Hong Kong Anaphylaxis Consortium Consensus Statements on prescription of adrenaline autoinjectors in the acute care setting.

BACKGROUND: Adrenaline autoinjectors (AAInj) facilitates early administration of adrenaline and remains the first-line treatment for anaphylaxis. However, only a minority of anaphylaxis survivors in Hong Kong are prescribed AAInj and formal guidance do not exist. International anaphylaxis guidelines have been largely based on Western studies, which may not be as relevant for non-Western populations. OBJECTIVE: To formulate a set of consensus statements on the prescription of AAInj in Hong Kong. METHODS: Consensus statements were formulated by the Hong Kong Anaphylaxis Consortium by the Delphi method. Agreement was defined as greater than or equal to 80% consensus. Subgroup analysis was performed to investigate differences between allergy and emergency medicine physicians. RESULTS: A total of 7 statements met criteria for consensus with good overall agreement between allergy and emergency medicine physicians. AAInj should be used as first-line treatment and prescribed for all patients at risk of anaphylaxis. This should be prescribed prior to discharge from the Accident and Emergency Department together with an immediate referral to an allergy center. The decision for prescribing AAInj should be based on the severity of previous reactions; including objective signs of respiratory involvement, objective signs of cardiovascular involvement and multiorgan involvement (regardless of severity). Patient demographics and comorbidities, specifically history of asthma or chronic obstructive pulmonary disease, should also be considered. Patients deemed eligible for AAInj should be offered avoidance advice and prescribed one AAInj while awaiting review by allergists. AAInj technique should be demonstrated by a healthcare professional or instruction video, and a return demonstration by the patient is required. The patient should also be counseled that the decision on the continued need of AAInj prescription in the long-term should be reviewed by an allergist. CONCLUSION: Consensus statements support the prescription of AAInj by front-line physicians with subsequent allergist review when treating patients at risk of anaphylaxis in Hong Kong.

Prevalence of drugged drivers among non-fatal driver casualties presenting to a trauma centre in Hong Kong.

OBJECTIVE: To investigate the prevalence and characteristics of abusive drug exposure among non-fatal motor vehicle driver casualties presenting to a designated trauma centre in Hong Kong. DESIGN: Cross-sectional study. SETTING: Designated trauma centre/regional accident and emergency department in Hong Kong. SUBJECTS: Non-fatal motor vehicle driver casualties who presented to the trauma centre from 1 January 2007 to 31 December 2007. MAIN OUTCOME MEASURES: Screening of abusive drug exposure using commercial bedside urine immunoassay kits. RESULTS: Drug screening was performed in 395 injured drivers, 10% of whom tested positive for the drugs of interest. Ketamine was the most commonly detected abusive substance (found in 45% of the subjects). A significantly higher proportion of young drivers (aged <25 years) screened positive (odds ratio=2.3; 95% confidence interval, 1.0-5.2; P=0.04), with the rate being 21%. The presence of these drugs in urine was related to the time of occurrence of the crash; those occurring between midnight and dawn revealed a trend towards a higher proportion of casualties testing drug-positive (odds ratio=2.2; 95% confidence interval, 0.9-5.3; P=0.07). There were no significant differences in the frequency of persons testing positive for the screened drugs with respect to gender, class of motor vehicle driven, or the day of the week on which the crash occurred. CONCLUSIONS: The prevalence of drugged driving among non-fatal casualties in our series of Hong Kong drivers was 10%. The frequency of such drivers testing positive for drugs was significantly higher in persons aged less than 25 years. These findings indicate a need to amend existing laws and implement on-site drug screening for suspected drugged drivers.

Oral bacterial flora of the Chinese cobra (Naja atra) and bamboo pit viper (Trimeresurus albolabris) in Hong Kong SAR, China.

OBJECTIVE: To determine the oral bacterial flora associated with two common local venomous snakes in Hong Kong, namely the Chinese cobra (Naja atra) and the bamboo pit viper (Trimeresurus albolabris). DESIGN: Cross-sectional study. SETTING: A non-government organisation and a regional hospital in Hong Kong. SUBJECTS: Thirty-two Chinese cobras and seven bamboo pit vipers. MAIN OUTCOME MEASURES: Species identification of bacteria in the oral cavity of both snakes and their antibiotic susceptibilities. RESULTS: The oral cavity of Chinese cobra harbour a wide range of pathogenic bacteria, including: Gram-negative bacterial species like Morganella morganii, Aeromonas hydrophila and Proteus, and Gram-positive bacteria like Enterococcus faecalis, coagulase-negative Staphylococcus as well as anaerobic species (clostridia). The oral cavity of the Chinese cobra is more likely than that of the bamboo pit viper to harbour pathogenic bacteria associated with snakebite infection (P<0.001). The median number of pathogenic bacteria per snake was significantly higher in the Chinese cobra (P<0.001). All pathogenic Gram-negative bacteria isolated were susceptible to levofloxacin. Amoxicillin/clavulanate provided good coverage against pathogenic Gram-positive bacteria (Enterococcus faecalis) and anaerobes. CONCLUSION: 'Prophylactic' antibiotic treatment for Chinese cobra bites may be beneficial, owing to the multiple pathogenic bacteria in its oral cavity and the higher risk of ensuing necrosis. The regimen of levofloxacin plus amoxicillin/clavulanate appears promising for this purpose, but further study is required to confirm its clinical utility in patients.

Evaluation of a point-of-care transcutaneous bilirubinometer in Chinese neonates at an accident and emergency department.

OBJECTIVE: To evaluate the use of a point-of-care transcutaneous bilirubinometer, JM-103 Minolta, for estimation of the serum bilirubin level in the management of neonatal jaundice in term or near-term Chinese neonates. DESIGN: Prospective correlation study. SETTING: Accident and Emergency Department of a regional hospital in Hong Kong. PATIENTS: All term or near-term Chinese neonates aged 3 to 7 days, who attended the Accident and Emergency Department because of jaundice between September and November 2007. MAIN OUTCOME MEASURES: Paired transcutaneous bilirubin measurements by the JM-103 Minolta and the total serum bilirubin measurement by a direct spectrophotometric method in the laboratory. RESULTS: The mean age of the 113 neonates at the time of data collection was 5 days (range, 3-7 days). Transcutaneous bilirubin showed a good correlation with total serum bilirubin; the highest correlation coefficient was 0.83 (P < 0.001). Transcutaneous bilirubin cutoff values of 230 micromoles per litre and 298 micromoles per litre could have 100% sensitivity and specificity respectively, to predict a total serum bilirubin level of higher than 250 micromoles per litre (the accepted threshold for treatment). The mean difference between transcutaneous and total serum bilirubin was 14 micromoles per litre (standard deviation, 28 micromoles per litre; P < 0.001); the JM-103 tended to overestimate total serum bilirubin. The 95% limits of agreement were between -40 and 69 micromoles per litre. CONCLUSION: The new point-of-care transcutaneous bilirubinometer, JM-103 Minolta, demonstrated good correlation with the serum bilirubin measurement in Chinese neonates aged 3 to 7 days. Thus, it is a useful screening device to facilitate quick decisions on disposal of jaundiced neonates presenting to accident and emergency departments or in out-patient clinic settings.