Search

Background The safety and effectiveness of intramuscular olanzapine or haloperidol compared to midazolam as the initial pharmacological treatment for acute agitation in emergency departments (EDs) has not been evaluated. Methods A pragmatic, randomised, double-blind, active-controlled trial was conducted from December 2014 to September 2019, in six Hong Kong EDs. Patients (aged 18–75 years) with undifferentiated acute agitation requiring parenteral sedation were randomised to 5 mg intramuscular midazolam (n = 56), olanzapine (n = 54), or haloperidol (n = 57). Primary outcomes were time to adequate sedation and proportion of patients who achieved adequate sedation at each follow-up interval. Sedation levels were measured on a 6-level validated scale (ClinicalTrials.gov Identifier: NCT02380118). Findings Of 206 patients randomised, 167 (mean age, 42 years; 98 [58·7%] male) were analysed. Median time to sedation for IM midazolam, olanzapine, and haloperidol was 8·5 (IQR 8·0), 11·5 (IQR 30·0), and 23·0 (IQR 21·0) min, respectively. At 60 min, similar proportions of patients were adequately sedated (98%, 87%, and 97%). There were statistically significant differences for time to sedation with midazolam compared to olanzapine (p = 0·03) and haloperidol (p = 0·002). Adverse event rates were similar across the three arms. Dystonia (n = 1) and cardiac arrest (n = 1) were reported in the haloperidol group. Interpretation Midazolam resulted in faster sedation in patients with undifferentiated agitation in the emergency setting compared to olanzapine and haloperidol. Midazolam and olanzapine are preferred over haloperidol's slower time to sedation and potential for cardiovascular and extrapyramidal side effects. Funding Research Grants Council, Hong Kong.

Objectives: This study aimed to assess the accuracy of ocular ultrasound performed by emergency physicians for diagnosis of retinal detachment. Methods: This was a prospective single-center observational study conducted between September 2013 and February 2015. All adult patients presenting to the emergency department with acute onset of visual changes were eligible to participate. Patients who met one of the following criteria were excluded: a diagnosis of retinal detachment had already been made by an ophthalmologist prior to attendance; pre-existing retinal detachment currently under treatment; hemodynamically unstable; suspected rupture eyeball; and unable to give consent. Six emergency physicians performed emergency ocular ultrasound using a linear 10-MHz ultrasound probe. An abnormal lifting of the retina or the presence of a retinal flap was considered diagnostic of retinal detachment. The final diagnosis of the ophthalmologist who was blinded to the study was used as the gold standard. Results: Among the 139 patients evaluated, 16 (12%) had retinal detachments and 14 of them were correctly identified (true positives). Of the 123 patients (88%) without retinal detachment, 107 patients were correctly identified (true negatives). The sensitivity and specificity of emergency ocular ultrasound for retinal detachment were 88% (95% confidence interval = 60 to 98) and 87% (95% confidence interval = 79 to 92), respectively. Conclusion: Emergency ocular ultrasound is a useful adjunct for the diagnosis of retinal detachment.

Introduction Estimation of haemodynamic status of acute and critically ill patients at Accident & Emergency (A&E) Departments is important. Measurement of inferior vena cava (IVC) diameter and collapsibility index by bedside ultrasound (USG) was known to correlate well with volume status of these patients. However, the value of similar estimation based on USG measurement of internal jugular vein (IJV) diameter was seldom studied. Whether USG measurement of IJV diameter can replace that of IVC diameter was unknown. Methods This was a cross-sectional study using a convenience sample of healthy volunteers among staff of a local A&E. The diameter of IJV and IVC (IJVD and IVCD) of the 51 participants were measured by bedside USG. The corresponding collapsibility index (CI) of IJV and IVC were then calculated. The correlation between IJVD and IVCD was assessed by the use of Bland-Altman plot. Results Median value of IVC-CI and of IJV-CI was 29.41% and 17.12% respectively. The mean of the difference of measurement of IJV-CI and IVC-CI was −11.10% (95% Confidence Interval: −15.27 to −6.92). The limits of agreement of the above difference were −40.77% and 18.58%. The range of these limits was too wide. Conclusion Because the range of limits of agreement between IJV-CI and IVC-CI were too wide, IJV-CI may not be used as an alternative to IVC-CI for the estimation of the volume status of normal adults.

Objectives Previous studies have shown that ultrasonography (USG), as an alternative to radiography, has a good accuracy in confirming nasogastric tube (NGT) position. Color flow detection of air insufflation is a novel approach in verifying NGT position. In our study, we aimed at evaluating its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in confirming the NGT position, as compared with 2-dimensional (2D) USG. Methods The study was conducted on adult patients over a period of 38 months in an emergency department in Hong Kong. 2D USG and color flow Doppler imaging were conducted for each subject. Chest X-ray was used as the gold standard for NGT position confirmation. Results 100 patients (59 males and 41 females) were recruited totally. Their mean age was 82. The sensitivity, specificity, PPV and NPV of 2D USG were 11.1% (95% CI 4.6%–17.6%), 100% (95% CI 100%–100%), 100% (95% CI 100%–100%), and 11.1% (95% CI 4.6%–17.6%) respectively. For color flow Doppler USG, the sensitivity, specificity, PPV and NPV were 90% (95% CI 83.7%–96.2%), 80% (95% CI 55.2%–100%), 97.6% (95% CI 94.3%–100%), and 47.1% (95% CI 23.3%–70.8%) respectively. The overall accuracy of color Doppler imaging was 89%, which was higher than that of 2D USG (20% only). Conclusions Color flow detection of air insufflation improves the diagnostic accuracy of ultrasound in verifying NGT position. It is a quick investigation such that fasting time of patients and their length of ED stay can be shortened.

Objectives (1) To assess the normal range of thickness of the epiglottis by means of ultrasound measurement. (2) To evaluate inter-observer agreement in measuring the thickness of the epiglottis of normal individuals by ultrasound. (3) To assess the association between biological factors and the thickness of the epiglottis. Methods Fifty adult volunteers working at a local accident and emergency department were recruited. The thickness of the epiglottis was measured by means of ultrasound examination, which was performed twice by two emergency physicians at different time. The study subjects' age, sex, height and body weight were recorded. Results The mean thickness of the epiglottis was 0.236 cm and the standard deviation was 0.020. Male subjects had thicker epiglottis. Interobserver agreement of the two emergency physicians who performed the ultrasound scan was very good. Multiple regression models showed that sex and height were useful predictors of the thickness of the epiglottis. Conclusions Bedside ultrasound assessment of the epiglottis is an easy, rapid and reliable method to evaluate its thickness. Further studies are needed to evaluate the thickness of the epiglottis in patients with epiglottitis before it can be put into clinical use.