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Background/Objectives Increased evidence suggests that metabolic syndrome (MetS) is correlated with lung function impairment. This study aimed to explore the associations between MetS risk factors and the lung function. Subjects/Methods The cross-sectional study included 6945 participants attending health examination between 2010 and 2012 in Taiwan. MetS was assessed according to the criteria of National Cholesterol Education Program III. Spirometric parameters were measured to define lung function. The relationships were tested using multiple linear regression and logistic regression analyses. Results The prevalence of MetS was significantly higher in males (16.2%) than females (3.8%). Although the prevalence of restrictive lung disease (RLD) was comparable between genders (20.7 and 21.0%), males with co-existent MetS had a higher prevalence of RLD than females (27.4 vs. 18.0%). Abdominal obesity, indicated by waist circumference (WC) and weight-to-height ratio (WHtR), was the most significant factor associated with lung function decline. Other components of MetS also showed statistically significant relationships, but very weak, with lung function. There was a trend toward an increased prevalence of RLD with the increasing number of MetS scores in males, independent of age, smoking, and body mass index. Conclusions Abdominal obesity was the key component of MetS associated with mechanical effect on lung function impairment in a prime-age adult population. Although RLD was not associated with increased probability of having MetS, the participants with more MetS scores were at a higher risk of losing lung function.

To improve the clinical outcomes of patients with acute ischemic stroke, the public, pre-hospital care system, and hospitals should cooperate to achieve quick assessment and management for such patients and to start treatment as soon as possible. To reach the goal, the Consensus Group, including emergency physicians and neurologists in the Taiwan Society of Emergency Medicine and Taiwan Stroke Society, performed an updated review and discussion for the local guidelines. The guidelines consist of 12 parts, including public education program, evaluation and management in the emergency medical system, emergency medical system, assessment of stroke care capability of the hospital by independent parties, stroke team of the hospital, telemedicine, organization, and multifaceted integration, improvement of quality of care process of stroke system, initial clinical and imaging evaluations after arriving at the hospital, imaging evaluation for indications of intravenous thrombolysis, imaging evaluation for indications of endovascular thrombectomy, and other diagnostics. For detailed contents in Chinese, please refer to the Taiwan Stroke Society Guideline and Taiwan Emergency Medicine Bulletin.

Cardiopulmonary resuscitation (CPR) training and its quality are critical in improving the survival rate of cardiac arrest. This randomized controlled study investigated the efficacy of a newly developed CPR training program for the public in a Taiwanese setting. A total of 832 adults were randomized to either a traditional or blended (18-minute e-learning plus 30-minute hands-on) compression-only CPR training program. The primary outcome was compression depth. Secondary outcomes included CPR knowledge test, practical test, quality of CPR performance, and skill retention. The mean compression depth was 5.21 cm and 5.24 cm in the blended and traditional groups, respectively. The mean difference in compression depth between groups was −0.04 (95% confidence interval −0.13 to infinity), demonstrating that the blended CPR training program was non-inferior to the traditional CPR training program in compression depth after initial training. Secondary outcome results were comparable between groups. Although the mean compression depth and rate were guideline-compliant, only half of the compressions were delivered with adequate depth and rate in both groups. CPR knowledge and skill retained similarly in both groups at 6 and 12 months after training. The blended CPR training program was non-inferior to the traditional CPR training program. However, there is still room for improvement in optimizing initial skill performance as well as skill retention. Clinical Trial Registration: NCT03586752; www.clinicaltrial.gov

Background The protocol for early goal-directed therapy (EGDT) is effective for improving both the costs and outcomes of septicemia treatment, including a significant reduction in case fatality. However, this complicated protocol may have a downside. Furthermore, the Joint Taiwan Critical Care Medicine Committee has launched a nationwide educational program after the publication of the Surviving Sepsis Campaign (SSC) to improve the overall survival rate from septicemia in the emergency care system of Taiwan. Objectives To assess the impact of the EGDT protocol and SSC education programs on island-wide septicemia-related emergency department (ED) visits. Methods Segmented regression techniques were utilized to assess the differences in annual rates and changes in septicemia-related ED visits between 1998 and 2012. We considered annual incidence of two medical comorbidities as potential confounders: metastatic malignant neoplasms and malignant neoplasms of the lymphatic and hematopoietic tissues. Results The EGDT protocol was associated with decreased septicemia-related ED visits in 2002 (level change; p < 0.001), while the SSC education program led to a slight increase in septicemia-related ED visits in 2007 (slope change; p < 0.001). For the EGDT protocol, the number of patient visits decreased by 32.9% after the protocol was implemented in 2002 compared with the expected number without the intervention. For the SSC education program, the number of patient visits increased by 20.2% (compared with the predicted number) in 2007 after the education program was implemented. Conclusions The EGDT protocol and SSC education program were associated with significant immediate changes and lagged intervention effects on island-wide septicemia-related ED visits., Highlights • The early goal-directed therapy (EGDT) and the Surviving Sepsis Campaign (SSC) program may increase awareness of the diagnosis of septicemia-related visits in emergency departments (ED). • Previous studies have demonstrated the implementation of the EGDT and SSC program in developed countries is associated with improved patient outcomes. • However, the impact of the EDGT and SSC program on ED septicemia-related visits was unclear. • The EGDT and SSC program were associated with significant immediate changes and lagged intervention effects on island-wide septicemia-related ED visits.

Introduction: Patients with ST-elevation myocardial infarction are at risk of developing cardiac arrest. A validated tool for predicting cardiac arrest would help physicians recognize these high-risk patients earlier. This study assessed the usefulness of various score systems in predicting cardiac arrest in patients hospitalized for ST-elevation myocardial infarction. Methods: Patients’ data were retrieved from the hospital’s ST-elevation myocardial infarction registry records. Patients aged 18 years or older seen at the emergency department with a diagnosis of ST-elevation myocardial infarction between 1 July 2013 and 30 June 2014 were enrolled. The Thrombolysis in Myocardial Infarction score, the 6-month Global Registry of Acute Coronary Event risk score, CHADS2 score, and HEART score were calculated and compared. Results: A total of 249 patients were recruited. The Thrombolysis in Myocardial Infarction score, 6-month Global Registry of Acute Coronary Event risk score, CHADS2 score, and HEART scores were calculated. In total, 41 (16.5%) patients had cardiac arrest at emergency department or during hospitalization and 12 (29.3%) of them survived. The 6-month Global Registry of Acute Coronary Event risk score had the biggest area under the receiver-operating characteristic curve (0.72). Conclusion: The 6-month Global Registry of Acute Coronary Event risk score is more useful in predicting cardiac arrest in patients hospitalized for ST-elevation myocardial infarction than the other three scores. It is recommended that the 6-month Global Registry of Acute Coronary Event risk score be calculated for identifying emergency department patients hospitalized for ST-elevation myocardial infarction who are at risk of cardiac arrest during their hospital stay.

Background Commotio cordis is ventricular fibrillation after a direct precordial blow without mechanical damage to organs. Early recognition and prompt cardiopulmonary resuscitation with defibrillation save lives. According to previous reports, the major determinants of commotio cordis include location and timing of the blow. Other risk factors are young age, a thin and undeveloped chest cage, and a small hard spherical projectile. The pathophysiology of commotion cordis remains uncertain, such as individual susceptibility to prolonged repolarization and long QT. Case report A 32-year-old man suddenly collapsed after a direct blow to the anterior chest from an elbow during a basketball game. A bystander called an ambulance and activated the emergency medical service immediately. Dispatch assisted the bystander with cardiopulmonary resuscitation via telephone. An automated external defibrillator was applied when emergency medical technicians arrived, which showed ventricular fibrillation. The patient regained a pulse after the first electrical shock and five-cycle-chest compression. Further examinations revealed a long QT on electrocardiogram and hypokalemia. The QT interval was within normal limits without any ventricular arrhythmia after the potassium level had been normalized. Conclusion This case reminds physicians of the risk of commotio cordis associated with exercise-induced hypokalemia. An electrocardiogram should be checked for QT prolongation immediately after return of spontaneous circulation in patients of sudden cardiac arrest. Supplying adequate potassium for hypokalemia related QT prolongation should be considered as treatment and primary prevention in such case.

Background In the provision of high-quality cardiopulmonary resuscitation (CPR) by health care providers, factors associated with high-quality CPR should be explored. Methods This is a post hoc analysis using data from a manikin-based survey of CPR quality among volunteer emergency medical technicians (EMTs) from 2 county fire departments in northern Taiwan. Results Among the 95 enrolled EMTs, 36 (37.9%) performed high-quality CPR on a manikin. The baseline characteristics that differed significantly between groups were board-certified EMT levels ( P = .010), body mass index (BMI, P = .029), average exercise frequency ( P = .001), and average exercise duration ( P = .005). Average total exercise time per week, which uses frequency times exercise duration, was independently associated with high-quality CPR performance after adjusting for variables via logistic regression analysis (odds ratio, 1.004; P = .044). An index was developed (BMI × ExeTime) based on the product of BMI and average total exercise time per week. A comparison of the area under curve for the different indices showed that BMI × ExeTime was a significant predictor of high-quality CPR, with an area under curve of 0.718 (95% confidence interval, 0.613-0.824; P 2 (sensitivity, 0.722; specificity, 0.678). Conclusions This study identified factors associated with the performance by health care providers of high-quality CPR, including BMI and exercise habits. To optimize CPR quality, a program of exercise frequency and duration adjusted according to individual's BMI should be considered in such populations.

ObjectivesThis study aimed to determine the inter-rater reliability of the five-level Taiwan Triage and Acuity Scale (TTAS) when used by emergency medical technicians (EMTs) and triage registered nurses (TRNs). Furthermore, it sought to validate the prehospital TTAS scores according to ED hospitalisation rates and medical resource consumption.MethodsThis was a prospective observational study. After training in five-level triage, EMTs triaged patients arriving to the ED and agreement with the nurse triage (TRN) was assessed. Subsequently, these trained research EMTs rode along on ambulance calls and assigned TTAS scores for each patient at the scene, while the on-duty EMTs applied their standard two-tier prehospital triage scale and followed standard practice, blinded to the TTAS scores. The accuracy of the TTAS scores in the field for prediction of hospitalisation and medical resource consumption were analysed using logistic regression and a linear model, respectively, and compared with the accuracy of the current two-tier prehospital triage scale.ResultsAfter EMT’s underwent initial training in five-level TTAS, inter-rater agreement between EMTs and TRNs for triage of ED patients was very good (κw=0.825, CI 0.750 to 0.900). For the outcome of hospitalisation, TTAS five-level system (Akaike’s Information Criteria (AIC)=486, area under the curve (AUC)=0.75) showed better discrimination compared with TPTS two-level system (AIC=508, AUC=0.66). Triage assignments by the EMTs using the the five-level TTAS was linearly associated with hospitalisation and medical resource consumption.ConclusionsA five-level prehospital triage scale shows good inter-rater reliability and superior discrimination compared with the two-level system for prediction of hospitalisation and medical resource requirements.

To examine the effect of ascent rate on the induction of acute mountain sickness (AMS) in young adults during a climb to Jiaming Lake (3350 m) in Taiwan.Prospective, nonrandomized.Climb from 2370 to 3350 m.Young adults (aged 18 to 26 years) (N = 91) chose to participate in either the fast ascent (3 days; n = 43) or slow ascent (4 days; n = 48) group (1 and 2).Two criteria were used to define AMS. A Lake Louise score ≥3 and Lake Louise criteria [in the setting of a recent gain in altitude, the presence of headache and at least 1 of gastrointestinal discomfort (anorexia, nausea, or vomiting), fatigue or weakness, dizziness or lightheadedness, or difficulty sleeping].Heart rate, blood oxygen saturation (SaO2), and symptoms of AMS were monitored each morning and evening.Baseline characteristics were similar between groups, except for significant differences in history of alcohol consumption (P = 0.009) and climbing experience above 3000 m (P0.001). The incidence of AMS was not associated with the rate of ascent. Acute mountain sickness was most prevalent in group 1 on day 2 in the evening and in group 2 on day 3 in the evening. In both groups, AMS correlated with the initial reduction in SaO2. Body mass index (BMI)24 kg/m was identified as a significant risk factor for AMS.The development of AMS was closely associated with an initial reduction in SaO2. A BMI24 kg/m also contributed to the occurrence of AMS.These findings indicate that factors other than ascent rate should be considered when trying to ameliorate the risk of AMS.

Background Most out-of-hospital cardiac arrest (OHCA) studies have been conducted in developed countries or metropolitan areas, and few in developing countries or rural areas. Objectives The aims of this study were to determine the weak links in the chain of survival and to estimate the outcomes of OHCA patients in Taoyuan, a nonmetropolitan area in Taiwan. Methods A retrospective review and analysis of OHCA data was conducted. The three outcomes were whether a return of spontaneous circulation (ROSC) was achieved, whether the patient survived to admission, or whether the patient survived to hospital discharge. Results From April to December 2008, 1048 OHCA patients were resuscitated, and 712 (67.9%) adult cardiac patients were used in this study. Among these 712 patients, 17.8% achieved ROSC (95% confidence interval [CI] 15.2–20.8%), 16.3% survived to admission (95% CI 13.6–19.0%), and 1.4% survived to discharge (95% CI 0.5–2.3%). Factors significantly associated with the three outcomes were witness status, response time to emergency medical services, and whether the patient had a shockable rhythm. Bystander cardiopulmonary resuscitation (CPR) did not add a notable benefit to the outcomes of OHCA. Conclusions The survival rate of OHCA patients in nonmetropolitan Taiwan was very low (1.4%). Lower witnessed rate, lower bystander CPR rate, and longer response interval in remote areas are the main causes of inferior survival rate.

Objective We aimed to compare the performance of Glasgow-Blatchford, preendoscopic Rockall, and model for end-stage liver disease (MELD) scores in cirrhotic patients with unstable upper gastrointestinal bleeding (UGIB) in the emergency department (ED). Methods This was a retrospective cohort study conducted at a university-affiliated teaching hospital. Adult cirrhotic patients who presented with acute UGIB and unstable vital signs (heart rate > 100 beats/min or systolic blood pressure

Supplemental Digital Content is available in the text, Effectiveness of bystander cardiopulmonary resuscitation (CPR) is known to provide emergency medical services which reduce the number of deaths in patients with out-of-hospital cardiac arrest. The survival at these patients is affected by the training level of the bystander, but the best format of CPR training is unclear. In this pilot study, we aimed to examine whether the sequence of CPR instruction improves learning retention on the course materials. A total of 95 participants were recruited and divided into 2 groups; Group 1: 49 participants were taught firstly how to recognize a cardiac arrest and activate the emergency response system, and Group 2: 46 participants were taught chest compression first. The performance of participants was observed and evaluated, the results from 1 pre-test and 2 post-tests between 2 groups were then compared. There was a significantly better improvement of participants in Group 2 regarding the recognition of a cardiac arrest and the activation of the emergency response system than of those in Group 1. At the post-test, participants in Group 2 had an improvement in chest compression compared to those in Group 1, but the difference was not statistically significant. Our study had revealed that teaching CPR first in a standardized public education program had improved the ability of participants to recognize cardiac arrest and to activate the emergency response system.

Cardiogenic shock is defined by tissue hypoperfusion due to heart failure. The manifestations of acute right ventricular (RV) failure include a distended jugular vein and hypotension, but not rales. The causes of isolated acute RV failure include RV infarction, pulmonary embolism, cardiac tamponade, congenital disease, and valvular heart disease. Rupture of a sinus of Valsalva aneurysm (SVA) is rarely seen in emergency departments (EDs). We report a 46 year-old male who suffered from SVA rupture triggering acute RV failure and cardiogenic shock.

Background/Aims: This study aimed to evaluate the effectiveness of homocysteine and C-reactive protein (CRP) as potential markers for chronic kidney disease (CKD) in adults in Taiwan, and to identify associations between these factors and CKD, stratifying by gender. Methods: This cross-sectional study analyzed multi-center data retrospectively. Data were collected from 22,043 adult Taiwanese at Chang-Gung Memorial Hospital from 2005 to 2011. Smoking/drinking history, personal medical/medication history, pregnancy, fasting times as well as laboratory parameters, including homocysteine and CRP were measured and analyzed. Results: Significant differences were observed between four homocysteine and CRP quartiles in eGFR and CKD. For males, only one model showed significant associations between plasma homocysteine and CKD, while in females, all three models showed significant associations with CKD. On the contrary, the gender difference in the case of CRP was opposite. Combined homocysteine and CRP were associated with CKD in males but not in females. Conclusion: Among Taiwanese adults, plasma homocysteine is associated with CKD in females and plasma hsCRP is associated with CKD in males. High hsCRP/high homocysteine is associated with elevated CKD risk in male. Our results suggest that homocysteine and hsCRP may be useful surrogate markers for evaluating CKD risk in adults.

To reduce patient boarding time at the emergency department (ED) and to improve the overall quality of the emergent care system in Taiwan, the Minister of Health and Welfare of Taiwan (MOHW) piloted the Grading Responsible Hospitals for Acute Care (GRHAC) audit program in 2007–2009. The aim of the study was to evaluate the impact of the GRHAC audit program on the identification and management of acute myocardial infarction (AMI)-associated ED visits by describing and comparing the incidence of AMI-associated ED visits before (2003–2007), during (2007–2009), and after (2009–2012) the initial audit program implementation. Using aggregated data from the MOHW of Taiwan, we estimated the annual incidence of AMI-associated ED visits by Poisson regression models. We used segmented regression techniques to evaluate differences in the annual rates and in the year-to-year changes in AMI-associated ED visits between 2003 and 2012. Medical comorbidities such as diabetes mellitus, hyperlipidemia, and hypertensive disease were considered as potential confounders. Overall, the number of AMI-associated patient visits increased from 8130 visits in 2003 to 12,695 visits in 2012 (P-value for trend

Supplemental Digital Content is available in the text, Nonurgent emergency department (ED) patients are a controversial issue in the era of ED overcrowding. However, a substantial number of post-ED hospitalizations were found, which prompted for investigation and strategy management. The objective of this study is to identify risk factors for predicting the subsequent hospitalization of nonurgent emergency patients. This was a retrospective study of a database of adult nontrauma ED visits in a medical center for a period of 12 months from January 2013 to December 2013. Patient triages as either Taiwan Triage and Acuity Scale (TTAS) level 4 or 5 were considered “nonurgent.” Basic demographic data, primary and secondary diagnoses, clinical parameters including blood pressure, heart rate, body temperature, and chief complaint category in TTAS were analyzed to determine if correlation exists between potential predictors and hospitalization in nonurgent patients. A total of 16,499 nonurgent patients were included for study. The overall hospitalization rate was 12.47 % (2058/16,499). In the multiple logistic regression model, patients with characteristics of males (odds ratio, OR = 1.37), age more than 65 years old (OR = 1.56), arrival by ambulance (OR = 2.40), heart rate more than 100/min (OR = 1.47), fever (OR = 2.73), and presented with skin swelling/redness (OR = 4.64) were predictors for hospitalization. The area under receiver-operator calibration curve (AUROC) for the prediction model was 0.70. Nonurgent patients might still be admitted for further care especially in male, the elderly, with more secondary diagnoses, abnormal vital signs, and presented with dermatologic complaints. Using the TTAS acuity level to identify patients for diversion away from the ED is unsafe and will lead to inappropriate refusal of care for many patients requiring hospital treatment.

Background The aim of this study was to examine the factors associated with emergency department (ED) length of stay (LOS) using the patient registry data from a medical burns center during a burn injury mass casualty incident (MCI) after a dust explosion in New Taipei City, Taiwan. Methods This was a retrospective cohort study conducted at an urban, tertiary care teaching hospital during an MCI event that occurred on June 27, 2015. A celebratory party was held at the Formosa Fun Water Park in New Taipei City, Taiwan. At 20:32, the was an explosion caused by an overheated spotlight accidentally igniting colored cornstarch powder that had been sprayed on the stage. Factors associated with ED LOS were compared. Results In total, 48 burn injury patients were enrolled for study analysis. The median total body surface area of second- to third-degree burns was 35.0% (interquartile range [IQR], 15.8%-55.0%). The median ED LOS was 121.5 minutes (IQR, 38.3-209.8 minutes). The output time interval accounted for the longest interval with a median time of 56.0 minutes (IQR, 15.3-117.3 minutes). In multivariate analysis of the variables, triage level (level III; hazard ratio, 0.06; 95% confidence interval, 0.01-0.52) and output time (hazard ratio, 0.97; 95% confidence interval, 0.96-0.98) were significant influential factors. Conclusions The triage level and output time intervals were significantly associated with ED LOS in a burn-related MCI. Time effectiveness analyses, using a patient flow model, might serve as an important indicator during a hospital MCI response.

Background and Aim Albuminuria is a well-known predictor of poor renal and cardiovascular outcomes and associated with increased risk of all-cause mortality. The study aimed to evaluate the associations between metabolic characteristics and the presence of albuminuria. Methods This cross-sectional study included 18,384 adult Chinese who participated in health examinations during 2013–2014. Differences in clinical characteristics were compared for microalbuminuria (MAU) and albuminuria, and between genders. Potential risk factors associated with the risk of developing MAU and albuminuria were analyzed using univariate logistic regression. Multiple logistic regression was applied to further identify the independent associations between different levels of risk factors and the presence of MAU and albuminuria. The area under the ROC curve (AUC) was used to determine the discriminatory ability of metabolic risk factors in detecting albuminuria. Results There were significant gender differences in clinical characteristics according to albuminuria status. Risk for the presence of albuminuria was significantly associated with age, male gender, waist circumference (WC), waist-to-height ratio (WHtR), hypertension, fasting plasma glucose (FPG), and triglycerides to high-density lipoprotein cholesterol ratio (TG/HDL-C) in univariate logistic regression. Multiple logistic regression analysis indicated that the factors significantly associated with the presence of MAU were WC > 90cm, WHtR at 0.6–0.7, hypertension, FPG > 6.1 mmole/L, and TG/HDL-C ratio > 1.6. The optimal cutoffs for risk factors of metabolic syndrome (MetS) to predict albuminuria in males and females were: WC, 90.8 vs. 80.0 cm; WHtR, 0.53 vs. 0.52; MAP, 97.9 vs. 91.9 mmHg; FPG, 5.40 vs. 5.28 mmole/L; and TG/HDL-C, 1.13 vs. 1.08. Conclusion MetS and all its components were associated with the presence of MAU in a health check-up population in China. Gender specific and optimal cutoffs for MetS components associated with the presence of MAU were determined.

Abdominal Compartment Syndrome (ACS) is defined by organ dysfunction caused by intra-abdominal hypertension. Increase in intra-abdominal pressure causes multiple adverse physiologic events and is uniformly fatal if left untreated. We report the case of a 76-year-old woman of pneumoperitoneum due to hydrocholoric acidinduced corrosive injury, leading to ACS with pulseless electrical activity. Emergency needle decompression was done and successfully restored circulation. It reminds possible ACS in patients of pneumoperitoneum and use of percutaneous needle decompression before operation in emergent condition.

Objectives To examine the effectiveness of a five-level Paediatric Triage and Acuity System (Ped-TTAS) by comparing the reliability of patient prioritisation and resource utilisation with the four-level Paediatric Taiwan Triage System (Ped-TTS) among non-trauma paediatric patients in the emergency department (ED). Methods The study design used was a retrospective longitudinal analysis based on medical chart review and a computer database. Except for a shorter list of complaints and some abnormal vital sign criteria modifications, the structure and triage process for applying Ped-TTAS was similar to that of the Paediatric Canadian Emergency Triage and Acuity Scale. Non-trauma paediatric patients presenting to the ED were triaged by well-trained triage nurses using the four-level Ped-TTS in 2008 and five-level Ped-TTAS in 2010. Hospitalisation rates and medical resource utilisation were analysed by acuity levels between the contrasting study groups. Results There was a significant difference in patient prioritisation between the four-level Ped-TTS and five-level Ped-TTAS. Improved differentiation was observed with the five-level Ped-TTAS in predicting hospitalisation rates and medical costs. Conclusions The five-level Ped-TTAS is better able to discriminate paediatric patients by triage acuity in the ED and is also more precise in predicting resource utilisation. The introduction of a more accurate acuity and triage system for use in paediatric emergency care should provide greater patient safety and more timely utilisation of appropriate ED resources.

Although the advent of emergency medicine as a specialty has led to advances in emergency airway management, airway management is still challenging for emergency physicians. Moreover, patients in need of intubation frequently present in the emergency department (ED) with medical or traumatic conditions that greatly increase the difficulty of managing the airway. In most cases, a direct laryngoscope is used for intubation, and a series of maneuvers are required to directly visualize the vocal cords and place a flexible plastic tube into the trachea. Difficult intubations usually occur with an inadequate glottic view. Operating room studies have shown that video and optical laryngoscopy, in which a miniature video camera enables the operator to visualize the glottis indirectly, improves glottic exposure and the ease of intubation compared with direct laryngoscopy. Video laryngoscopy is becoming more accessible to emergency physicians, yet whether these performance characteristics translate to emergency patients remains unclear. The aim of our article is to provide an up-to-date literature review of video laryngoscopy. We especially focus on learning with mannequins, and clinical performance in normal and difficult airways in the ED and prehospital settings.

The role of the leader of a medical unit has evolved over time to expand from simply a medical role to a more managerial one. This study aimed to explore how the behavior of a hospital-based emergency department's (ED's) leader might be related to ED unit performance and ED employees' work satisfaction. One hundred and twelve hospital-based EDs in Taiwan were studied: 10 in medical centers, 32 in regional hospitals, and 70 in district hospitals. Three instruments were designed to assess leader behaviors, unit performance and employee satisfaction in these hospital-based EDs. A mail survey revealed that task-oriented leader behavior was positively related to ED unit performance. Both task- and employee-oriented leader behaviors were found to be positively related to ED nurses' work satisfaction. However, leader behaviors were not shown to be related to ED physicians' work satisfaction at a statistically significant level. Some ED organizational characteristics, however, namely departmentalization and hospital accreditation level, were found to be related to ED physicians' work satisfaction.

Objective An ideal emergency department (ED) triage system accurately prioritises patients on the basis of the urgency of interventions required to avoid under- or over-triage. The objective of this study was to develop and validate a five-level Taiwan triage and acuity scale (TTAS) with an electronic decision support tool. Methods This prospective, multicentre, observational study included 10533 patients triaged at 11 academic medical centres, 18 regional and four district hospitals. Adult patients presenting to the ED were independently triaged by the duty triage nurse in the usual way and trained research nurses using TTAS with a computerised decision support system. Weighted κ statistics were used to assess the reproducibility. Hospitalisation, length of stay, and medical resource consumption were analysed by TTAS acuity levels. Results Most cases were stratified into levels 2 to 3 by the existing four-level triage system, whereas the TTAS stratified most patients to levels 3 (41.4%) and 4 (25.0%), and only a small number to level 1 (3.9%) (resuscitation; most urgent). Weighted κ for TTAS assignment was 0.87 (95% CI 0.85 to 0.89). The decrease in mean medical resource consumption and hospitalisation rate was statistically significant with each decrease in the TTAS triage acuity level. The length of stay also decreased significantly as the TTAS level acuity fell from levels 2 to 5. Conclusions The TTAS was found to be a reliable triage system that accurately prioritises the treatment needed to avoid overtriage, more efficiently deploying the appropriate resources to ED patients.

Background/Purpose Since the implementation of National Health Insurance in Taiwan, Emergency Department (ED) volume has progressively increased, and the current triage system is insufficient and needs modification. This study compared the prioritization and resource utilization differences between the four-level Taiwan Triage System (TTS) and the standardized five-level Canadian Triage and Acuity Scale (CTAS) among ED patients. Methods This was a prospective observational study. All adult ED patients who presented to three different medical centers during the study period were included. Patients were independently triaged by the duty triage nurse using TTS, and a single trained research nurse using CTAS with a computer support software system. Hospitalization, length of stay (LOS), and medical resource consumption were analyzed by comparing TTS and CTAS by acuity levels. Results There was significant disparity in patient prioritization between TTS and CTAS among the 1851 enrolled patients. With TTS, 7.8%, 46.1%, 45.9% and 0.2% were assigned to levels 1, 2, 3, and 4, respectively. With CTAS, 3.5%, 24.4%, 44.3%, 22.4% and 5.5% were assigned to levels 1, 2, 3, 4, and 5, respectively. The hospitalization rate, LOS, and medical resource consumption differed significantly between the two triage systems and correlated better with CTAS. Conclusion CTAS provided better discrimination for ED patient triage, and also showed greater validity when predicting hospitalization, LOS, and medical resource consumption. An accurate five-level triage scale appeared superior in predicting patient acuity and resource utilization.

Aims. (1) To understand nurses’ subjective perceptions of the current nursing workforce in their emergency departments, (2) to examine the relationship between nurses’ workforce perceptions and its impact on the managerial outcomes and (3) to analyse the correlation between nurses’ characteristics and the scores on workforce perception. Background. While the association between workforce perceptions and nurse outcomes is well-documented, few studies have examined how emergency department nurses perceive current workforce and related outcomes. Design. A cross-sectional questionnaire survey. Method. A self-reported workforce perception questionnaire was used to survey 538 registered nurses in the emergency departments of 19 hospitals in northern Taiwan, during May to October 2006. Data were analysed using descriptive statistics, chi-square test, independent t-test, Pearson correlation and one-way anova. Results. The mean score of workforce perception was 6·28 points (total = 10 points). Both overtime (p = 0·02) and number of callbacks on days off (p = 0·01) were significantly correlated to current nursing workforce and hospital level. Older nurses tended to have more emergency department experience (r = 0·37; p = 0·01) and those with more emergency department experience tended to have vacation accumulation (r = 0·09; p = 0·04), overtime (r = 0·10; p = 0·03) and better perception of their emergency department’s current workforce (r = 0·09; p = 0·05). Conclusions. Although nurses’ perceptions were found to be only moderate, overtime and number of callbacks on days off are potential problems that should be addressed by nursing leaders to benefit future emergency nurses. Relevance to clinical practice. The findings can help drive strategies to ensure adequate staffing, to stabilise the nursing workforce and to prevent nurses from burnout factors such as working long hours, unpredictable schedules and a stressful work environment that may impact both the quality of emergency care and the quality of the nurses’ work environment.

To describe the characteristics of children who present to an emergency department (ED) with facial palsy and determine the association of outcome with etiology, degree of initial paralysis, and ED management.This was a retrospective cohort study of children who presented to an ED with facial nerve paralysis (FNP).There were 85 patients with a mean age of 8.0 (SD, 6.1) years; 60% (n = 51) of the patients were male, and 65.9% (n = 56) were admitted to the hospital. Bell palsy (50.6%) was the most common etiology followed by infectious (22.4%), traumatic (16.5%), congenital (7.1%), and neoplastic etiologies (3.5%). Patients with Bell palsy had shorter recovery times (P = 0.049), and traumatic cases required a longer time for recovery (P = 0.016). Acute otitis media (AOM)-related pediatric FNP had shorter recovery times than non-AOM-related cases (P = 0.005) in infectious group. Patients given steroid therapy did not have a shorter recovery time (P = 0.237) or a better recovery (P = 0.269). There was no difference in recovery rate of pediatric patients with Bell palsy between hospitalization or not (P = 0.952).Bell palsy, infection, and trauma were most common etiologies of pediatric FNP. Recovery times were shorter in pediatric patients with Bell palsy and AOM-related FNP, whereas recovery took longer in traumatic cases. Steroid therapy did not seem beneficial for pediatric FNP. Hospitalization is not indicated for pediatric patients with Bell palsy.

Since emergency departments (ED) are designed to manage people with urgent and life-threatening conditions, cancer patients presenting with pain may not receive the appropriate care in the ED. The purpose of this study was to identify the incidence and factors related to ED visits by cancer patients with pain complaints. Medical charts selected by stratified random sampling were retrospectively reviewed to obtain information about ED visits by cancer patients during a 1-year period. The sample included 1,179 ED visits by 1,026 cancer patients. Pain was the most common reason for ED visits by cancer patients. The incidence of ED visits for pain as a presenting problem was 27.8%. The 72-h ED return-visit rate was 8.2% for cancer patients who visited the ED with pain complaints. Patients with gastrointestinal and genitourinary cancers were more likely to visit the ED for pain. Patients who had received radiation therapy were less likely to visit the ED for pain. Effective cancer pain management programs need to be developed and tested to reduce ED visits by cancer patients with pain. More research is needed to explore why cancer patients with pain visit the ED.

Wang, Shih-Hao(1,2) Tai-Yi Hsu,(1,2) Jen-Tse Kuan,(1,2) Jih-Chang Chen,(1,2) Wei-Fong Kao,(3) Te-Fa Chiu,(1,2) Yu-Cheng Chen,(1,2) and Hang-Cheng Chen.(1,2) Medical problems requiring mountain rescues from 1985 to 2007 in Yu-Shan National Park, Taiwan. High Alt. Med Biol. 10:77-82, 2009.-Medical problems requiring mountain rescue in densely populated and low-latitude locations like Taiwan have rarely been studied or discussed. The purpose of this research was to examine mountain-rescue operations that occurred in Yu-Shan National Park Taiwan from 1985 to 2007. Of 186 mountain-rescue operations, 128 involved medical problems (illnesses or injuries). Of the medical problems, 62% involved trauma and 41% involved illness. Ninety-nine ground rescues, 14 helicopter rescues, 38 combination ground and helicopter rescues, and 20 rescues using unclear methods were conducted, and the remaining 15 rescue operations did not involve visitors. In the 186 rescue operations, 330 visitors were rescued, 240 of them survived, 66 were dead, and 24 had an unclear outcome. Factors that affected the type of injury or the probability of survival included the activity, altitude, composition of the visitor group, weather, and occurrence of natural disasters. Mountain-rescue operations in which both ground and helicopter rescue were utilized were more successful. Our retrospective findings indicate that wilderness emergency services should have the capability of performing rescues in rugged terrain and be flexible in their approach to any situation arising in mountainous regions; proper training of onboard helicopter medical personnel is also necessary. In conclusion, we recommend setting up a standard system for reporting mountain- rescue operations, with statistics compiled annually.

Difference of the clinical characteristics and outcome of acute appendicitis (AA) between young old (age 60 to 79 years) and octogenarian patients (age 80) is unknown. We hypothesized that octogenarian patients would have more atypical presentation and worse outcomes.Our study was a 10-year retrospective analysis of a hospital based database. All patients with histopathologically confirmed AA from 1995 to 2005 registered in this database were selected for study. Demographic data, preexisting conditions, clinical manifestations, Alvarado score, delay in surgery, complications, and mortality were compared between the octogenarians and young old. Independent effect of age on outcomes was examined by logistic regression model controlling for sex, comorbidities, and time delayed for surgery.Octogenarian patients constituted 93 (14.8%) of 628 geriatric patients with AA. On clinical manifestations, migrating pain and localized iliac fossa tenderness were less common in the octogenarians. Low sensitivity of Alvarado score in diagnosing AA was noted in both young old (50.7%) and octogenarian (44.1%) patients. Compared with young old patients, octogenarians had a longer delay in surgery and worse outcomes. Octogenarians had a significantly higher perforation rate (65.6% vs 49.5%, P0.001), postoperative morbidity rate (18.3% vs 10.1%, P0.001), and mortality rate (6.5 % vs 1.5 %, P0.001). Octogenarian age was independently associated with appendiceal perforation (OR, 95% CI; 1.94, 1.23 approximately 3.08), postoperative morbidity (2.0, 1.10 approximately 3.62), and mortality (4.5, 1.54 approximately 13.41).The clinical presentation of AA in octogenarian patients is atypical and the outcomes are worse than young old patients.

Background Several risk score systems are designed for triage patients with acute nonvariceal upper gastrointestinal bleeding (UGIB). Blatchford score, which relies on only clinical and laboratory data, is used to identify patients with acute UGIB who need clinical intervention (before endoscopy). Clinical Rockall score, which relies on only clinical variables, is used to identify patients with acute UGIB who have adverse outcome, such as death or recurrent bleeding. Complete Rockall score, which relies on clinical and endoscopic variables, is also used to identify patients with acute UGIB who died or have recurrent bleeding. In our study, we define patients who need clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control) as high-risk patients. Our study aims to compare Blatchford score with clinical Rockall score and complete Rockall score in their utilities in identifying high-risk cases in patients with acute nonvariceal UGIB. Methods International Classification of Diseases, Ninth Revision, Clinical Modification codes for admission diagnosis were used to recognize a cohort of patients (N = 354) with acute UGIB admitted to a tertiary care, university-affiliated hospital. Medical record data were abstracted by 1 research assistant blinded to the study purpose. Blatchford and Rockall scores were calculated for each enrolled patient. High risk was defined as a Blatchford score of greater than 0, a clinical Rockall score of greater than 0, and a complete Rockall score of greater than 2. Patients were defined as needing clinical intervention if they had a blood transfusion or any operative or endoscopic intervention to control their bleeding. Such patients were defined as high-risk patients. Results The Blatchford score identified 326 (92.1%) of the 354 patients as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control). The clinical Rockall score identified 289 (81.6%) of the 354 patients as high-risk, and the complete Rockall score identified 248 (70.1%) of the 354 patients as high-risk. The yield of identifying high-risk cases with the Blatchford score was significantly greater than with the clinical Rockall score ( P P In our total 354 patients, 246 (69.5%) patients were categorized as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control, as aforementioned) in our study. The Blatchford score identified 245 (99.6%) of 246 patients as high-risk. Only 1 patient who met the study definition of needing clinical intervention was not identified via Blatchford score. This patient did not have recurrent bleeding nor die and did not receive blood transfusion. The clinical Rockall score identified 222 (90.2%) of 246 patients as high-risk. Twenty-four patients who met the study definition of needing clinical intervention were not recognized via clinical Rockall score. Of these patients, 0 died, 7 developed recurrent bleeding, and 6 needed blood transfusion. The complete Rockall score identified 224 (91.1%) of 246 patients as high-risk. Twenty-two patients who met the study definition of needing clinical intervention were not recognized via complete Rockall score. Of these patients, 2 died, 3 developed recurrent bleeding, and 20 needed blood transfusion. Conclusions The Blatchford score, which is based on clinical and laboratory variables, may be a useful risk stratification tool in detecting which patients need clinical intervention in patients with acute nonvariceal UGIB. It does not need urgent endoscopy for scoring and has higher sensitivity than the clinical Rockall score and the complete Rockall score in identifying high-risk patients.

Following acute administration, ethanol has been assumed to be evenly distributed throughout the brain. However, some evidence exists for unequal extracellular levels of ethanol in different areas of the brain, suggesting the existence of locally elevated intracellular levels. The aim of this study was to investigate the relative tissue levels and rates of decline of ethanol in various regions of the brain and in the plasma of rats.Adult male Wistar rats (250-300 g) were injected intraperitoneally with a 14% ethanol/water solution at a dose of 1 g/kg of body weight. Brain and plasma samples were analyzed by an enzymatic rate method 30, 60, 90, or 120 minutes after injection for ethanol content.The highest tissue and plasma concentrations of ethanol occurred 30 minutes after administration, with concentrations of ethanol being highest in the striatum. All regions of the brain and plasma followed zero-order kinetics of elimination of ethanol; however, the rate of elimination in the brain declined at a slower rate than in the plasma. The rate remained constant during the 90-minute period. Elimination was slower in the brain than in the plasma.Ethanol can accumulate to higher levels and can be eliminated more slowly from the brain than from the plasma, thus raising questions about blood alcohol testing as a measure of intoxication. The higher level of ethanol in the striatum, an area implicated in movement regulation and substance addiction, thus may have a significant bearing on the neurological effects and addictive properties of ethanol.

Dyspnea is one of the most common emergency department (ED) symptoms, but early diagnosis and treatment are challenging because of multiple potential causes. Hemodynamic parameters may aid in the evaluation of dyspnea, but are difficult to assess. Impedance cardiography is a noninvasive hemodynamic measurement method that may assist in early ED decision making.This study is intended to determine the accuracy in differentiating cardiac from noncardiac causes of dyspnea using impedance cardiography-derived hemodynamic parameters compared to ED physician opinion in light of initial history, and physical and laboratory tests. The final diagnosis, made after patient hospital record review, was compared with ED physician and impedance cardiography diagnoses.A total of 52 patients were included: 14 women and 38 men, aged 68.5 +/- 14.2 years. There were significant differences in values of stroke index (25.7 vs 32.9, P.05), cardiac index (2.3 vs 3.1, P.0001), velocity index (35.1 vs 53.2, P.01), and systolic time ratio (0.55 vs 0.44, P.05) between the cardiac and noncardiac groups, respectively. Impedance cardiography measurements demonstrated better sensitivity (75% vs 60%), specificity (88% vs 66%), and positive and negative predictive values (79% vs 52% and 85% vs 72%, respectively) compared with those of the ED physician in distinguishing cardiac from noncardiac causes of dyspnea.Impedance cardiography data result in improvement in ED physician differentiation of cardiac from noncardiac causes of dyspnea.

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Diabetes is associated with renal calcium and magnesium wasting, but the molecular mechanisms of these defects are unknown. We measured renal calcium and magnesium handling and investigated the effects of diabetes on calcium and magnesium transporters in the thick ascending limb and distal convoluted tubule in streptozotocin (STZ)-induced diabetic rats. Rats were killed 2 weeks after inducing diabetes, gene expression of calcium and magnesium transporters in the kidney was determined by real-time polymerase chain reaction, and the abundance of protein was assessed by immunoblotting. Our results showed that diabetic rats had significant increase in the fractional excretion for calcium and magnesium (both P0.01), but not for sodium. Reverse transcriptase-polymerase chain reaction revealed significant increases in messenger RNA abundance of transient potential receptor (TRP) V5 (223 +/- 10%), TRPV6 (177 +/- 9%), calbindin-D28k (231 +/- 8%), and TRPM6 (165 +/- 8%) in diabetic rats. Sodium chloride cotransporter was also increased (207 +/- 10%). No change was found in paracellin-1 (cortex: 108 +/- 8%; medulla: 110 +/- 10%). Immunofluorescent studies of renal sections showed significant increase in calbindin-D28k (238 +/- 10%) and TRPV5 (211 +/- 10%), but no changes in paracellin-1 in Western blotting (cortex: 110 +/- 7%; medulla: 99 +/- 7%). Insulin administration completely corrected the hyperglycemia-associated hypercalciuria and hypermagnesiuria, and reversed the increase of calcium and magnesium transporter abundance. In conclusion, our results demonstrated increased renal calcium and magnesium transporter abundance in STZ-induced diabetic rats, which may represent a compensatory adaptation for the increased load of calcium and magnesium to the distal tubule.

To evaluate the value of helical computed tomography of the thorax (HCTT) as a definitive tool for diagnosing traumatic aortic injury, this study retrospectively examined 53 patients with blunt thoracic injuries and HCTT during a 5-year period. All CT scans were reviewed for direct signs of aortic injury and correlated with aortography or surgery. Correlations between clinical parameters, as well as combinations of direct signs and individual signs, and mortality were analyzed in all traumatic aortic injury (TAI) cases. Direct signs were seen on the HCTT in 25 cases and 22 had TAI. All false positive results came from the group with only a single direct sign depicted on HCTT. Among individual direct signs examined, intimal flap and luminal thrombus were the most specific (100%), whereas irregular aortic contour was the most sensitive (100%). A combination of > or = 3 direct signs (p = 0.006) and periaortic contrast material extravasation significantly correlated with early rupture and mortality (p = 0.002). In conclusion, intimal flap on HCTT is both the most specific and sensitive sign for TAI. TAI patients with > or = 3 direct signs, including periaortic contrast material extravasation, may not require aortography before immediate surgery.

Summary Background The serum concentration of cardiac enzymes may be influenced by mechanical and electrical trauma due to cardiopulmonary resuscitation (CPR) attempts. This could complicate the determination of whether an acute myocardial infarction (AMI) had occurred. In this study, only patients without any of the known confounding factors affecting cardiac enzyme release were included, and the specific time course and patterns of serum cardiac enzyme levels after resuscitation were evaluated. The purpose is to help clinicians distinguish between spontaneous myocardial damage and that induced by CPR. Methods and results This prospective, observational study was performed in the emergency department on eight patients surviving cardiac arrest. They were selected for not having heart disease, chest trauma or septic shock; and not receiving defibrillation. The median (range) duration of return of spontaneous circulation (ROSC) was 13 min (5–30 min). Cardiac enzyme measurements were taken immediately after ROSC and every 6 h thereafter. Although cardiac troponin I (cTnI) level reached as high as 62.6 ng/ml at 24 h in one patient, five of the eight (62.5%) patients had their cTnI level fall below the normal reference range (i.e. 2 ng/ml) by 30 h. The time to maximum and peak concentration of cTnI was 16.50 ± 10.99 h and 16.85 ± 21.50 ng/ml, respectively. Both MB creatine kinase (CKMB) and total creatine kinase (CK) levels were above their normal reference ranges. In addition, the CKMB/CK ratio exceeded 5% in all patients at any time point during this study. Conclusion In this study, the influence of resuscitative procedures – defibrillation excluded – on the release of cardiac enzymes were examined. During 30 h after ROSC cTnI level exhibited a bell-shaped configuration, which is distinct from that after AMI; whereas the enzymatic activities of CKMB and CK, as well as CKMB/CK ratio, were constantly higher than normal. This chronological pattern of cardiac enzyme levels may help physicians differentiate primary cardiac disease from other aetiologies in out-of-hospital cardiac arrests.

Melatonin has been used to treat experimental pancreatitis, although not all the drug's therapeutic mechanisms of melatonin have been defined. Prostaglandins (PGs) are proinflammatory mediators that exert their effects mainly locally during inflammatory diseases. The present study was undertaken to examine whether treatment with melatonin influences local PG production. An acute pancreatitis model in male Sprague–Dawley rats (225–275 g) was established by continuously infusing caerulein (15 mg/kg/hr). Mean arterial pressure and pancreatic perfusion were monitored continuously. Melatonin was delivered via the intraperitoneal route at doses of either 2 or 10 mg/kg, 30 min after caerulein injection. Malondialdehyde and glutathione levels of the pancreas and liver and the trypsinogen activation peptide levels in the serum were measured at the end of the experiment (8 hr after infusion of caerulein). Intraperitoneal injection of melatonin (2 and 10 mg/kg) reduced the reduction in systemic arterial pressure and decreased pancreatic perfusion in the rat model of caerulein pancreatitis. Moreover, melatonin treatment changed local PG production toward control level. Higher dose of melatonin was somewhat more effective in preventing the caerulein-induced alterations than was the lower dose.

This study evaluated the expression of neutrophil apoptosis and the effects of melatonin at different concentrations on delayed neutrophil apoptosis in different severities of acute pancreatitis in patients.The study population was comprised of 10 patients with severe acute pancreatitis (SAP) and 10 with mild acute pancreatitis (MAP). A total of 10 mL of blood was drawn 24 hours after the onset of the clinical disease for isolation and incubation of the human neutrophils with 4 different concentrations of melatonin. Neutrophil apoptosis activity, CD18 expression, and respiratory burst activity were assessed with flow cytometry 12 hours after incubation. Another group of neutrophils from a healthy control group was used (n = 6) for comparison.Neutrophil apoptosis in patients with SAP is delayed compared with that of patients with MAP. Neutrophils from patients with SAP or MAP are functionally activated. Melatonin at concentrations of 10(-8), 10(-7), or 10(-6) M reverses the delayed process and enhances apoptosis activity in neutrophils in patients with MAP. Melatonin at concentrations of 10(-7) and 10(-6) M reverses the delayed process and increases apoptosis activity in neutrophils in patients with SAP. Neutrophils from patients with SAP and MAP showed significantly increased CD18 expression and respiratory burst activity. Melatonin at concentrations of 10(-7) or 10(-6) M reverses CD18 expression and respiratory burst activity in neutrophils in patients with SAP.This study highlights the importance of neutrophil apoptosis in patients with SAP and raises the possibility of a therapeutic strategy. Study data show that melatonin promotes neutrophil apoptosis in human acute pancreatitis.

Delayed neutrophil apoptosis has been implicated as the mechanism of the systemic inflammatory response. Herein, we examined the effect of melatonin on the neutrophil apoptosis in ischemia and reperfusion of the human liver. We studied seven patients receiving elective hepatectomy for liver tumor and ten patients receiving laparoscopic cholecystectomy for gallstones. Ten milli liters of blood was drawn isolation and incubation of the human neutrophils. Neutrophil apoptosis activity and CD18 expression and respiratory burst activity were assessed flow cytometrically. Another group of neutrophils included those from the patients receiving hepatectomy and isolated and incubated with melatonin. Neutrophil apoptosis is delayed from patients after hepatectomy or laparoscopic cholecystectomy when compared with that of the preoperative state. The decrease in the apoptosis activity is more severe in patients receiving hepatectomy as compared with those receiving laparoscopic cholecystectomy. Neutrophils from patients receiving hepatectomy or laparoscopic cholecystectomy are functionally activated. Melatonin can reverse the delayed process and enhance the apoptosis activity in neutrophils from patients receiving hepatectomy. This study demonstrates that melatonin enhances neutrophil apoptosis in patients receiving hepatectomy involving ischemia and reperfusion of the human liver.

A Singapore airline crash in 2000 was the first documented mass casualty incident (MCI) caused by an aircraft disaster in Taiwan. This report reviews the emergency medical preparedness of the airport and examines its effects on the medical response during this incident. The anticipated benefits from the new MCI plan and prior medical preparedness were not achieved during this disaster. Poor compliance with the new MCI plan by the airport authority was noted. Victims were not triaged and did not receive adequate field medical care. Structural problems with the MCI plan were also noted. Site medical teams responding from hospitals could not function as the plan had been designed. This article discusses factors causing the poor compliance, various problems, and related issues in medical response to the incident. As learned from this experience, a properly and practically designed MCI plan, good compliance of responders, and a strong support system of responding agencies are the most important factors for successful emergency response to any MCI.

Background The associations between dysglycemia and mortality in septic patients with and without diabetes are yet to be confirmed. Our aim was to analyze the association of diabetes and sepsis mortality, and to examine how dysglycemia (hyperglycemia, hypoglycemia and glucose variability) affects in-hospital mortality of patients with suspected sepsis in emergency department (ED) and intensive care units. Methods Clinically suspected septic patients admitted to ED were included, and stratified into subgroups according to in-hospital mortality and the presence of diabetes. We analyzed patients’ demographics, comorbidities, clinical and laboratory parameters, admission glucose levels and severity of sepsis. Odds ratio of mortality was assessed after adjusting for possible confounders. The correlations of admission glucose and CoV (blood glucose coefficients of variation) and mortality in diabetes and non-diabetes were also tested. Results Diabetes was present in 58.3% of the patients. Diabetic patients were older, more likely to have end-stage renal disease and undergoing hemodialysis, but had fewer malignancies, less sepsis severity (lower Mortality in Emergency Department Sepsis Score), less steroid usage in emergency department, and lower in-hospital mortality rate (aOR:0.83, 95% CI 0.65–0.99, p = 0.044). Hyperglycemia at admission (glucose≥200 mg/dL) was associated with higher risks of in-hospital mortality among the non-diabetes patients (OR:1.83 vs. diabetes, 95% CI 1.20–2.80, p = 0.005) with the same elevated glucose levels at admission. In addition, CoV>30% resulted in higher risk of death as well (aOR:1.88 vs. CoV between 10 and 30, 95%CI 1.24–2.86 p = 0.003). Conclusions This study indicates that while diabetes mellitus seems to be a protective factor in sepsis patients, hyper- or hypoglycemia status on admission, and increased blood glucose variation during hospital stays, were independently associated with increased odds ratio of mortality.

Purpose The boarding of critically ill patients in the emergency department (ED) could reduce quality of care and increase mortality. An ED intensive care unit (ICU) was set up in a 3715-bed medical center to facilitate timely delivery of critical care. This study reports comparative outcomes of EDICU patients with specialty ICU patients. Materials and methods Medical records of adult nontrauma ED patients admitted to nonsurgical ICUs (EDICU, medical, cardiac, alimentary, and neurological units) between January 2007 and July 2011 were retrospectively reviewed. The respective number of admissions, bed turnover rate, and length of stay were compared. Cox regression models were also applied to compare inhospital mortality risks among these patients. Results With only 13% (14/108) of all ICU beds, EDICU admitted 36% (3711/10 449) of patients. Emergency department ICU patients had an unfavorable adjusted hazard ratio for inhospital mortality compared with medical ICU and cardiac ICU patients, but after excluding patients with an ICU length of stay of 2 days or less, the difference in hazard ratio became nonsignificant. Conclusions Emergency department ICU has admitted a disproportionately higher proportion of patients without sacrificing quality of care. Specialty care could be secured through direct communication between EDICU and specialty physicians and forming close collaboration between departments and ICUs.

Background Overtriage has been observed among pediatric patients in emergency departments (EDs) under 5-level acuity pediatric triage systems. This study aimed to investigate the causes of overtriage and to provide suggestions for future amendments to such systems. Methods This study has a retrospective follow-up design in which 42000 pediatric patients who were admitted to the ED of the largest medical center in Taiwan between January and December of 2010 were recruited. The study variables included patient demographics, chief concerns, individual vital signs (ie, blood pressure, heart rate, body temperature, respiratory rate, and O 2 saturation), triage level, ED final disposition, ED expenses, and total medical expenses. A logistic regression model was applied to explore the causes of overtriage and the effectiveness of a modified acuity system. Results Approximately 13.6% of the pediatric ED visits were upgraded to acuity level 1 based on vital signs that included heart rate (97.3%). The strength of the trend association (odds ratio) between decreasing acuity urgency (from levels 1 to 5) and hospitalization increased from 0.73 (95% confidence interval, 0.72-0.75) with the Pediatric Triage and Acuity System (Ped-TTAS) to 0.57 (95% confidence interval, 0.55-0.59) with the modified Ped-TTAS, which downgraded acuity levels by excluding the weighting of vital signs. Further validation was accomplished by comparing the trend association between decreasing acuity urgency and total medical expenses (Ped-TTAS: β = −0.13; modified Ped-TTAS: β = −0.18). Conclusions Heart rate is prone to be affected by emotional responses among pediatric patients in certain specific age groups. Appropriate revisions of the pediatric triage system are suggested.

Leukocyte-endothelial adherence and changes of blood flow in microcirculation are associated with the development of ischemia-reperfusion injury in the liver. Polymorphonuclear neutrophil (PMN) apoptosis is essential to maintain homeostasis and plays a major role in limiting the reperfusion-related systemic effects. This study investigates the effects of a prostacyclin analogue (OP-2507) on hepatic ischemia-reperfusion injury. Adult, male Sprague-Dawley rats were used. Five groups were evaluated: (1) sham-operated control, n = 8; (2) ischemia control (1-h ischemia, 5-h reperfusion), n = 8; (3) intravenous infusion with OP-2507 ([15 cis-14-propylcyclohexyl]-16,17,18,19,20-pentanor-9-deoxy-9alpha,6-ni-trilo-PGF, methyl eater) at a dose of 1 microg/kg/min plus ischemia, n = 8; (4) intravenous infusion with OP-2507 at a dose of 0.1 microg/kg/min plus ischemia, n = 8, and (5) sham-operated control and intravenous infusion with OP-2507 at a dose of 1 microg/kg/min, N =8. Laser-Doppler flowmetry and an in vivo microscopy were used to investigate hepatic microcirculation. PMN apoptosis was quantitated by flow-cytometric labeling of DNA strand breaks. Tissue malondialdehyde and adenosine triphosphate were determined at the end of the experiment. Compared with the ischemia control group, OP-2507 significantly improved harmful insults following ischemia-reperfusion. The changes of mean systemic arterial pressure following ischemia-reperfusion have been significantly attenuated by OP- 2507 at both doses. OP-2507 lessened adherent leukocyte count in the post-sinusoid venules, and improved flow velocity in these areas. OP-2507 at both doses reduced malondialdehyde and increased adenosine triphosphate levels and this effect was dose-related. The activity of delayed ex vivo PMN apoptosis was significantly lower in the ischemia group than that of control and treatment groups. OP-2507 induced the activity of PMN apoptosis and its effect is dose-related, also. The PMN apoptosis activity is strongly correlated with parenchymal damages. This study demonstrates that OP-2507 treatment with ischemia may ameliorate the ischemia-reperfusion injury of the liver in the rat model, and increase spontaneous neutrophil apoptosis ex vivo.