Frontiers in Emergency Medicine
Year:2022 | Volume:6 | Issue:4|Papers Count:16

Objective: Determining the exact underlying etiology of loss of consciousness (LOC) can become a real challenge for physicians due to the broadness of differential diagnoses. The current study aimed to assess the accuracy of a commercially available strip for urine drug screening, in patients presenting with LOC. Methods: One hundred fifty patientswith LOCwere enrolled in the current cross-sectional study. The diagnostic accuracy of a multidrug urinary strip rapid test was evaluated in comparison to blood analysis as the reference test, and the screening performance characteristics of the rapid test for each substance were estimated. Results: The average age of patients was 46. 21±, 18. 59 years (72. 67% male). The most frequent false positive results of the test were related to Benzodiazepine (21. 5%), Methamphetamine (7. 5%), and Tramadol (5. 4%), respectively. The screening performance characteristics of the test tape were the best in detection of Amitriptyline with 100. 0% (95% CI: 30. 99 –,100. 0) sensitivity, Cocaine with 100. 0% (95% CI: 5. 46 –,100. 0) sensitivity, and Methadone with 91. 54% (95% CI: 81. 88 –,96. 51) sensitivity, respectively. Conclusion: The current study reveals that employing a urinary strip test for detecting drug intoxication in the setting of emergency department can lead to significant false positive and negative results. Accordingly, relying on a urine drug screen to determine the underlying etiology of LOC should be done with caution.

Since the authoring of the seminal report by the Institute of Medicine (IOM) “, To Err is Human: Building a Safer Health System”,in 2000, there has been an increased focus on patient safety and the responsibility born by the healthcare system to reduce what are known as adverse events (AE). One of the recommendations of the IOM report was the establishment and development of Incident Reporting System (IRS) that would track AE resulting in serious injury and death. The Joint Commission in the USA similarly requires all hospitals have and use an IRS. The objective of this review is to explore barriers and feature of IRS and patient safety.

Objective: Emergency medicine (EM) is considered a competitive specialty worldwide with an acceptance rate of 57% in Canada, but it is even more competitive in Saudi Arabia with 18. 7% acceptance. Factors that may influenced the applicant’, s acceptance into residency programs included letters of recommendation, interview performance, research experience, and gender. This study aims to determine the factors playing a role in applicants matching to EM residency programs in Saudi Arabia from the viewpoint of program directors. Methods: A pilot study was done using a self-administered questionnaire distributed to EM residency program directors (PDs) in Saudi Arabia during the period of 16-21 November 2021. The data were analyzed using SPSS, and all ethical considerations were observed. Results: Twenty-seven PDs participated in the study, 19 (70. 4%) were male, and most were former PDs (59. 3%). The most crucial aspect in the applicant’, s acceptance was the excellent impression in the interview (4. 00 ±,1. 00). The most crucial aspect of recommendation letters was a recommendation from a program director (29. 6%). In addition, total duration of electives inEM(40. 7%)was important, quality in EMresearch (29. 6%) played a critical role, and professionalism (29. 6%) was the factor sought during the interview. The PD’, s gender or status or the region of the program did not significantly affect the preference of the applicant’, s gender. Conclusion: For those considering EM residency programs in Saudi Arabia, the chance of getting accepted can be increased by getting a recommendation from a program director, increasing the duration of electives in EM, focusing on the research quality, and showing professionalism during the interview.

Spontaneous subcapsular renal hematoma is a rare complication with potentially fatal effects in clinical practice. We discuss a case of a patient who arrived at the emergency room with abrupt onset flank discomfort and hematuria. The damaged kidney was effectively embolized by interventional radiology, and the patient quickly recovered. Follow-up tests revealed that the hematoma had shrunk in size. We believe that early arterial embolization should be explored in the care of patients with renal bleeding because it may enhance outcomes.

1. Case presentation A 62 years old Palestinian woman with a history of diabetes mellitus presented to our department with a decrease in urine output since a week before, and complete anuria with the onset of bilateral flank pain more prominent in the right side in the last 3 days. The pain was dull in nature, continuous, severe, and changing with the position. Other symptoms included epistaxis, anorexia, nausea, and eye redness appearing 10 days before the admission, which resolved in 2 days on home remedies (herbal compressor). Laboratory test revealed increased c-reactive protein (CRP), high creatinine, anemia, elevated perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) (>100) and normal C3, C4, cytoplasmic anti-neutrophil cytoplasmic antibodies (cANCA), and anti-glomerular basement membrane (Anti GBM) antibody. The patient also had proteinuria. Blood film ruled out hemolysis. Septic workup was done, including blood and urine culture, which showed extended spectrum beta-lactamase (ESBL). High resolution chest computed tomography (CT) scan showed atelectasis bands and bilateral pleural effusion. Renal ultrasound findings ruled out hydronephrosis or signs of chronic kidney disease. She was started on pulse steroid therapy. The treatment protocol included hemodialysis, plasmapheresis, and antibiotics. The patient developed hypertension, for which antihypertensive medications were administrated. Renal biopsy was taken and it showed sclerosed glomeruli with acute tubular necrosis and localized vessel necrosis, confirming the diagnosis of ANCA glomerulonephritis and vasculitis. The protocol of cyclophosphamide therapy was planned. After taking one cycle of cyclophosphamide and during the fourth session of plasmapheresis, the patient became unresponsive, clenched teeth, and spastic. She was immediately transferred to ICU. Urgent intubation was done without complications. Electroencephalogram (EEG) findings were abnormal and brain magnetic resonance imaging (MRI) showed bilateral multiple areas of high signal in T2 and flair in the supratentorial white matter mainly in the subcortical region. Furthermore, there was no diffusion restriction (no acute infarction), intra-cranial hemorrhage, mass effect, or hydrocephalus. Chest CT revealed the presence of multifocal, bilateral, patchy infiltrations. The patient had vesicles on lips and buccal mucosa. We suspected herpes encephalitis and started her on acyclovir. Lab tests showed disseminated intravascular coagulation and bacteremia with EBSL, sensitive to vancomycin. We started her on antibiotics and anticoagulant. Her status improved, she regained consciousness, and she was transferred out of ICU after 12 sessions of hemodialysis. The patient was discharged and put on prednitab, Cyclophosphamide 500 mg / month with a total of 6 doses and antihypertensive medication. The level of creatinine on last follow up was normal and there were no further complications. 2. Learning points The most common symptoms at the time of presentation of Wegener’, s granulomatosis (WG) are nose, ear, and throat symptoms (70-100%), pulmonary manifestations (50-90%), and kidney involvement (40-100%) (1). However, the occurrence of acute renal failure as a first presentation remains uncommon. Diagnosing WG may be difficult in some cases and it is often misdiagnosed as tuberculosis, lung neoplasms, and other conditions leading to a delay in the management. Currently, the prognosis of untreated patients with WG is considered to be poor and about 90% of untreated patients die within 2 years (2). Reports show that the 5-year relapse rate for WG is high (3). Infections are considered as a frequent cause of death among WG patients (4). In this article, we described a new case of WG who developed encephalitis and sepsis after receiving cyclophosphamide as an immunosuppressive and plasmapheresis. In this article, we reported a case of WG presenting with acute renal failure treated with hemodialysis and plasmapheresis, who got herpes encephalitis and disseminated intravascular coagulation related to bacterial sepsis after receiving one dose of cyclophosphamide. WG is a rare disorder involving mainly small and medium-sized vessels. The termWegener refers to Dr. Friedrich Wegener, a German pathologist who first described the disease in 1936 (5). It is considered an autoimmune disease, but its pathogenesis is unclear. Its average age of onset is about 40 years, with a male to female ratio of 1: 1. It usually presents with prodromal and various symptoms involving many organs (6). In a Chinese cohort, the incidence of WG with acute renal failure was 15%, with an average age of 50 years old. The common symptoms were fever and weight loss, while the most common extra-renal organ damages involved lung and nose. Renal damages manifested as mild or moderate proteinuria and hematuria. However, oliguria and anuria are rare (7). Our patient presented with epistaxis, eye involvement, anuria, and urinary infection. Bajema et al. performed a meta-analysis on 349 cases and showed that WG with renal involvement was, clinically, in a more progressive state than WG without renal involvement (8). In addition, it is generally accepted that patients with WG who are of older age, with renal involvement or infection, have worse outcomes and higher mortality rates compared with other patients who developWG (9). The diagnosis of this disease is made by the detection of necrotizing granulomatous vasculitis on tissue biopsy, in addition to the clinical presentation. The treatment of WG is currently done in two phases: induction and maintenance phases. Severe disease, including biopsy proven renal disease, requires a treatment including pulse steroids and cyclophosphamide or rutiximab to induce remission. Some patients may need plasmapheresis, especially patients presenting with severe renal disease with a level of creatinine above 5. 7 and those with pulmonary hemorrhage and those not responding to steroids and cyclophosphamide (10-12). Severe infection is a recognized problem in ANCA-associated vasculitis, with some important prognostic factors, such as having increased disease activity at the time of diagnosis and age. These complications are associated with permanent organ damage and increased odds of mortality (13). Although complications may appear during treatment, a rationally designed combination treatment of steroid hormones and immunosuppressive drugs may improve the prognosis ofWG (14). Our patient developed her symptoms after being treated with antibiotics, which made us think about a viral infection. Further lab tests showed disseminated intravascular coagulation and bacteremia with EBSL. Most importantly, all concomitant infections need to be treated prior to immunosuppression. In such cases, plasma-exchange therapy may be the initial modality of choice to restore kidney function, given its rapid action to reduce antibody load and its moderate immunosuppressive action (15). This case of WG illustrates the narrow path between therapeutic control of the disease and opportunistic infections due to medical immunosuppression. The overall goal is disease remission without infectious complications or side effects. To reach this goal, various variables including age, and renal and liver function need to be considered on an individual basis.

Providing early health care services in natural disaster is one of the essential applications of telemedicine. This narrative review aims to investigate the applications, advantages and challenges of telemedicine in natural disaster-stricken areas. Medline (through PubMed), Web of Science (WOS), and Scopus databaseswere searched for related articles published from beginning to 2022. The keywords used for the search included "telemedicine" and "natural disaster. " After removing duplicate papers, irrelevant review articles and letters to editors, 44 relevant papers were selected and reviewed. Information sharing through audio, visual, and data-oriented services is among critical approaches that telemedicine services mainly use. Teleconsultation, tele-education, remote interpretation, tele-psychiatry, and tele-surgery are among measures that can be implemented in emergencies like earthquakes, fires, floods, storms, and drought. The fundamental requirements of a telemedicine-oriented system for providing emergency services in natural disasters include wireless scales, conversation tools, blood pressure monitor, respiratory rate monitor, spo2 sensor, glucometer, portable ultrasound unit, wearable thermometers, virtual stethoscopes, portable three leads electrocardiographmonitor, and digital otoscopes. Simple telemedicine systems can have many advantages in the natural disasters. However, the main challenge in this regard is to adapt the necessary communication systems to a telemedicine paradigm. Another critical challenge is to interpret and apply the summary of acquired information and the inevitable interaction outcomes at the required time and place.

Objective: Through the reporting of this case series, we aim to establish whether a conservative approach, through managing arrhythmias and vital signs, can be reliably used as a treatment modality for oleander poisoning in developing countries. Methods: This study is a case series of 11 patients who presented with oleander poisoning and were conservatively managed in the absence of standard antidote. Results: All 11 patients treated with conservative approach survived. Conservative approach included use of atropine for management of symptomatic bradycardia followed by Dopamine infusion, correction of serum potassiumandmagnesium levels, standby defibrillation, and transvenous pacing. Conclusion: The absence of reliable dosage of poison ingested, the lack of facilities for serum digoxin estimation, and the unavailability of digoxin fab antibodies pose challenges for themanagement of patientswith oleander poisoning. Patients can, however, be managed conservatively following the Advanced Cardiac Life Support (ACLS) algorithmin a setting that lacks the standard treatment of this poison.

To the Editor-in-Chief In viral pandemics, the possibility of accompanied bacterial infections is always a serious challenge for health care providers. In the recent pandemic with COVID-19, studies showed an increase in bacterial infections in patients with COVID-19, especially those requiring intensive care unit (ICU) admission (1). Various meta-analyses have shown that the prevalence of some secondary bacterial infections, especially infection with Mycoplasma pneumoniae, Gramnegative germs like extended-spectrum beta-lactamase, and Klebsiella pneumoniae, has increased significantly (2). Recent studies have also shown that the pathogens that cause bloodstream infections have changed during the COVID-19 pandemic for a variety of reasons, including the widespread use of antibiotics, the effects of COVID-19 on the immune system, and so on. Increased prevalence of bloodstream infections with Gram-negative bacteria that are resistant to third generation of cephalosporins and carbapenems in patients with COVID-19 has been reported in several studies. Studies have also shown increased isolation of pathogens such as members of the Enterobacteriaceae family, including Klebsiella and Escherichia specimens, from blood cultures of patients hospitalized due to COVID-19 (3-5). Klebsiella pneumoniae is a nosocomial pathogen and studies have warned about the outbreak of a resistant strain of this germ during the COVID-19 pandemic. Most of these studies have indicated that carbapenem-resistant Klebsiella was prevalent as a secondary infection among patients hospitalized due to COVID-19 (6-9). In addition to secondary infection, we have observed that the prevalence of bloodstream infection has also increased in patients who have previously been infected by COVID-19 and have recovered. Based on our observations at Shahid Beheshti Hospital in Qom, Iran, there has been an increase in the number of positive blood cultures for Klebsiella specimens compared to similar times before the pandemic. In the last 6 months, we had 6 positive blood cultures for Klebsiella pneumoniae, which is a significant increase compared to the time before the pandemic,and has increased by 40 percent, compared to a To the Editor-in-Chief In viral pandemics, the possibility of accompanied bacterial infections is always a serious challenge for health care providers. In the recent pandemic with COVID-19, studies showed an increase in bacterial infections in patients with COVID-19, especially those requiring intensive care unit (ICU) admission (1). Various meta-analyses have shown that the prevalence of some secondary bacterial infections, especially infection with Mycoplasma pneumoniae, Gramnegative germs like extended-spectrum beta-lactamase, and Klebsiella pneumoniae, has increased significantly (2). Recent studies have also shown that the pathogens that cause bloodstream infections have changed during the COVID-19 pandemic for a variety of reasons, including the widespread use of antibiotics, the effects of COVID-19 on the immune system, and so on. Increased prevalence of bloodstream infections with Gram-negative bacteria that are resistant to third generation of cephalosporins and carbapenems in patients with COVID-19 has been reported in several studies. Studies have also shown increased isolation of pathogens such as members of the Enterobacteriaceae family, including Klebsiella and Escherichia specimens, from blood cultures of patients hospitalized due to COVID-19 (3-5). Klebsiella pneumoniae is a nosocomial pathogen and studies have warned about the outbreak of a resistant strain of this germ during the COVID-19 pandemic. Most of these studies have indicated that carbapenem-resistant Klebsiella was prevalent as a secondary infection among patients hospitalized due to COVID-19 (6-9). In addition to secondary infection, we have observed that the prevalence of bloodstream infection has also increased in patients who have previously been infected by COVID-19 and have recovered. Based on our observations at Shahid Beheshti Hospital in Qom, Iran, there has been an increase in the number of positive blood cultures for Klebsiella specimens compared to similar times before the pandemic. In the last 6 months, we had 6 positive blood cultures for Klebsiella pneumoniae, which is a significant increase compared to the time before the pandemic,and has increased by 40 percent, compared to a similar time before the pandemic. These 6 patients, had been infected with COVID-19, which was confirmed by Reverse transcription polymerase chain reaction (RT-PCR) test, about 1 to 2 months before their blood culture was found to be positive for Klebsiella pneumoniae, and they had recovered within one to two weeks. These 6 patients were between 60 to 80 years old, and 4 had type 2 diabetes and hypertension, while the other two did not have any specific underlying disease. All of them had anemia (mean hemoglobin level = 8. 5 mg/dl) and lymphopenia (mean lymphocyte count = 780/&l) in their course of hospitalization. In addition to blood culture, Klebsiella species were isolated from one patient’, s pulmonary secretion culture and from another patient’, s urine culture. Klebsiella species isolated from blood culture were sensitive to meropenem, and these patients were treated with meropenem during their hospitalization. Five of these six patients were discharged with improvement in general condition, but one patient expired. Based on our observations, it is possible that COVID-19 infection may predispose individuals to septicemia with Klebsiella species. Further studies with appropriate controls are needed in this area.

Shortly after the onset of the coronavirus pandemic, different vaccines were developed to combat it. The vaccines had different mechanisms and triggered cellular and humoral immune responses against the virus. In addition to their positive effects, various side effects have been reported for them. They rarely cause severe complications. They can also rarely trigger latent infections. The present case report presents a patient who developed herpes simplex encephalitis after receiving the second dose of the Covaxin (BBV152).

This is the fourth installment in the electrocardiogram (ECG) interpretation series by Jerry W. Jones MD FACEP FAAEM for this journal. At first, he discussed simple atrioventricular (AV) dissociation versus AV dissociation caused by third degree AV block (1),then, he shares some very important pearls regarding ECG interpretation (2). And in latest one, he pointed to the importance of Hexaxial Reference Grid (3). For this paper, some valuable references were reviewed (4-6). Figure 1 shows an ECG that was recorded barely in time to capture the maximum amount of information available. The rhythm is sinus and regular except for one premature atrial complex. The rate is 75 beats/minute. There do not appear to be any sinoatrial (SA), atrioventricular (AV) or bundle branch blocks on the tracing. . .

Objective: About one out of every 10 patients with chest pain in the emergency department (ED) are finally diagnosed with acute coronary syndrome (ACS). A HEART score of ·,3 has been shown to rule out ACS with a low risk of major adverse cardiac events (MACE) occurrence. It has been proposed that a negative CARE rule (·, 1), which stands for the first four elements of the HEART score and excludes the troponin assay requirement, may have similar rule-out reliability. This study aimed to externally validate the CARE rule. Methods: In this multicenter, observational study a convenience sample consisting of patients over the age of 15 who had at least one troponin study were included. The performance of the CARE rule at the cut-off ·, 1 for MACE prediction was assessed and compared to a HEART score of ·, 3 and physicians’,gestalt. MACEwas defined as myocardial infarction, coronary angioplasty, coronary artery bypass graft, and all-cause mortality in 6 weeks. Results: The data of 154 patients was analyzed. Of these, 121 patients had a negative CARE score of ·, 1 and 33 individuals had a positive CARE score. Of those with a negative CARE score, only 1 (3%) experienced an adverse cardiac event while in those with a positive CARE score, 26 individuals (16. 88 %) experienced MACE. The sensitivity of the CARE rule was 96. 15% and the specificity was 25% with a negative likelihood ratio (LR-) of 0. 15. The indices for HEART score were 88%, 59. 69%, and 0. 2, respectively. In comparison, physicians’,gestalt had a sensitivity of 96%, specificity of 49. 22%, and a LR-of 0. 08. Of note, utilizing the CARE rule with a cut-off of <3 showed sensitivity of 96%, specificity of 41. 86%, and a LR-of 0. 1. Conclusion: The CARE rule miss rate in MACE was more than 2% and while its performance was better than the HEART score, physicians’,gestalt outperformed both rules for ruling out MACE.

To the Editor-in-Chief War is an organized and prolonged armed dispute between states or nations (1). It is characterized by high mortality, violence, and social or economic costs. There are multiple causes of war and conflict, including extreme poverty, high unemployment, and social, political, or economic disparities. The incidence of wars has increased since 1950, especially between states (2). Small Arms Survey reports that warfare kills nearly 133, 750 persons, yearly (3). The rates of disability and death caused by war are more than many major diseases globally. It destroys the healthcare systems and public health services of the included states or societies, which results inmore diseases and deaths (4). . .

Evaluation of a pregnant trauma patient (PTP) in the emergency department (ED) is somehow challenging, as two patients should bemanaged simultaneously. Here, we reviewed recently published articles to provide up-todate information on the management of PTPs. We examined 35 articles and categorized their topics as follows: trauma severity, management of trauma patients, general approach to pregnant women with trauma, primary evaluation of pregnant women with trauma, breathing and ventilation, airway, circulatory system evaluation simultaneous with bleeding control, uterine replacement, blood transfusion, uterine displacement, cardiovascular resuscitation, defibrillation, pneumatic anti-shock garment, and perimortem cesarean section. Concerning trauma during pregnancy, the basic principle should be successfulmaternal resuscitation, which is vital for fetus survival.

Objective: Acute kidney injury (AKI) is an independent risk factor in critically ill patients. This study aimed to evaluate the prevalence of AKI in resuscitated cardiac arrest (CA) patients, its potential risk factors, and outcomes of AKI in cardiac arrest survivors. Methods: A hundred and forty-nine cases of post-CA patients that survived for at least 24 hours, admitted to three hospitals between 2016 and 2020, were studied. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss, and End-stage) criteria. Baseline demographic data, resuscitation variables, the prevalence of AKI, in-hospital and six-month mortality were collected. Logistic regression evaluated the factors associated with AKI occurrence and mortality. Results: AKI occurred in 59 (39. 6%) of the patients. Of these, 9 patients (15. 3%) required renal replacement therapy (RRT) during their hospital stay. There were 47 (52. 2%) in-hospital deaths in patients without AKI and 41 (69. 5%) in patients with AKI (P=0. 036). Post-CA AKI was significantly associated with six-month mortality (OR=1. 65,95% CI: 1. 39, 2. 88,P=0. 029). Older age, the higher cumulative dosage of epinephrine during cardiopulmonary resuscitation, post-CA shock, in-hospital CA, initial pulseless electrical activity (PEA) or asystole rhythm, longer duration of cardiac arrest, as well as higher admission creatinine and lactate levels were independently associated with AKI,in contrast, higher admission base excess level was negatively associated with AKI. Conclusion: AKI occurred in nearly 40% of CA patients. AKI was associated with a higher in-hospital and sixmonthmortality rates.

1. Case presentation: A 33-year-old woman presented to the emergency department with colicky abdominal pain, nausea and vomiting, constipation, obstipation, and rectorragia. She had a history of similar abdominal pain from a few months ago. She had no history of any specific disease and taking any medication. She had no history of surgery and specific family diseases. Her vital signs on admission were heart rate 90/minute, respiratory rate 18/minute, blood pressure 110/70 mmHg, and temperature of 37. 1±, C. There were several brown spots on her lips and inside her mouth. On abdominal examination, she had a generalized tenderness, especially in the LLQ. In the digital rectal examination, the rectum was empty. Lab tests showed the following results: leukocyte count 4000/mm3 with 80. 9% neutrophils, hemoglobin 12. 1 g/dl, platelet 320000/&l, and creatinine 0. 6 mg/dl, BUN 14 mg/dl, glucose 152 mg/dl, sodium 137 mEq/L, potassium4. 5 mEq/L. Chest and abdominal radiographs were performed on the patient (Figure 1). No subdiaphragmatic free air was seen in the chest x-ray. The abdominal x-ray showed no airfluid levels as well as any gas in the rectum. On abdominal and pelvic ultrasound, a moderate amount of free fluid was seen in the abdomen along with jejunoileal intussusception in the LLQ with an intestinal loops thickness increase. . .

Objective: This study was implemented to assess various types of violent incidents involving emergency medical technicians (EMTs) working in Tehran, Iran. Furthermore, the characteristics of violent people and possible causes of their violence were assessed. Methods: In this cross-sectional study, 500 EMTs working in the capital city of Tehran were randomly invited. The participantswere asked to fill out a questionnaire ofworkplace violence. Univariate andmultivariate logistic regression were also performed for identifying the possible risk factors of violence. In addition, the distribution and association of violence patterns were also analyzed considering demographic features and characteristics of violent people. Results: In total, 320 EMTs with the mean age of 31. 8 ±,6. 7 years participated, 315 (98. 4%) of whom were men. Overall, 279 (87. 2%) out of the 320 participants experienced 654 episodes of violence, mostly bullying, in the last 4 months. The relationship between the level of education and experiencing violent incidents was statistically significant (p=0. 035). Also, non-Persian EMTs had experienced significantly more violent behaviors than Persian EMTs [171 (91. 0%) vs. 108 (81. 8%),p=0. 016]. Nonetheless, the prevalence of violent incidents was not significantly correlated with marital status, years of work experience, employment situation, and working hours. The odds of facing violent behavior among EMTs with associate degree was 2. 9 times higher than those with technical diploma (p=0. 048). Furthermore, the odds of experiencing violence among non-Persian EMTs was 2. 2 times higher than Persian EMTs (p=0. 039). Conclusion: We found that EMTs had faced numerous episodes of violence in their workplace, especially verbal threats, which weremore prevalently committed by patients’,relatives during night shifts.