Adult Emergency Patients Research Articles

Etiologies of acute hypoglycemia in a Taiwanese Hospital Emergency Department

The etiologies of acute hypoglycemia (< 2.8 mmol/L) in adult emergency patients were assessed to provide more proper and prompt management. There were 228 hypoglycemic patients (112 women and 116 men, ranging in age from 22 to 93 years, mean = 69.6 years) identified for the study. These patients had hypglycemia mainly due to excessive use of sulfonylureas or insulin. There was a diabetic history in 182 patients (79.83%). Other primary etiologies of acute hypoglycemia were sepsis in 13 (5.70%), and extensive liver disease in 13 (5.70%). This study indicates that good diabetic control can dramatically decrease the number of episodes of acute hypoglycemia in Taiwan. For acute hypoglycemic patients without a diabetic history, the possibility of sepsis or extensive liver disease is a problem in Taiwan.

Prevalence of genuine epilepsy among adult emergency patients with an episode of unconsciousness

Objective: Loss of consciousness (LOC) is caused by a variety of conditions including epileptic, cardiac, psychiatric, and autonomic disorders. We investigated the prevalence of presenting attacks of genuine epilepsy among patients of Emergency Department and Department of Cardiology evaluated for an episode of LOC with or without a convulsion. Patients and methods: We retrospectively studied 371 adults presenting to the Emergency Department and Department of Cardiology of our hospital from 1991 to 1999 with a chief complaint of an episode of LOC with or without a convulsion. Ages ranged from 15 to 78 years. Patients were free of severe chronic illnesses, drug abuse, and alcoholism. LOC was considered to represent genuine epilepsy either when the interictal electroencephalogram (EEG) showed epileptiform discharges in the absence of imaging abnormalities, or when both the EEG and imaging studies were unrevealing but one or more previous attacks had occurred and administration of an anticonvulsant prevented subsequent attacks. Results: Patients included 302 patients without a convulsion, and 69 patients with a convulsion. Of the former, 14 subjects had epileptiform discharges on EEG, and three subjects had no epileptiform discharges but had three or four attacks of LOC that were abolished by anticonvulsant therapy. Of the 69 patients with a convulsion, seven had epileptiform discharges, and 12 had two to five attacks, no epileptiform discharges, and a response to anticonvulsant therapy. Conclusions: The prevalence of presenting attacks of genuine epilepsy in 371 adult patients with an episode of LOC was remarkably high (9.7%: 36 subjects).

Elderly use of the ED in an Asian metropolis

To compare emergency department (ED) use by elderly patients (age 65 yrs or older) with that by younger adult patients (age 15–64 yrs), a prospective consecutive chart review study was conducted from August 1, 1995 through May 31, 1996 in eight designated hospitals in Taipei city (which has 2.6 million residents, 8.4% of whom are 65 yrs or older). Patient age, sex, mode of arrival, living status, triage category, advanced life support (ALS) eligibility, referral, confinement to bed, intensive care unit (ICU) admission, impression, trauma mechanism, and disposition were recorded and compared between the two groups. Of 27,765 adult emergency patients studied during the 10 months, 24% were elderly. The elderly were more likely to be ambulance cases, of high acuity and ALS eligibility, living alone, bed-ridden, and ICU cases (19.4% v 10.5%, 14.8% v 5.5%, 14.7% v 4.3%, 9.7% v 4.1%, 16% v 1.1%, and 4.0 v 1.1%, respectively). The three leading illnesses in the elderly were cerebral vascular accident (6.6%), cancer (5.6%), and cardiovascular disease (5.6%), and the two most common trauma mechanisms were trip (fall from the same level surface) (57.2%) and traffic accident (20.7%). Twenty-seven percent and 22.7% of elderly were disposed to admission and observation, respectively, compared with the 10.9% and 11.4% of the younger patients. Elderly patients have significantly different and more severe presentations to the ED compared with younger adults.

Confidential inquiry into quality of care before admission to intensive care

Objective: To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions.Design: Prospective confidential inquiry on the basis of...

Rates of and factors associated with self-reported prior HIV testing among adult medical patients in an inner city emergency department in the Bronx, New York City.

We studied the rates of and factors associated with self-reported prior human immunodeficiency virus (HIV) testing in adult patients visiting an emergency department (ED) in the Bronx, New York City. A total of 1,744 consecutive noncritical adult medical emergency patients responded to a standardized interview administered by ED physicians. The interview included questions pertaining to demographic characteristics, prior HIV testing, and HIV risk behaviors. On multivariate analysis, female gender, younger age, history of weight loss, injecting drug use (IDU), syphilis, and genital herpes were all associated with increased reported prior testing rates. Race (i.e., black race) was an independent predictor of increased rates among male subjects; comparatively low rates were reported by patients with a first language other than English, patients lacking medical insurance, and highly sexually active, nonblack men. Increased HIV testing rates were reported by subjects with recognized HIV risk behaviors in a New York City ED population; however, substantial proportions of subjects at risk had not been tested. Programs of HIV testing and counseling need to include older, uninsured, and non-English-speaking segments of the population who engage in high-risk behaviors.

Endobronchial administration of emergency drugs

Endobronchial emergency drug therapy is reviewed. Although intravenous drug administration is always preferable endobronchial application is a comparatively safe alternative when venous access is not available because an endotracheal tube is usually inserted during CPR. The optimal procedure remains to be clarified, however. Drugs and dosages currently being recommended for endobronchial use are described. With the reservations mentioned above the following recommendations can be made for the endobronchial administration of drugs to adult emergency patients: (1) Endobronchial administration of drugs is indicated in cases of cardiac arrest when an initial examination after the start of mechanical measures suggests that intravenous application will be difficult. This is also the case for emergency patients without cardiac arrest who are already intubated, and for whom the immediate administration of emergency drugs, such as lidocaine or atropine, is urgent and for whom venous injection cannot be carried out or cannot be carried out sufficiently quickly. We cannot at present share the view that the primary endobronchial administration of epinephrine is to be regarded as the treatment of first choice in every case of asystolic cardiac arrest (J. Schüttler et al., Anästh. Intensiwther. Notfallmed., 22 (1987) 63), as in most cases peripheral venous access can readily be established, thus avoiding the possible disadvantages of endobronchial administration (prolonged tachycardia, hypertension, arrhythmia from the depot effect, and also additional impairment of the pulmonary gas exchange). However, the washingin of the administered drug is important after peripheral venous administration. (2) For adults, the present recommendation for the i.v. administration of epinephrine during resuscitation is 0.5–1 mg (7.5–15 μg/kg). Animal experiments show that under stable circulatory conditions ten times as much epinephrine must be administered endobronchially as intravenously in order to produce comparable pharmacodynamic effects or plasma levels. During resuscitation the corresponding value is approximately five times. Nevertheless, because of the dangers from the depot effect, an endobronchial dosage of 2–3 mg should not at present be exceeded. The best method probably consists of a combination of an initial restricted endobronchial dose with, if necessary, a further dose through a venous site which has been established in the interim. This recommendation seems to be reasonable because, as described, there are no exact data on the optimal dosage for epinephrine, even for i.v. administration (3) In the presence of a stable circulation the endobronchial dosage of the other drugs mentioned should also be two to three times that used for intravenous administration. During cardiac arrest not more than twice this dosage should be given, and lidocaine in particular should not be applied at more than 2 mg/kg endobronchially. (4) Saline should serve as diluent giving a total volume of between 5 and 10 ml. (5) In cases of cardiac arrest there are possible advantages in using a deep endobronchial catheter for administration. In this case, as after simple injection into the tube, vigorous insufflations should be carried out immediately after administration. In general we are of the opinion that emergency drugs should still be preferentially administered i.v., in spite of the possibility of endobronchial administration. Endobronchial application should not be used routinely as the method of first choice, as too many questions regarding this technique remain unanswered.