.215 and p=0.710). The application of GPS reduced the error value between estimated and actual response time by 8.73%. It also reduced the mean error value between estimated and actual transport time by 1.42%. The result shows that the GPS navigation device allowed for more accurate travel time estimation and its application in an urban setting such as Kuala Lumpur has the potential to reduce ambulance response time.

Training standardized patients for undergraduate Psychiatry examinations: experience of a Malaysian university

Simulated/ standardized patients (SPs) have become one of the significant components in today’s medical education and students’ assessment. Some differences exist in the training method of SPs for psychiatry examinations compared to other medical disciplines. This brief report highlights the challenges encountered in the training process and methods to overcome those challenges. A wellstructured, intensive training remains as one of the most important factors in ensuring standardization of SPs for psychiatric examinations.

A Study of House Officers in a Teaching Hospital on Knowledge, Perception of Skills and Confidence Level in Performing CPR

Cardio-pulmonary Resuscitation (CPR) is important and should be mastered by House Officers (HO). House officers who have just completed their studies are assigned to acute medical and surgical wards. If a patient in the ward has a cardiac arrest (CA), these doctors are usually the first to attend. Therefore an HO must be confident with CPR skills. They must be competent in performing CPR. The authors assessed 26 new HOs from Universiti Kebangsaan Malaysia Hospital (HUKM) with respect to their self-perception about CPR skills, confidence level in performing CPR and knowledge in performing CPR. Knowledge was assessed by a questionnaire. We found that 16 of 26 (61.5%) assessed themselves to have inadequate knowledge and 46.2% had no confidence in performing CPR. The mean score of the written test was 5.7 ± 1.8. Seven out of 26 (27.0%) HOs had incorrect hand placement position for CPR. Only 4 and 9 out of 26 HOs had their sternal paddle and cardiac apex paddle positions correctly placed respectively. In conclusion, knowledge, perception of skills and confidence levels of HOs on CPR are inadequate and need further assessment and improvement. Medical schools need to review their CPR curriculum in order to prepare HOs adequately to work in emergency situations.