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Background: Older people (⩾65 years) present a unique challenge in emergency department triage. Hong Kong’s Hospital Authority adopts a five-level emergency department triage system, with no special considerations for older people. We evaluated the validity and reliability of this triage scale in older people in a regional Hong Kong emergency department. Methods: In total, 295 cases stratified by triage category were randomly selected for review from November 2016 to January 2017. Validity was established by comparing the real emergency department patients’ triage category against (1) that of an expert panel and (2) the need for life-saving intervention. Triage notes were extracted to make case scenarios to evaluate inter- and intra-rater reliabilities. Emergency department nurses (n = 8) were randomly selected and grouped into Results: The percentage agreement between the real emergency department patients’ triage category and the expert panel’s assignment was 68.5%, with 16.3% and 15.3% over-triage and under-triage, respectively. Quadratic weighting kappa for agreement with the expert panel was 0.72 (95% confidence interval: 0.53–0.91). The sensitivity, specificity and positive likelihood ratio for the need for life-saving interventions were 75.0% (95% confidence interval: 47.6%–92.7%), 97.1% (95% confidence interval: 94.4%–98.8%) and 26.2 (95% confidence interval: 12.5%–54.8%), respectively. The Fleiss kappa value for inter-rater reliability was 0.50 (95% confidence interval: 0.47–0.54) for junior and senior nurse groups, respectively. Conclusion: The current triage scale demonstrates reasonable validity and reliability for use in our older people. Considerations highlighting the unique characteristics of older people emergency department presentations are recommended.

Background There is limited knowledge regarding the risk factors for influenza B virus–associated pneumonia in adults. This study aimed to determine the risk factors for influenza B virus–associated pneumonia in adults. Methods We used viral surveillance data during the pandemic season between November 2017 and April 2018 from the University of Hong Kong-Shenzhen Hospital medical record database. The files of patients ages 18 years or older were reviewed for demographics, clinical characteristics, laboratory findings, and outcome. Multivariate logistic regression analysis was performed to identify risk factors associated with influenza B virus–associated pneumonia. Results A total of 78 patients with influenza B, ages 20 to 87 years, were identified. Comparing cases with pneumonia vs cases without pneumonia, there were significant differences in the following: age in years (67.41 ± 16.63 vs 58.16 ± 17.65; P = .028), age group (74.1% vs 51.0%; P = .049), chronic respiratory diseases (70.4% vs 21.6%; P = .000), shortness of breath (40.7% vs13.7%; P = .007), abnormal breath sounds on auscultation (51.9% vs 21.6%; P = .006), and serum alanine transaminase level (30.07 ± 10.73 vs 38.64 ± 21.68; P = .022). Logistic regression models indicated that chronic respiratory diseases (odds ratio, 8.452; 95% confidence interval, 2.768-25.808; P = .000) and shortness of breath (odds ratio, 1.261; 95% confidence interval, 1.015-1.566; P = .036) were independent risk factors. Conclusions This study suggests that chronic respiratory diseases and shortness of breath are independent risk factors for influenza B virus–associated pneumonia in adult patients.

Objectives: Endotracheal intubation is an essential skill of every emergency department clinician. The current practice of emergency intubation in the emergency departments in China and its safety is largely unknown. This study aimed at evaluating the practice and the safety profile of emergency intubation in an emergency department in Shenzhen. Methods: This study was of retrospective design. It was conducted in the emergency department of a university affiliated hospital. All patients requiring emergency intubation from 1 January 2017 to 30 June 2018 were recruited. Data on demographic and clinical characteristics of patients and characteristics of intubations were collected and analyzed. Results: A total of 128 patients were analyzed. Patients with spontaneous intracerebral hemorrhage were most common. Airway protection for patency was the most common indication of intubation. Most intubations were performed by emergency department staff with direct laryngoscopy. The first attempt success rate was 93.8%. Serious adverse events were rare. Conclusion: The practice of endotracheal intubation in the emergency department is in line with international ones. The safety profile is good. A national registry of emergency airway management is recommended.

Background: Overutilisation of the Accident and Emergency Department is an increasingly serious healthcare challenge. Online symptom checkers could help alleviate this challenge by allowing patients to self-triage before visiting the Accident and Emergency Department. Objectives: This study aimed to assess the triage accuracy of online symptom checkers, which would help determine the potential roles of symptom checkers in an Accident and Emergency Department setting. Methods: A total of 100 random Accident and Emergency Department records were sampled from the Queen Mary Hospital in Hong Kong. The inclusion criteria were patients over the age of 18 attending the Queen Mary Hospital Accident and Emergency Department in 2016. Symptom checkers by Drugs.com and FamilyDoctor were selected as representative tools. One triage recommendation was generated by each symptom checker for each case record. Each symptom checker’s triage accuracy was then evaluated using a few outcome measures: overall sensitivity, sensitivity for emergency cases and specificity for non-emergency cases, when compared with the triage categories assigned by the triage nurses. Results: The results showed that Drugs.com had a higher overall triage accuracy than FamilyDoctor (74% and 50%, respectively), but both checkers are inadequately sensitive to emergency cases (70% and 45%, respectively) with low negative predictive values (43% and 24%, respectively). Conclusion: In their current states, symptom checkers are not yet suitable as alternatives to Accident and Emergency Department triage protocols due to their low overall sensitivities and negative predictive values. However, symptom checkers might serve as useful Accident and Emergency Department adjuncts in other ways, such as to provide more information prior to a patient’s arrival to streamline the triage and preparation process at the Accident and Emergency Department.

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.

Background A straight line–based model is often used to calculate the distance between an out‐of‐hospital cardiac arrest ( OHCA ) and the location of an automated external defibrillator ( AED ). This model may be inaccurate as it overlooks any obstacles between the OHCA and AED . This study aimed to elucidate the effect of the straight line–based and walking route–based calculation on the average distance between an historical OHCA and the closest AED and the coverage rate of AEDs, ie, the proportion of historical OHCAs that were within 100 meters of an AED . It is hoped that the findings will help policy makers in deploying AEDs in optimal urban settings. Methods and Results This was an observational study conducted in Hong Kong. The average distance between an historical OHCA and its closest AED and the coverage rate of AEDs were calculated with both the straight line–based and walking route–based model. A total of 1637 AEDs and 5119 cases of OHCA were included for analysis. The average distances calculated by the straight line–based and walking route–based model were 230.8 and 545.3 meters, respectively. The coverage rate calculated by the straight line–based model was 30.04%, while that by the walking route–based model was 11.17%. Conclusions The straight line–based model may underestimate the average distances and overestimate the coverage rate in an urban setting. The walking route–based model may be more useful for studies of AED deployment in urban cities.

Background: Assessment of geriatric patients presented with abdominal pain had been challenge for emergency physicians with the ageing population. A rapid, reproducible risk stratification model for the assessment of the need for admission for geriatric abdominal pain would be required to identify low-risk patients to be managed as out-patient basis. Objective: Assess the feasibility of risk stratification model to predict the need of hospital admission based on readily available bedside parameters in emergency departments. Methods: This is a multicenter retrospective cohort study in four emergency departments. Patients aged at least 65 who presented with chief complaint of abdominal pain within the previous 7 days of attendance as the chief complaint were included. Chart review was performed for the included patients. The primary outcome was defined as a composite of mortality, abdominal surgery or endoscopic treatment, and other inpatient treatments for abdominal diseases within 14 days, surrogating the need of hospital admission. Logistic regression was modeled to identify independent predictors. The diagnostic accuracy of the risk model was evaluated with the receiver operating characteristic curve and compared with the clinical gestalt of decision for hospital admission by the attending physician. Results: In total, 553 patients were included. Symptoms of upper gastrointestinal bleeding, non-ambulatory presenting status, pain duration, focal abdominal tenderness, hyperglycemia, leukocytosis, and elevated creatinine were independent predictors of the outcome. The area under the receiver operating characteristic curve of the predicted probabilities of the logistic model was 0.741. In keeping for a low-risk criterion to achieve more than 90% sensitivity, the predictive model would only achieve 18.2% specificity which was inferior to clinical gestalt for hospital admission (sensitivity 99.3%, specificity 44.3%). Conclusion: Risk stratification model by clinical assessment and laboratory markers alone were inadequate and inferior to clinical gestalt for identification of the group of patients requiring inpatient treatment.

Background: Bystander cardiopulmonary resuscitation can improve the survival rate of patients with out-of-hospital cardiac arrest. Teaching cardiopulmonary resuscitation in schools by teachers is one of the ways to increase the number of bystanders who can perform cardiopulmonary resuscitation. Nevertheless, there have been no studies on the readiness of teachers in Hong Kong to teach cardiopulmonary resuscitation in their schools. Objective: To assess whether secondary school teachers are prepared to teach their students cardiopulmonary resuscitation. Methods: This was a questionnaire survey. Teachers from 22 local secondary schools were recruited. The questionnaires were designed with questions covering their knowledge about cardiopulmonary resuscitation and attitudes towards teaching their students cardiopulmonary resuscitation. A knowledge score and attitude score were calculated. Result: 557 teachers completed the questionnaires. Most had never witnessed a cardiac arrest and over half of them had never been trained cardiopulmonary resuscitation or use of an automated defibrillator. About 25% of them answered all questions on knowledge wrong. Only 25% supported teaching cardiopulmonayr resuscitation in schools and 32% were willing to teach it. Legal liability was a major concern. Conclusion: Local teachers’ readiness for teaching students cardiopulmonary resuscitation in secondary schools is likely poor. More efforts are required to raise their knowledge level on cardiopulmonary resuscitation and instill a positive attitude towards cardiopulmonary resuscitation education in schools.

Background: Point-of-care ultrasound plays an important role in patient management in the prehospital setting. Prehospital ultrasound training for the paramedics has been developed in the West for many years. However, the present training curriculum for the local ambulance personnel does not include point-of-care ultrasound. This study is the first of its kind in Hong Kong on the feasibility of teaching ambulance personnel how to perform focused assessment with sonography in trauma by a 1-day course. Objective: It aimed to assess whether the ultrasound-naïve ambulance personnel could acquire the skills and knowledge of point-of-care ultrasound following a tailor-made training programme. Methods: This was a prospective observational study. The training programme was a 1-day course consisted of didactic lectures and hands-on practice. Each participant was assessed by a written test and a skills test. Descriptive statistics were used to describe the ambulance personnel and their results of the written and skills test. Significance testing was by Mann–Whitney U test and Spearman correlation test where appropriate. Results: Seventeen members of Ambulance Service Institute (Hong Kong Branch) participated in the programme. All of them currently are the ambulance personnel and they joined the programme via the captioned institute. Enrollment was voluntary. The median score in the written test was 20 out of 25. The median time to complete the four views of the focused assessment with sonography in trauma scan was 3.4 min. There was no significant relationship between test performance and educational background and work experience of the ambulance personnel. Conclusion: Training the local ambulance personnel point-of-care ultrasound is feasible. Their acquisition of skills and knowledge of point-of-care ultrasound after a 1-day course was satisfactory.

Background: The healthcare need of the elderly in Hong Kong is a major issue. Foreign domestic helpers, especially those from the Philippines, play a significant role in response to the healthcare need of a home-dwelling elder as they are often the sole caregiver of the elders. Objectives: This study primarily aimed at exploring the Filipino domestic helpers’ knowledge of and attitude to managing a medical emergency of a home-dwelling elder. Methods: This was a questionnaire survey of the Filipino domestic helpers working in Hong Kong and was conducted from 1 July 2015 to 29 February 2016. The survey collected their demographic data, evaluated their first aid knowledge by a test of multiple-choice questions and assessed their attitudes to providing first aid to the elders they cared in terms of confidence and perceived responsibility. Descriptive statistics were used to describe the findings. Results: In all, 398 Filipino domestic helpers were surveyed. Most had completed university education. About one third had been trained in first aid. The average mark attained by the respondents on first aid knowledge assessment was 4.5 (full mark = 16). Their knowledge was especially poor in heat exhaustion, choking, external bleeding, epistaxis and scald injury. Their median confidence score was 10 (full score = 15) and median perceived responsibility score was 13 (full score = 20). Conclusion: The first aid knowledge among the Filipino domestic helpers surveyed in this study was poor. They were not confident enough in providing first aid to an elder and their perceived responsibility was also low.

ObjectivesTo assess the level of all-hazards disaster preparedness and training needs of emergency department (ED) doctors and nurses in Hong Kong from their perspective, and identify factors associated with high perceived personal preparedness.DesignThis study was a cross-sectional territory-wide online survey conducted from 9 September to 26 October, 2015.ParticipantsThe participants were doctors from the Hong Kong College of Emergency Medicine and nurses from the Hong Kong College of Emergency Nursing.MethodsWe assessed various components of all-hazards preparedness using a 25-item questionnaire. Backward logistic regression was used to identify factors associated with perceived preparedness.ResultsA total of 107 responses were analyzed. Respondents lacked training in disaster management, emergency communication, psychological first aid, public health interventions, disaster law and ethics, media handling, and humanitarian response in an overseas setting. High perceived workplace preparedness, length of practice, and willingness to respond were associated with high perceived personal preparedness.ConclusionsGiven the current gaps in and needs for increased disaster preparedness training, ED doctors and nurses in Hong Kong may benefit from the development of core-competency-based training targeting the under-trained areas, measures to improve staff confidence in their workplaces, and efforts to remove barriers to staff willingness to respond. (Disaster Med Public Health Preparedness. 2018; 12: 329–336)

Studies done in the 1990's suggested nursing home residents with cardiac arrest had minimal chance of survival and resuscitation was not recommended. More recent studies showed opposing results. In Hong Kong, the proportion of elderly living in the residential care homes for the elderly is increasing. There is no study of out-of-hospital cardiac arrest outcomes in this population. This study aimed at evaluating the prognosis of out-of-hospital cardiac arrest occurring in the residential care homes for the elderly. It is hoped that the findings may inform the local emergency medical service concerning the issue of futility of resuscitating the residents with cardiac arrest in the residential care homes.This study was a retrospective analysis of a database of all patients aged 65 years or above with atraumatic out-of-hospital cardiac arrest and who were attended by the emergency medical service in a 12-month period. Data in the database were prospectively collected by the emergency medical service. The characteristics of patients and cardiac arrests, timeliness of the emergency medical service, and survival were analyzed. Comparison was made between elderly living in and not living in the residential care homes. Predictors of survival were evaluated with logistic regression.3919 patients aged ≥ 65 years were analyzed. There were 1506 cases of cardiac arrest occurring in the residential care homes for the elderly. Resuscitation was discontinued at the emergency department in over 70% of these cases. The survival to hospital admission rate and the 30-day survival rate were 9.6% and 0.3% respectively. Both were lower than patients not residing in the residential care homes. Younger age, witnessed arrest, bystander defibrillation, and shorter call to ED interval were associated with higher chance of surviving to hospital admission.Elderly suffering from cardiac arrest in residential care homes had a poor chance of survival. Except age, witnessed arrest, bystander defibrillation, and call to ED interval are modifiable predictors of survival. It is inappropriate to declare that resuscitating elderly in residential care homes is futile unless those factors have been fully addressed.

INTRODUCTION Total ischaemic time should be shortened as much as possible in patients with ST-segment elevation myocardial infarction (STEMI). This study evaluated whether prehospital 12-lead electrocardiogram (ECG) could shorten system delay in STEMI management. METHODS From November 2015 to November 2017, 15 ambulances equipped with X Series Monitor/ Defibrillator (Zoll Medical Corporation) were used in the catchment area of Queen Mary Hospital, Hong Kong. Prehospital ECG was performed for patients with chest pain; the data were tele-transmitted to attending emergency physicians at the Accident and Emergency Department (AED) for rapid assessment. Data from patients with STEMI who were transported by these 15 ambulances were compared with data from patients with STEMI who were transported by ambulances without prehospital ECG or who used self-arranged transport. RESULTS Data were analysed from 197 patients with STEMI. The median patient delay for activation of the emergency response system was 90 minutes; 12% of patients experienced a delay of >12 hours. There was a significant difference in delay between patients transported by ambulance and those who used self-arranged transport (P

Out-of-hospital cardiac arrest (OHCA) is an urgent disease entity, and the outcomes of OHCA are poor. This causes a significant public health burden, with loss of life and productivity throughout society. Internationally, successful programmes have adopted various survival enhancement measures to improve outcomes of OHCA. A territory-wide organised survival enhancement campaign is required in Hong Kong to maintain OHCA survival rates that are comparable to those of other large cities. One key component is to establish an OHCA registry, such as those in Asia, the United States, Europe, Australia, and New Zealand. An OHCA registry can provide benchmarking, auditing, and surveillance for identification of weak points within the chain of survival and evaluation of the effectiveness of survival enhancement measures. In Hong Kong, digitisation of records in prehospital and in-hospital care provides the infrastructure for an OHCA registry. Resources and governance to maintain a sustainable OHCA registry are necessary in Hong Kong as the first step to improve survival and outcomes of OHCA.

We described the case report of a patient presented with no known predisposing factor, generalized malaise with vomiting, locked jaw, perioral paraesthesia, carpopedal spasm and a positive Chvostek’s sign which resulted from severe electrolyte disturbance at 5 hours after use of oral sodium phosphate solution (NaPO4) as bowel preparation for colonoscopy. On presentation, she developed hyperphosphatemia and symptomatic hypocalcaemia with serum phosphate of 1.84 mmol/L and adjusted calcium level 1.67 mmol/L respectively. Her symptoms subsided after immediate intravenous calcium gluconate followed by oral calcium supplement. The electrolyte disturbances were normalized with an uneventful clinical course. The potentially fatal complications of sodium phosphate solution which commonly prescribed as bowel preparation for conventional colonoscopy could develop though previously reported as uncommon in patients without predisposing factors, and should not be overlooked. Urgent assessment and immediate correction of electrolyte disturbances are needed. Recommendations on patient selection of use of sodium phosphate to minimize risk of developing adverse events are needed to incorporate in clinical protocols.

Introduction After ST-segment elevation myocardial infarction (STEMI), it is vital to shorten reperfusion time. This study examined data from a pilot project to shorten the door-to-balloon (D2B) time by using prehospital 12-lead electrocardiogram (ECG). Methods Fifteen ambulances equipped with X Series® Monitor/Defibrillator (Zoll Medical Corporation) were deployed to the catchment area of Queen Mary Hospital, Hong Kong, from November 2015 to December 2016. For patients with chest pain, prehospital 12-lead ECG was performed and tele-transmitted to attending physicians at the accident and emergency department for immediate interpretation. The on-call cardiologist was called before patient arrival if STEMI was suspected. Data from this group of patients with STEMI were compared with data from patients with STEMI who were transported by ambulances without prehospital ECG or by self-arranged transport. Results From 841 patients with chest pain, 731 gave verbal consent and prehospital ECG was performed and transmitted. Of these, 25 patients with clinically diagnosed STEMI required emergency coronary angiogram with or without primary percutaneous coronary intervention. The mean D2B time for these 25 patients (93 minutes) was significantly shorter (P=0.003) than that for 58 patients with STEMI transported by ambulances without prehospital ECG (112 minutes) and that for 41 patients with STEMI with self-arranged transport (138 minutes). However, shorter reperfusion time was only recorded during daytime hours (08:00-17:59). No statistically significant difference in 30-day mortality was found. Conclusion Prehospital ECG is technologically feasible in Hong Kong and shortens the D2B time. However, shorter reperfusion time was only recorded during daytime hours.

Background Little is known about the use of sedation drugs for the management of acute agitation in Hong Kong's Accident and Emergency Departments (AEDs) and how it compares with Australasian practice. Objective The aim of this study was to determine drug preferences, clinicians' perceived confidence in management, barriers/gaps in training and perceived usefulness of existing clinical practice guidelines (CPGs) in Hong Kong. Method A validated questionnaire was used, with case vignettes typical of patients presenting to AEDs with acute agitation. The questionnaire was distributed by hand to all trainees and fellows of the Hong Kong College of Emergency Medicine (HKCEM). Two reminders were sent. Results Of 483 HKCEM members, 280 (58.0% [95% CI 53.5–62.3]) responded. For monotherapy, 46.8% (95% CI 41.0–52.6) of respondents chose haloperidol to manage the undifferentiated patient, followed by midazolam (33.9%, 95% CI 28.6–39.7) and diazepam (13.9%, 95% CI 10.4–18.5). Most respondents (83.6%, 95% CI 78.8–87.5) would not administer combination therapy. Respondents were confident in managing agitation overall. The lack of local/institutional CPGs (55.7%, 95% CI 49.9–61.4) was perceived as an important barrier. Institutional guidelines were considered the most useful CPGs (66.4%, 95% CI 60.7–71.7). Most respondents (72.9%, 95% CI 67.4–77.7) perceived a HKCEM endorsed CPG would be useful. Conclusion Haloperidol and benzodiazepines are frequently used as monotherapy for the management of acute agitation in Hong Kong's AEDs. Management in Hong Kong differs from Australasian practice in that combination therapy is less common and clinicians' choice of sedation drugs are less variable overall. Results suggest that future work on CPG development and training regarding the safe use of combination therapy would be well received.

Objective We aim to investigate whether prehospital Modified Early Warning Score (MEWS) can identify non-trauma patients requiring life-saving intervention (LSI) within 4 h of presentation to the ED. Methods It was a prospective study of non-trauma ED patients by ambulance who were 16 years or older from 1 to 27 November 2013. Prehospital MEWS was calculated according to vital signs measured by the ambulance crew. Data on patients' demographics, triage category, LSI within 4 h of ED presentation and 24 h mortality were retrieved. LSI was defined as emergency interventions to airway, breathing and circulation, emergency procedures and medications administered. The performance of prehospital MEWS was analysed with sensitivity, specificity, predictive values (PV), likelihood ratios (LR) and the receiver operating characteristic curve. Results Recruited during the study period were 1493 patients. The median age was 78 years. Of the patients, 49.9% belonged to critical, emergent or urgent triage categories. LSI was required in 321 patients (21.5%). Thirteen died within 24 h of ED presentation. The area under the receiver operating characteristic curve of prehospital MEWS relating to LSI was 0.72 (95% confidence interval 0.69 to 0.75). The sensitivity, specificity, positive PV, negative PV, positive LR and negative LR were 0.57, 0.76, 0.40, 0.87, 2.43 and 0.56, respectively, when prehospital MEWS ≥3 was chosen as the cut-off value. Conclusions Prehospital MEWS is useful in identifying non-trauma patients requiring LSI within 4 h of ED presentation. This may in turn enhance the triage accuracy in the ED in addition to clinical assessment.

Purpose To evaluate the performance of a prehospital trauma diversion system in Hong Kong, China. Methods A retrospective analysis of prospectively collected data in the trauma registry of Queen Mary Hospital, Hong Kong from 1 January 2009 to 31 December 2013 was done. All adult patients aged 18 years or above, either primarily or secondarily diverted to Queen Mary Hospital according to the trauma patient diversion protocol, were recruited. Need for trauma center level of care was based on a consensus-based criterion standard published in 2014. Performance of the protocol in terms of over-diversion and under-diversion was determined. Results A total of 209 patients were included for analysis. About 30% of the patients required trauma center level of care. The most common reason was the need for vascular, neurologic, abdominal, thoracic, pelvic, spine or limb-conserving surgery within 24 h of presentation. The over-diversion rate and under-diversion rate were 69.6% and 19.7% respectively. Conclusion The trauma patient diversion protocol currently in use in Hong Kong is not accurate enough. Further revision and refinement is needed.

BACKGROUND AND OBJECTIVE: Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are prone to sustaining trauma that requires emergency department (ED) admission. Methylphenidate (MPH) can reduce ADHD symptoms and may thus theoretically reduce the risk of trauma-related ED admission, but previous studies do not make this association clear. This study examines this association. METHODS: A total of 17 381 patients aged 6 to 19 years who received MPH prescriptions were identified by using the Clinical Data Analysis & Reporting System (2001–2013). Using a self-controlled case series study design, the relative incidence of trauma-related ED admissions was compared with periods of patient exposure and nonexposure to MPH. RESULTS: Among 17 381 patients prescribed MPH, 4934 had at least 1 trauma-related ED admission. The rate of trauma-related ED admission was lower during exposed periods compared with nonexposed periods (incidence rate ratio [IRR]: 0.91 [95% confidence interval (CI): 0.86–0.97]). The findings were similar only when the incident trauma episode was assessed (IRR: 0.89 [95% CI: 0.82–0.96]). A similar protective association was found in both genders. In validation analysis using nontrauma-related ED admissions as a negative control outcome, no statistically significant association was found (IRR: 0.99 [95% CI: 0.95–1.02]). All sensitivity analyses demonstrated consistent results. CONCLUSIONS: This study supports the hypothesis that MPH is associated with a reduced risk of trauma-related ED admission in children and adolescents. A similar protective association was found in both male and female patients. This protective association should be considered in clinical practice.

Background Injection of botulinum toxin type A for cosmetic purposes is common. It is believed to be safe, but adverse reactions have been reported, including dysphagia, generalized paralysis, respiratory depression, and death caused by focal injection of the toxin. Early administration of antitoxin in patients with adverse reactions is the mainstay of management, but the time window for its clinical efficacy is not well defined. Case Reports Two female adult patients with clinical botulism after botulinum toxin type A injection are described. Both patients had received intramuscular injection of botulinum toxin type A in their calves at beauty shops for cosmetic reasons. They developed clinical botulism about 3 days postinjection. They presented late to the emergency department. Monovalent type A botulinum antitoxin was administered 7 and 9 days from symptom onset, respectively. Both patients showed clinical improvement after the antitoxin treatment. Why Should an Emergency Physician Be Aware of This? Patients may present to the emergency department with systemic effects of botulinum toxin type A after cosmetic injection. Clinical efficacy of botulinum antitoxin treatment was observed in two patients who were given the drug 7 and 9 days after the occurrence of symptoms of botulism after cosmetic injection of botulinum toxin type A. It may be worthwhile to commence antitoxin treatment even if patients present late.

The concept of public access defibrillation was proposed more than 20 years ago. Since then, various programmes have been implemented in many major cities although not all have been successful. Fourteen years ago, the question of whether Hong Kong needed public access defibrillation was raised. This article aimed to answer this question based on the best available evidence. Over the years, the clinical effectiveness of public access defibrillation in out-of-hospital cardiac arrest has been proven. Nonetheless various studies have indicated that among others, cost-effectiveness, knowledge and attitudes of the public, and incidence of ventricular fibrillation are important factors that will affect the likelihood of success of such programmes. In Hong Kong, because of the long interval between recognition of arrest and first defibrillation, public access defibrillation is probably needed. To ensure the success of such a programme, careful planning in addition to the installation of more automated external defibrillators are essential.

Crayfish or Procambarus clarkii is a freshwater crustacean with worldwide distribution. Tons of crayfish are consumed each year. In this report, four adult patients with rhabdomyolysis after consuming crayfish were described. All of them presented to the emergency department with myalgia. The diagnosis of rhabdomyolysis was supported by an elevated creatine kinase level. All recovered with supportive treatment. The clinical picture of these 4 patients was compatible with Haff disease. Haff disease is a syndrome in which rhabdomyolysis develops subsequent to consumption of certain cooked seafood. Crayfish is a common culprit. Diagnosis depends on obtaining a diet history and creatine kinase level. Most patients recover uneventfully with supportive treatment for rhabdomyolysis.

The objective of this review was to summarize published evidence of the effectiveness of therapeutic hypothermia in patients with drowning-associated asphyxial out-of-hospital cardiac arrest (OHCA) and to explore any preliminary favorable factors in the management of therapeutic hypothermia to improve survival and neurological outcome. Drowning may result in asphyxial OHCA or hypothermic OHCA, but the former does not provide any potential neuroprotective effect as the latter may do. Electronic literature searches of Ovid Medline, Embase, Cochrane Library, and Scopus were performed for all years from inception to July 2016. Primary studies in the form of case reports, letters to the editor, and others with higher quality are included, but guidelines, reviews, editorials, textbook chapters, conference abstracts, and nonhuman studies are excluded. Non-English articles are excluded. Relevant studies are then deemed eligible if the drowning OHCA patient's initial temperature was above 28°C, which implies asphyxial cardiac arrest, and intentional therapeutic hypothermia was instituted. Because of the narrow scope of interest and strict definition of the condition, limited studies addressed it, and no randomized controlled trials (RCT) could be selected. Thirteen studies covering 35 patients are included. No quantitative synthesis, assessment of study quality, or assessment of bias was performed. It is conjectured that extended therapeutic hypothermia of 48-72 hours might help prevent reperfusion injury during the intermediate phase of postcardiac arrest care to benefit patients of drowning-associated asphyxial OHCA, but this finding only serves as preliminary observation for future research. No conclusive recommendation could be made regarding the duration of and the time of onset of therapeutic hypothermia. Future research should put effort on RCT, particularly the effect of extended duration of 48-72 hours. Important parameters should be reported in detail. Asphyxial and hypothermic OHCA should be differentiated.

Introduction Out-of-hospital cardiac arrest is a global health care problem. Like other cities in the world, Hong Kong faces the impact of such events. This study is the first territory-wide investigation of the epidemiology and outcomes of out-of-hospital cardiac arrest in Hong Kong. It is hoped that the findings can improve survival of patients with cardiac arrest. Methods This study was a retrospective analysis of the prospectively collected data on out-of-hospital cardiac arrest managed by the emergency medical service from 1 August 2012 to 31 July 2013. The characteristics of patients and cardiac arrests, timeliness of emergency medical service attendance, and survival rates were reported with descriptive statistics. Predictors of 30-day survival were evaluated with logistic regression. Results A total of 5154 cases of out-of-hospital cardiac arrest were analysed. The median age of patients was 80 years. Most arrests occurred at the patient's home. Ventricular fibrillation or ventricular tachycardia was identified in 8.7% of patients. The median time taken for the emergency services to reach the patient was 9 minutes. The median time to first defibrillation was 12 minutes. Of note, 2.3% of patients were alive at 30 days or survived to hospital discharge; 1.5% had a good neurological outcome. Location of arrest, initial electrocardiogram rhythm, and time to first defibrillation were independent predictors of survival at 30 days. Conclusion The survival rate of out-of-hospital cardiac arrest patients in Hong Kong is low. Territory-wide public access defibrillation programme and cardiopulmonary resuscitation training may help improve survival.

Background: Literature on prognosis of transient ischemic attack (TIA) in Chinese is scarce. The short-term prognosis of TIA and the predictive value of the ABCD2 score in Hong Kong Chinese patients attending the emergency department (ED) were studied to provide reference for TIA patient management in our ED. Methods: A cohort of TIA patients admitted through the ED to 13 acute public hospitals in 2006 was recruited through the centralized electronic database by the Hong Kong Hospital Authority (HA). All inpatients were e-coded by the HA according to the International Classification of Diseases, Ninth Revision (ICD9). Electronic records and hard copies were studied up to 90 days after a TIA. The stroke risk of a separate TIA cohort diagnosed by the ED was compared. Results: In the 1,000 recruited patients, the stroke risk after a TIA at days 2, 7, 30, and 90 was 0.2, 1.4, 2.9, and 4.4%, respectively. Antiplatelet agents were prescribed in 89%, warfarin in 6.9%, statin in 28.6%, antihypertensives in 39.3%, and antidiabetics in 11.9% of patients after hospitalization. Before the index TIA, the prescribed medications were 27.6, 3.7, 11.3, 27.1, and 9.7%, respectively. The accuracy of the ABCD2 score in predicting stroke risk was 0.607 at 7 days, 0.607 at 30 days, and 0.574 at 90 days. At 30 days, the p for trend across ABCD2 score levels was 0.038 (OR for every score point = 1.36, p = 0.040). Diabetes mellitus, previous stroke and carotid bruit were associated with stroke within 90 days (p = 0.038, 0.045, 0.030, respectively). A total of 45.4% of CTs of the brain showed lacunar infarcts or small vessel disease. There was an increased stroke risk at 90 days in patients with old or new infarcts on CT or MRI. Patients with carotid stenosis ≥70% had an increased stroke risk within 30 (OR = 6.335, p = 0.013) and 90 days (OR = 3.623, p = 0.050). Stroke risks at days 2, 7, 30, and 90 in the 289 TIA patients diagnosed by the ED were 0.35, 2.4, 5.2, and 6.2%, respectively. Conclusion: The short-term stroke risk in Hong Kong Chinese TIA patients is low. The administered nonurgent treatment cannot solely explain the favorable outcome, the lower risk can be due to the different pathophysiological mechanisms of stroke between Caucasians and Chinese. The predictive value of the ABCD2 score is low in our population.

Introduction Understanding how medical students view the Specialty of Emergency Medicine is important. The knowledge helps the leaders in Emergency Medicine better plan the development of the specialty. In the medical literature, few studies primarily investigated this subject. Most were on the career choice of medical students. This study aimed at addressing this knowledge gap. Methods It was a cross-sectional questionnaire survey of the year 3 to 5 medical students studying at the Li Ka Shing Faculty of Medicine, the University of Hong Kong. The questionnaire measuring their attitude consisted of 16 items in 3 domains: overall merits of Emergency Medicine, the role and function of emergency physicians and the career prospect in Emergency Medicine. Descriptive statistics were used for data analysis. Their attitude was represented by an attitude score with 80 being most positive and 16 most negative. Results A total of 298 students participated in the survey. The response rate was 64.5%. The overall median attitude score was 59. Year 5 students had a statistically significant higher score. Emergency Medicine ranked third in their first specialty choice after qualification. There was no statistical relationship between a student's attitude score and the specialty choice. Conclusion The students' overall attitude towards Emergency Medicine was positive. Senior students held a more positive attitude. A student's specialty choice after qualification did not seem to relate to their attitude towards the specialty. (Hong Kong j.emerg.med. 2014;21:67-72)

Introduction The survival rate of out-of-hospital cardiac arrest in Hong Kong is low. A long delay between collapse and defibrillation is a contributing factor. Public access to defibrillation may shorten this delay. It is unknown, however, whether Hong Kong's public is willing or able to use an automatic external defibrillator. This study aimed to evaluate public knowledge of how to use an automatic external defibrillator in out-of-hospital cardiac arrest. Methods A face-to-face semi-structured questionnaire survey of the public was conducted in six locations with a high pedestrian flow in Hong Kong. Results In this study, 401 members of the public were interviewed. Most had no training in first aid (65.8%) or in use of an automatic external defibrillator (85.3%). Nearly all (96.5%) would call for help for a victim of out-of-hospital cardiac arrest but only 18.0% would use an automatic external defibrillator. Public knowledge of automatic external defibrillator use was low: 77.6% did not know the location of an automatic external defibrillator in the vicinity of their home or workplace. People who had ever been trained in both first aid and use of an automatic external defibrillator were more likely to respond to and help a victim of cardiac arrest, and to use an automatic external defibrillator. Conclusion Public knowledge of automatic external defibrillator use is low in Hong Kong. A combination of training in first aid and in the use of an automatic external defibrillator is better than either one alone.

Objective To test the validity of the Hong Kong version of Appropriateness Evaluation Protocol and estimate the prevalence of inappropriate acute hospitalisations in Hong Kong. Methods A retrospective chart review of two hundred randomly selected patients admitted to the specialty of Internal Medicine and General Surgery via the Accident & Emergency department of 2 regional hospitals in 2008. Comparison between the Hong Kong version of Appropriateness Evaluation Protocol and the consensus of an expert panel on appropriateness of admissions was made. The extent of agreement between the reviewer using the protocol and the expert panel was measured. Results The kappa coefficient for agreement was 0.73 (95% confidence interval: 0.63-0.83). The prevalence of inappropriate acute hospitalisations was 29%. Conclusions The Hong Kong version of Appropriateness Evaluation Protocol is a valid tool for assessing the appropriateness of acute hospitalisations.

We aim to investigate whether prehospital Modified Early Warning Score (MEWS) can identify non-trauma patients requiring life-saving intervention (LSI) within 4 h of presentation to the ED.It was a prospective study of non-trauma ED patients by ambulance who were 16 years or older from 1 to 27 November 2013. Prehospital MEWS was calculated according to vital signs measured by the ambulance crew. Data on patients' demographics, triage category, LSI within 4 h of ED presentation and 24 h mortality were retrieved. LSI was defined as emergency interventions to airway, breathing and circulation, emergency procedures and medications administered. The performance of prehospital MEWS was analysed with sensitivity, specificity, predictive values (PV), likelihood ratios (LR) and the receiver operating characteristic curve.Recruited during the study period were 1493 patients. The median age was 78 years. Of the patients, 49.9% belonged to critical, emergent or urgent triage categories. LSI was required in 321 patients (21.5%). Thirteen died within 24 h of ED presentation. The area under the receiver operating characteristic curve of prehospital MEWS relating to LSI was 0.72 (95% confidence interval 0.69 to 0.75). The sensitivity, specificity, positive PV, negative PV, positive LR and negative LR were 0.57, 0.76, 0.40, 0.87, 2.43 and 0.56, respectively, when prehospital MEWS ≥3 was chosen as the cut-off value.Prehospital MEWS is useful in identifying non-trauma patients requiring LSI within 4 h of ED presentation. This may in turn enhance the triage accuracy in the ED in addition to clinical assessment.

Objective To investigate the effect of wearing a face mask on body temperature in healthy subjects. Methods The study was of repeated measures design. It was conducted from July to August 2003 in two accident & emergency departments on Hong Kong Island. Staff of the two departments, who were free from any active disease at the time of measurement, were recruited. Their body temperature (oral and aural) was measured while they were not wearing a mask and at 30 minutes after they had worn a mask (either surgical mask or N95 mask). Paired t-test was used for significance testing. Pearson product-moment correlation coefficient was calculated to elucidate the relationship between oral and aural temperature measurement. Results Ninety-three subjects were included. Oral temperature was significantly higher when a mask was worn (p=0.002, 95% CI 0.06–0.26). When considered separately, only those wearing N95 mask demonstrated such significance (p=0.005, 95% CI 0.088–0.454). The correlation coefficient for oral/aural temperature measurements was 0.219 (without mask, p=0.035) and 0.169 (with mask, p=0.104). Conclusion Wearing a face mask may increase the oral temperature in healthy subjects. However, the difference may not be clinically significant.

Objectives. To evaluate the effectiveness of the local emergency medical services system in resuscitation of out-of-hospital cardiac arrest and identify areas for improvement. Methods. This was a prospective descriptive study of adults with nontraumatic out-of-hospital cardiac arrest treated in the three accident & emergency departments that serve the whole of Hong Kong Island from March 15, 1999, to October 15, 1999. Patient characteristics, circumstances of cardiac arrest, final outcomes, and response times of the ambulance service were recorded according to the Utstein style. Results. Three hundred twenty patients were included. There was male predominance, and the mean age was 71.5 years. The majority of cardiac arrests occurred at patients' homes. In 57.5% of cases the arrest was not witnessed. The bystander cardiopulmonary resuscitation (CPR) rate was 15.6%. The most common electrocardiographic (ECG) rhythm at scene was asystole. Ventricular fibrillation or pulseless ventricular tachycardia constitu...

OBJECTIVE To investigate the impact of subinguinal microsurgical varicocelectomy on semen parameters and pregnancy outcomes in couples with male factor subfertility. DESIGN Case series. SETTING Male Infertility Clinic in an academic institution in Hong Kong. PATIENTS The clinical records of 42 consecutive subfertile male patients who had subinguinal microsurgical varicocelectomy (from January 2000 to December 2009) were retrospectively reviewed. All the patients had a known history of subfertility and abnormalities in one or more semen parameters. Female subfertility factors were not addressed. Only grade 2 or higher clinically palpable varicoceles were operated on. MAIN OUTCOME MEASURES Preoperative and postoperative semen analyses based on the World Health Organization criteria; the outcome measures included changes in semen parameters and whether a pregnancy ensued. RESULTS The mean age of patients and their spouses were 38 and 33 years, respectively. The mean duration of infertility was 4 years; 37 patients had primary infertility and five had secondary infertility. The mean (± standard deviation) sperm concentration improved from 12 ± 19 million/mL to 23 ± 29 million/mL following varicocelectomy (P

OBJECTIVE. To validate the Hong Kong Accident and Emergency Triage guidelines. DESIGN. Retrospective chart review. SETTING. The Accident and Emergency Department of a tertiary hospital in Hong Kong. PARTICIPANTS. Patients who attended the Accident and Emergency Department on one day in February 2012. MAIN OUTCOME MEASURES. The inter-rater reliability in two pairs of nurses grouped according to experience and validity as compared with an expert panel. RESULTS. Of the 100 patients recruited and triaged into levels 1 to 5, the weighted kappa coefficient (inter-rater reliability) for the two pairs of nurses was 0.699 and 0.717, respectively. The weighted kappa coefficient for validity was 0.766. When only patients in triage levels 3 and 4 were included, the weighted kappa coefficient for reliability dropped to 0.632 and 0.585, respectively. The weighted kappa coefficient for validity also decreased to 0.558. CONCLUSIONS. The overall inter-rater reliability and validity of the Guidelines appeared acceptable. Further revision of the Guidelines on triaging patients to levels 3 or 4 is probably necessary. Language: en

Focused Abdominal Sono-graphy for Trauma (FAST) is widely used for the detection of intraperitoneal free fluids in patients suffering from blunt abdominal trauma (BAT). This study aimed at assessing the diagnostic accuracy of this investigation in a designated trauma centre.This was a retrospective study of BAT patients over a 6 year period seen in a trauma centre in Hong Kong. FAST findings were compared with laparotomy, abdominal computed tomography or autopsy findings, which served as the gold standard for presence of intraperitoneal free fluids. The patients who did not have FAST or gold standard confirmatory test performed, had preexisting peritoneal fluid, died at resuscitation or had imcomplete documentation of FAST findings were excluded. The performance of FAST was expressed as sensitivity, specificity, predictive values (PV), likelihood ratios (LR) and accuracy.FAST was performed in 302 patients and 153 of them were included in this analysis. The sensitivity, specificity, positive PV, negative PV, positive LR, negative LR and accuracy for FAST were respectively 50.0%, 97.3%, 87.0%, 84.6%, 18.8, 0.5 and 85.0%. FAST was found to be more sensitive in less severely injured patients and more specific in more severely injured patients.FAST is a reliable investigation in the initial assessment of BAT patients. The diagnostic values of FAST could be affected by the severity of injury and staff training is needed to further enhance its effective use. Key words: Laparotomy; Autopsy; Tomography, X-ray computed; Tomography, spiral computed; Ultrasonography.

BACKGROUND This case report describes a university student who participated in an orientation activity and developed exertional rhabdomyolysis. METHODS With prompt intravenous volume expansion started in the accident and emergency department, he made an uneventful recovery despite a marked elevation of creatine kinase. The riskfactors of developing exertional rhabdomyolysis were reviewed. Suggestions based on these risk factors were made to the organizers of such orientation programmes. RESULTS He was discharged on day 6. On follow-up on day 8 after presentation at theaccident and emergency department, the CK level was 46 000 U/L and it fell to 2600 U/L in another 2 weeks. On follow-up 3 weeks after the incident, he remained well without symptoms. CONCLUSION For the clinicians, once rhadbomyolysis is suspected or diagnosed, intravenous fluid therapy with a crystalloid should be initiated as soon as possible to prevent the occurrence of acute renal faiure.