Perioral Paresthesia, Generalize Muscle Cramps, and Rhabdomyolysis After a Socotra Island Blue Baboon Tarantula (Monocentropus Balfouri) Bite.

BACKGROUND: Literature on systemic envenomation caused by tarantula bites, particularly from the Theraphosidae family, is relatively scarce. This case report provides a formal description of the first known instance of systemic envenomation caused by the Socotra Island Blue Baboon Tarantula (Monocentropus balfouri). CASE REPORT: In this case, a 23-year-old employee of an exotic pet shop suffered from perioral paresthesia, generalized muscle cramps, and rhabdomyolysis because of a Monocentropus balfouri bite. His symptoms were successfully relieved with oral benzodiazepines. EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the potential for serious complications resulting from the bite of Monocentropus balfouri, a species gaining popularity among global exotic pet collectors.

Use of high flow nasal cannula oxygen therapy for patients infected with SARS-CoV-2 outside intensive care setting.

Background: In early 2022, there was a sudden surge of patients infected by the Omicron variant of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Hong Kong (HK), resulting in 9,163 deaths as of 29 May 2022. Many of the local population had not been vaccinated before this wave. The number of patients who developed coronavirus disease 2019 (COVID-19) related respiratory failure outnumbered the capacity of intensive care unit (ICU) beds. Some of these patients had to be supported with high flow nasal cannula (HFNC) therapy outside ICU setting. HK was in crisis situation. The primary objective of this study is to assess the 28-day mortality of this group of patients. The secondary objective is to explore any predictors of non-survivors to help clinical decision-making in future crisis. Methods: This is a retrospective observational study of patients suffering from COVID-19 related respiratory failure who received HFNC therapy in general medical wards of two hospitals during the period of 17 Mar to 30 Apr 2022. Survival and risk factors were reviewed. Results: Forty-nine patients were recruited. Twenty-six patients (53%) survived at 28-day after initiation of HFNC support. Three clinical parameters were found to be significantly associated with mortality at 28-day: (I) SpO2/FiO2 (SF) ratio <160 at 48 hours; (II) SF ratio <191 at 72 hours; (III) serial SF ratio at 48 or 72 hours showing no improvement over that at the time of initiation of HFNC therapy. Conclusions: Use of HFNC outside ICU setting showed benefit to patients suffering from COVID-19 related acute hypoxemic respiratory failure (AHRF). Serial SF ratio monitoring at 48 and 72 hours after therapy initiation might serve as predictors of outcome and thus guide clinical decision-making for medical resource allocation in outbreak situation.

Attitudes and educational needs of emergency doctors providing palliative and end-of-life care in Hong Kong: a cross-sectional analysis based on a self-report study.

BACKGROUND: Due to the ageing population in Hong Kong, the importance and need of palliative care and end-of-life (EOL) care are coming under the spotlight. The objectives of this study were to evaluate the attitudes of emergency doctors in providing palliative and EOL care in Hong Kong, and to investigate the educational needs of emergency doctors in these areas. METHODS: A questionnaire was used to study the attitudes of ED doctors of six different hospitals in Hong Kong. The questionnaire recorded the attitudes of the doctors towards the role of palliative and EOL care in EDs, the specific obstacles faced, their comfort level and further educational needs in providing such care. The attitudes of emergency doctors of EDs with EOL care services were compared with those of EDs without such services. RESULTS: In total, 145 emergency doctors completed the questionnaire, of which 60 respondents were from EDs with EOL care services. A significant number of participants recognized that the management of the dying process was essential in ED. Providing palliative and EOL care is also accepted as an important competence and responsibility, but the role and priority of palliative and EOL care in ED are uncertain. Lack of time and access to palliative care specialists/ teams were the major barriers. Doctors from EDs with EOL care services are more comfortable in providing such care and discuss it with patients and their relatives. Further educational needs were identified, including the management of physical complaints, communication skills, and EOL care ethics. CONCLUSIONS: The study identified obstacles in promoting palliative and EOL care in the EDs Hong Kong. With the combination of elements of routine ED practice and a basic palliative medicine skill set, it would promote the development of palliative and EOL care in Emergency Medicine in the future.

Predictive model integrating dynamic parameters for massive blood transfusion in major trauma patients: The Dynamic MBT score.

BACKGROUND: Currently existing predictive models for massive blood transfusion in major trauma patients had limitations for sequential evaluation of patients and lack of dynamic parameters. OBJECTIVE: To establish a predictive model for predicting the need of massive blood transfusion major trauma patients, integrating dynamic parameters. DESIGN: Multi-center retrospective cohort study. SETTING: Four designated trauma centers in Hong Kong. METHODS: Trauma patients aged >12years were recruited from the trauma registries from 2005 to 2012. MBT was defined as delivery of ≥10units of packed red cells within 24h. Split sampling method was adopted for model building and validation. Multivariate logistic regression was adopted for model building, with weight assigned based on logarithmic of adjusted odds ratios. The performance of the dynamic MBT score (DMBT) was compared with the PWH score and the Trauma Associated Severe Hemorrhage (TASH) score in the validation data set. RESULTS: 4991 patients were included in the study. The DMBT was established with 8 parameters: systolic blood pressure, heart rate, hemoglobin, hemoglobin drop within the first 2h, INR, base deficit, unstable pelvic fracture and hemoperitoneum in radiological imaging. At cut-off score of 6 the DMBT achieved sensitivity of 78.2% and specificity of 89.2%. In the validation set, the AUCs of the DMBT, PWH score, and TASH score were 0.907, 0.844, and 0.867 respectively. CONCLUSIONS: The DMBT score allows both snapshot and sequential activation along the trauma care pathway and has better performance than the PWH score and TASH score.

Local antivenom treatment for ophthalmic injuries caused by a Naja atra.

We report a case of local antivenom therapy for ocular exposure to the venom of Naja atra. An 83-year-old woman sustained conjunctival and corneal injuries by the venom of a spitting N. atra. Local instillation of N. naja antivenom quickly relieved the pain as measured by visual analog scale, and she recovered uneventfully. Good recovery ensuing topical antivenom administration for ocular exposure to the venom of spitting N. atra and Naja nigricollis has been described in literature, but the pain response was not thoroughly documented. The mechanism of antivenom for pain relief remains to be established. In light of the associated positive outcome observed in human, the role of ocular antivenom therapy merits further study.

Hemolytic anemia after zopiclone overdose.

INTRODUCTION: Zopiclone is associated with methemoglobinemia. We report a case of zopiclone overdose manifested with another hematological complication, hemolysis. CASE: A 46-year-old woman overdosed with 50-100 tablets of 7.5 mg zopiclone. Oxidative hemolysis was evident by anemia, bite cells, raised unconjugated bilirubin and lactate dehydrogenase, lowered haptoglobin, and reticulocytosis. DISCUSSION: In zopiclone overdose, there may be oxidative stress rendering the development of not only methemoglobinemia but also hemolysis.

A preliminary survey of Hong Kong snake shops and the potential snake bite risks for the healthcare system.

Consumption of snakes is a traditional part of Chinese life. Snake shops, which provide both the food products and live snakes to the public, are believed by the medical community to stock only local species. The medical risk posed by these live snakes is therefore regarded as manageable as they are indigenous and thus effective anti-snake venom (ASV) is believed to be available. This study visited four snake shops, reviewed the snakes present and interviewed the vendors regarding the snakes' likely geographical origin. Snakes species were definitively identified and, in addition, the current stocking of ASV by hospitals in terms of amount and species covered was determined. Snakes were also examined to determine whether they had been de-fanged and thus rendered unable to inflict a venomous bite. The study identified that non-indigenous species are being imported, capable of delivering a venomous bite, which provide a tangible medical risk as ASV is not available to deal with envenomations.

Two cases of methemoglobinemia following zopiclone ingestion.

INTRODUCTION: Most cases of methemoglobinemia result from exposure to certain medications and chemicals such as nitrates, nitrites, aniline, dapsone, phenazopyridine, benzocaine, and chlorates which oxidize the iron from the ferrous state. Intoxication with zopiclone is expected to produce drowsiness, confusion and coma but not methemoglobinemia. We report two cases of zopiclone overdose with methemoglobinemia. CASE REPORTS: Case one: A 43-year-old woman presented to the emergency department two hours after ingesting 100 tablets of 7.5 mg zopiclone. Her initial vital signs, physical examination, chest x-ray, and electrocardiogram were normal. Two hours post-ingestion her methemoglobin level was 9.8%; 14 hours post-arrival she showed cyanosis of the lips and extremities and dyspnea after walking. The blood sample 16 hours post-ingestion was dark brown in color and the methemoglobin was 23.8%. Shortly after the second of two doses of methylene blue (1 mg/kg each) her methemoglobin was 3.6%. Case two: A 30-year-old woman came to the emergency department 50 hours after ingesting 150 to 200 tablets of 7.5 mg zopiclone. Her vital signs and physical examination were normal. Her methemoglobin level was 5.2% at 52 hours post-ingestion and it peaked at 10.4% one hour later. She recovered following symptomatic care. DISCUSSION AND CONCLUSIONS: Methemoglobinemia has not previously been reported following acute zopiclone overdose. In our patients, there were no identifiable alternative causes explaining the methemoglobinemia and zopiclone was confirmed in both patients by laboratory analysis. These two cases suggest that zopiclone overdose is capable of producing delayed methemoglobinemia, which may be related to formation of a sufficient quantity of the N-oxide metabolite.