The effect of personal protective equipment on emergency airway management by emergency physicians: a mannequin study.

OBJECTIVE: Emergency medical personnel are at risk of secondary contamination when treating victims of chemical-biological-radiological-nuclear incidents. Hence, it is crucial to train them on the appropriate management of patients involved in chemical-biological-radiological-nuclear incidents. Personal protective equipment (PPE) plays an important role in treating patients suffering from various types of poisoning. However, very few studies have examined whether the use of PPE impedes airway management in an emergency department setting. The present study evaluated the effect of PPE on physicians' performance of emergency airway management using mannequins. METHODS: Forty emergency physicians with 1-4 years of experience participated, and were divided by years of experience (1-2 vs. 3-4 years). Each participant both intubated a tracheal tube and inserted a laryngeal mask airway into a mannequin, with and without wearing protection using preassembled intubation aids. The intubation time for both methods was assessed along with participants' preferences and experiences in airway management. RESULTS: The mean (SD) times to successful tracheal tube/mask placement with and without protection were similar [tracheal tube: 17.86 s (6.38) vs. 17.83 s (11.13), P=0.99; laryngeal mask: 10.51 s (4.39) vs. 9.65 s (3.29), P=0.32]. CONCLUSION: Protective equipment had no effect on physicians' emergency airway placement time. The effect of wearing PPE is limited if postintubation care is excluded from the evaluation. Furthermore, intubation experience influenced participants' preferred approach for airway management.

An investigation of snakebite antivenom usage in Taiwan.

BACKGROUND/PURPOSE: Four types of antivenom are used to treat snakebites by the six species of venomous snakes native to Taiwan. Research into antivenom use in Taiwan and its outcomes, as well as the utility of current Taiwan Poison Control Center guidelines for antivenom use, has been limited. We aimed to provide increased understanding by investigating the treatment and outcomes of patients treated for snakebite in Taiwan. METHODS: On the basis of data collected from the 2009 Taiwan National Health Insurance database, patients with snakebites were identified and categorized into two sets of groups according to types of antivenom administered. The relationships between antivenom types, dosage and the variables of antibiotic use, surgical intervention, acute respiratory failure acute, renal failure, antivenom-related allergic reaction, mortality, need for hospital admission, and length of hospitalization were analyzed by multivariate logistic regression and the Kruskal-Wallis test. RESULTS: The majority of patients were successfully treated by administration of 1 vial of antivenom and discharged without complications. However, patients treated for neurotoxic-type venom snakebite required administration of larger doses of antivenom and > 30% required surgical intervention, particularly those treated for Chinese cobra snakebite. Approximately 10% of patients were administered two types of antivenom. CONCLUSION: The results partially support Taiwan Poison Control Center guidelines for treating the hemorrhagic-type venom snakebite. However, deficit in the guidelines for treatment of neurotoxic-type venom snakebite is obvious and new guidelines for treatment of neurotoxic-type venom snakebite and diagnosis should be developed.

Is neostigmine effective in severe pufferfish-associated tetrodotoxin poisoning?

CONTEXT: Pufferfish-associated tetrodotoxin poisoning occurs occasionally in coastal regions of Asian countries and sporadically elsewhere. While anecdotal reports have suggested neostigmine use, evidence for its clinical effectiveness remains unclear. OBJECTIVE: We sought to determine whether neostigmine was likely to be effective in tetrodotoxin-poisoned patients with acute respiratory failure caused by pufferfish consumption. METHODS: We searched in PubMed, EMBASE, CINAHL, Google Scholar, and other databases to collect cases of acute pufferfish-associated tetrodotoxin poisoning ever published without limiting publishing years. We screened each identified title and abstracts that were published in English language, selected, and reviewed full-text publications that were published in English or Chinese and reported at least one adult case (aged ≥ 16 years) of acute respiratory failure attributable to pufferfish-associated tetrodotoxin poisoning. RESULTS: Overall, we identified 435 titles and retrieved 71 full-text publications for further review. After excluding duplicates, review articles, articles reporting cases of minor severity only, incomplete clinical information or non-tetrodotoxin poisoning, and non-English, non-Chinese articles, we selected 37 citations (23 case series and 14 case reports) for data extraction and evidence synthesis. Clusters of acute pufferfish poisoning were mostly reported from coastal countries in the western Pacific or in the Indian Ocean, whereas sporadic cases have occurred in Mediterranean countries and Puerto Rico. Although 10 of the 14 case series reported neostigmine use in respiratory failure, age of these cases was not separately reported. Group-level outcome reporting irrespective of severity or the universal use of neostigmine in severe cases did not allow separate quantitative synthesis of evidence. In contrast, 32 cases from the other 9 case series and 14 case reports had individual information available for pooled analysis, yet only three of which were given neostigmine. CONCLUSION: Both qualitatively and quantitatively, the current literature was insufficient to provide an evidence base for or against the use of neostigmine in adults with tetrodotoxin-associated respiratory failure. This lack of quality evidence has mainly resulted from poor reporting in published case series. More research in collaborative data collection using standardized reporting and in animal experiments may be needed to tackle this problem. In addition, future case reports should adhere to the CARE guidelines to facilitate experience sharing, evidence synthesis, and consensus forming.

Ellagic acid suppresses oxidised low-density lipoprotein-induced aortic smooth muscle cell proliferation: studies on the activation of extracellular signal-regulated kinase 1/2 and proliferating cell nuclear antigen expression.

Proliferation of intimal vascular smooth muscle cells is an important component in the development of atherosclerosis. Ellagic acid is a phenolic compound present in fruits (raspberries, blueberries, strawberries) and walnuts. The present study investigated the effect of ellagic acid on the oxidised LDL (ox-LDL)-induced proliferation of rat aortic smooth muscle cells (RASMC). The study found that ellagic acid significantly inhibited ox-LDL-induced proliferation of RASMC and phosphorylation of extracellular signal-regulated kinase (ERK) 1/2. Furthermore, ellagic acid also blocked the ox-LDL-induced (inducible) cell-cycle progression and down regulation of the expression of proliferating cell nuclear antigen (PCNA) in RASMC. Therefore, ellagic acid reduced the amount of ox-LDL-induced proliferation of RASMC via inactivation of the ERK pathway and suppression of PCNA expression. These results may significantly advance the understanding of the role that antioxidants play in the prevention of atherosclerosis.