Non-randomized comparative study on the efficacy of a trauma protocol in the emergency department / 中华创伤杂志(英文版)

PURPOSE@#Trauma is a major health problem in developing countries and worldwide which requires many resources and much time in an emergency department (ED). Although Advanced Trauma Life Support (ATLS) is the gold standard, operator dependence can affect the quality of care. The objective was to identify differences in numbers and time to lifesaving interventions, investigation, ED length of stay, and mortality between an in-house protocol and conventional practice.@*METHODS@#This was a single-center prospective non-randomized study for adult trauma patients in the ED. The trauma protocol was developed from the recent ATLS guideline.@*RESULTS@#Thirty-two and 41 cases were in the in-house protocol group and conventional practice group, respectively. Endotracheal intubation was done more frequently in the in-house protocol group (84% vs. 59%, p = 0.03). Intercostal drainage tube insertion was done faster (6-26 min, median 11 min vs. 15-84 min, median 35 min, p = 0.02) and pre-arrival notification by emergency medical service increased in the in-house protocol group (66% vs. 30%, p = 0.01). Hypothermia in the operating room was found only in the conventional practice group (62% vs. 0, p = 0.007) and a warm blanket was used significantly more often in the in-house protocol group (25% vs. 0, p < 0.001). A directed acyclic graph with multivariate analysis was used to identify confounders. Time to Focused Assessment Sonography in Trauma was significantly shorter in the in-house protocol group (6.5-15.6 min, median 11 min, p = 0.019).@*CONCLUSION@#In addition to the ATLS guideline, the trauma protocol could improve trauma care by reduced time to investigation, early notification of the trauma team in pre-hospital situations, reduced incidence of hypothermia in the operating room, and increased use of a warm blanket.

Comparison of Rapid Sequence Intubation Protocol Versus Conventional Intubation at the Emergency Department in Songklanagarind Hospital: A Pilot Study.

Objective: To compare the success rates, complication rates and intubation time between the diagnostic-based Rapid Sequence Intubation (RSI) protocol and conventional intubation without muscle relaxants.Materials and methods: This comparative prospective observational study was conducted at the Emergency Department in Songklanagarind Hospital from 1 April, 2008 to 30 November, 2008. Patients included were those over 18 years old who needed endotracheal intubation at the Emergency Department. The data was divided into 2 groups on consecutive periods; the pre-protocol (conventional) and post-protocol (RSI) groups. The patient’s information included sex, age, vital signs, indication for intubation, intubators, complications, intubation time and drugs used.Results: There were 45 patients; 38 patients in the conventional group and 7 patients in the RSI group. The overall success rate (intubation in term of ≤ 2 attempts) was 88.9%, without statistically significant between the groups regarding success rate and intubation time (p-value=1.000 and 0.088 respectively). The complication rate in the conventional group was significantly higher than in the RSI group (p-value= 0.047).Conclusions: This pilot study showed that the RSI had the same success rate and intubation time with the conventional intubation with fewer complications. 

Canadian triage and acuity scale in the Emergency Department

 Objectives: To determine the relationship between expense and waiting time with using Canadian Triage and Acuity Scale (CTAS) level, to evaluate the validity of the CTAS triage that was implemented in Emergency Department (ED)Materials and methods: This was a prospective observational study conducted between April 1st and July 6th, 2008. Patients who were triaged by emergency medicine residents at our institution using CTAS (level I-V) were included in the study. The correlations between CTAS levels with waiting times and hospital expense of the patient was calculated.Results: Seven hundred and eighty nine patients were enrolled. The median expenses associated with each CTAS level were CTAS level I 2,576 Baht, CTAS level II 745 Baht, CTAS level III 155 Baht, CTAS level IV 124 Baht and CTAS level V 80 Baht. The median waiting times were CTAS level I 9 minutes, CTAS level II 12 minutes, CTAS level III 18 minutes, CTAS level IV 32 minutes and CTAS level V 42 minutes. For both variables, the differences between groups were statistically significant as determined by the Kruskal-Wallis test in both variables.Conclusion: CTAS is significantly related to the cost of treatment and the waiting time in patients who visited the ED.

The incidence of anaphylaxis in Emergency Room of Songklanagarind Hospital

Objective: To study the incidence rate of anaphylaxis in the emergency room of Songklanagarind Hospital.Method: The medical records of patients diagnosed as having anaphylaxis who visitedSongklanagarind Hospital's Emergency Room from June 1st, 2006 to May 31st, 2008 were reviewed.Result: The incidence of anaphylaxis was 1 in 686 or 146 in 100,000 cases per year of all patients visited at the emergency room of Songklanagarind Hospital. The presenting symptoms were 142 cases (98.6%) of cutaneous system, 105 cases (74.5%) of respiratory system and one patient required intubation, 41 cases (28.3%) of cardiovascular system and 58 cases (41.4%) of gastrointestinal system. The most common causes of anaphylaxis were food (33.8%), medicine (22.1%) and insect stings (13.1%).Conclusion: The incidence of anaphylaxis at the emergency room of Songklanagarind Hospital was 146 in 100,000 cases per year. The most common cause of anaphylaxis was food.

Poisoning and drug overdoses in the Emergency Department at Songklanagarind Hospital

 Objective: To study the prevalence of poisoning and drug overdoses in the Emergency Department (ED) Songklanagarind Hospital.Method: A Retrospective study from January 1, 2007 to December 31, 2007. The records of all patients who presented to the ED with ingested poisons or drug overdoses were reviewed.Result: A total of 133 patient records were included in this study. The prevalence of drug overdose was 0.25% of a total of 52,542 patients/year. There were female 82 cases (61.7%) and male 51 cases (38.3%). Most were 15-24 years old. Drugoverdose was the most common problem (46.6%). The most common reason was attempted suicide(67.7%); 53.4% of the patients were sent to consult a psychiatrist. 47.4% were admitted to the hospital and 15% had complications. The mortality rate was zero.Conclusion: Poisoning and drug overdose was found 0.25% in Emergency Department. Most of patients were 15-24 years old and the most common problem is drug overdose for attempted suicide.

Emergency department diagnosis of acute abdominal pain in elderly patients

Objectives: To study the incidence and correctness of diagnoses in elderly patients examined in the Emergency Department (ED) for acute abdominal pain and compare the morbidity and mortality of patients whom are diagnosed in agreement and disagreement between the final and initial diagnoses.Methods: This was a retrospective study of 378 elderly patients examined in the ED for acute non-traumatic abdominal pain from January 1 through December 31, 2005. The patients’ medical records were reviewed for demographics, initial diagnosis, final diagnosis, length and cost of hospitalization, mortality and morbidity.Results: Of 378 patients; median age 71 (60- 94 years; 46.3% were men and 71.2% had underlying diseases. 83.1% were diagnosed correctly and the common causes were nonspecify 35.2%; acute gastritis, gastroenteritis and diarrhea 10.6%; cholecystitis, cholelithiasis and biliary tract disease 8.2%. 26.5% of all patients were admitted, and in this subgroup, the diagnoses were correct only 66% of the time and the common diagnoses were cholecystitis, cholelithiasis and biliary tract disease 30.0%; intestinal obstruction 17.0%; nonspecify 10.0%. The patients who had discordance between initial and final diagnoses increased morbidity significantly since they had more hospitalization time (5.5 VS 8.0 days) and costs (12,107 VS 22,674 Baht), (p = 0.016 and 0.022, respectively). Fortunately, no one died in our study.Conclusion: This study examined the rate of incorrect diagnoses in elderly patients admitted to our ED due to acute abdominal pain. The impacts of incorrect diagnoses are mainly prolonged hospitalization and increased hospital costs.