Advanced Journal of Emergency medicine
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How Should Emergency Medical Services Personnel Protect Themselves and the Patients During COVID-19 Pandemic?
Get PDFEmergency medical services (EMS) play a vital role in the management of public health emergencies such as epidemics of infectious diseases. Unique challenges, however, are expected under these circumstances beyond what occurs during normal conditions. EMS personnel often have limited information about their patients, work under uncontrolled conditions, and accompany their patients in enclosed spaces of the ambulance. They are at particular risk of contracting the infectious agent unless standard and transmission-based precautions are implemented. Appropriate use of personal protective equipment (PPE) by responding personnel is, therefore, of paramount importance. Since the report of the first cases of COVID-19 in late December 2019, the disease has spread beyond China. As of March 29th, a total of 634,835 confirmed cases have been reported globally and 29,975 people have died. The Center for Diseases Control (CDC) and other authorities and advisory agencies have prepared guidelines regarding safety precautions for EMS personnel, including appropriate selection and use of PPE
Personal Protective Equipment for Protecting Healthcare Staff during COVID-19 Outbreak: A Narrative Review
Get PDFContext: The World Health Organization (WHO) declared a pandemic state as the coronavirus spread across the world. Personal protective equipment (PPE) has become a critical subject during the COVID-19 outbreak. It is necessary to prevent coronavirus transmission to healthcare workers (HCWs) as providing care. They are at high risk of exposure to coronavirus. The aim of this study was to provide a brief review of some routes of transmission of COVID-19, what, when and why PPE is recommended base on the route of transmission. Evidence acquisition: In this review, articles were extracted from the Google Scholar, Scopus, Web of Science, and PubMed search engines. The main keywords for search were coronavirus, COVID-19, personal protective PPE, healthcare, transmission, contact, and protect. Results: Findings showed the COVID-19 transmission rate in the HCWs that wore PPE significantly decreased. All HCWs must use appropriate and adequate PPE in order to minimize the COVID-19 transmission. Conclusion: Although still uncertainty remains around COVID-19 transmission and it is early to have conclusion on its prevention, most of recommendations and guidance have emphasized to apply the PPE during COVID-19 outbreak among HCWs
The COVID-19 Pandemic and the Health Care Providers; What Does It Mean Psychologically?
Get PDFIn late 2019, the COVID-19 epidemic began in Wuhan, China, which quickly spread around the world, becoming an international concern and pandemic. As with previous SARS and Influenza H1N1 pandemics, medical staffs providing services to patients are exposed to increased levels of mental stress. This review article introduces these symptoms based on the experience of previous pandemics and the data available on COVID-19 pandemic, introducing the underlying and protective factors against mental distress. Evidence suggests that levels of stress, depression and anxiety symptoms increase in health care providers. Moreover, these symptoms are more common in women, nurses, and people who are at the frontline of providing health care services for COVID-19 patients. Given the need to pay attention to maintain and promote the mental health of medical workers to provide effective services, this review offers suggestions to the effective management of these conditions at the individual and organizational levels
A Limited Self-Claimed Web-Based Survey COVID-19 Contamination among Iranian Healthcare Workers
Get PDFIntroduction: It is likely that high rate of healthcare workers (HCWs) infection has occurred in Iran, but there is not any proof yet. Objective: This study was conducted to highlight the rate of Iranian HCWs infected by COVID-19 and some of its surrounding points. Methods: This cross-sectional study was conducted in Tehran, Iran. Using web-based applications including WhatsApp, Telegram, Instagram and Facebook, the link to the questionnaire was sent and exposed to the eligible ones. The target population of the study was HCWs who were diagnosed as approved cases of COVID-19. They were asked about their baseline characteristics and also possible source of infection, symptoms onset, hospitalization and etc. All findings presented by frequency and percent. Results: From March 29, 2020 to April 5, 2020, a total of 452 HCWs had completed the online questionnaire of whom 50.9% were women; mostly were in the age range of 25-29 years old. Among the participants, physicians had the largest population with 312 people (69.0%). The most frequent clinical symptoms were fatigue, fever and myalgia, respectively. The highest frequency with 85 cases (18.8%) was reported their symptoms onset within 20-24th February, 2020. The most commonly used piece of equipment was gloves, which was used in 57.3% of the cases, followed by simple surgical mask, which was used by 47.1% of the participants. In 21.9% cases no personal protective equipment was used. Totally, 348 cases (91.6%) were treated in an outpatient setting and only 36 cases (9.5%) needed to be hospitalized. In 160 cases (35.4%), at least one other person was infected with COVID-19 in their household. Conclusions: Considerable number of participants that declared their infection in this study, emphasizes on the considerable rate of Iranian HCWs infected by COVID-19
Point of Care Ultrasound as a Triage Tool in Novel Coronavirus. Is It Necessary or Not?
Get PDFOvercrowding during pandemics, such as COVID-19 necessitates the separation of respiratory patients in different locations with special protective measures. Thus, we allocated space to such a purpose and named it "respiratory emergency” in our emergency department and started to triage the patients coming in with respiratory tract signs and symptoms apart from others. However, the most critical point for the triage of respiratory patients is differentiation between COVID-19 and non COVID-19 suspicious patients as well as decision-making in terms of self- quarantine and outpatient treatment or admission. Considering the lack of test kits and more importantly, the uncertainty revolving around the performance and efficacy of tests, we used computed tomography (CT) scan as a triage tool, yet our machines cannot scan all these patients because we had up to more than eight hundred patients per day. Meanwhile three of us - emergency attending physicians - were under the impression that lung ultrasound may help. Therefore, we started to use lung ultrasound in a limited fashion. Fortunately, typical cases had peripheral and sub-pleural lesions that could be seen by ultrasound. Parallel to these efforts, limited reports were published about the use of ultrasound for COVID-19 in other regions. Evidently, a screen test is expected to have high sensitivity rather than specificity and the ultrasound provides this opportunity. Also we know the findings are not specific and for example we had observed these patterns in other viral epidemics, such as severe acute respiratory syndrome (SARS) or middle East Respiratory Syndrome (MERS). To date, several triage systems have been developed. The Italian version used by Dr. Volpicelli first and developed further by others, like that of Liam Devonport can exemplify this case. Furthermore, a simple triage system has been developed by Dr. Mike Stone, based on the ultrasound of lungs plus oxygen need. This flowchart summarizes Dr. Stone’s idea with three elements for decision-making consisting of: a) O2 requirement, b) B lines and c) consolidation. Three categories are enrolled. All patients with cough, fever and dyspnea or patients coming in from high-risk areas or those having close contact with covid-19 patients are enrolled. After bedsides sampling for polymerase chain reaction (PCR) test, the O2 saturation is measured and lung ultrasound is also done and then according to the data obtained, four categories are created as follows:
Inpatients for whom supplementary O2 is not required. If lung ultrasound shows A profile, patients can be discharged to home quarantine. If lung shows profile B, patients should undergo quarantine plus follow-up. This quarantine can be at home or institutes considering the facilities available.
Patients, depending on supplementary oxygen, should be admitted according to the findings of lung ultrasound. If they have only B lines, they are admitted in the ward but if they have profile B plus consolidation, we should consider intensive care unit (ICU) beds for them.
In essence, all these systems use lung ultrasound for decision-making, which is efficient in a majority of occasions, yet we have critically ill patients with dyspnea and decreased O2 saturation without proportionate changes in lungs even according to CT scanning. Thus, we could not justify their health status based on the findings of the imaging of respiratory system. To discover the cause of dyspnea in these patients, we included heart ultrasound in addition to lung ultrasound and witnessed a decline in ejection fraction and global hypokinesia, which can justify their unsatisfying health status. In the meantime, several case series about myocarditis in covid-19 reveal the prevalence of myocarditis between 7% and 20% among patients. Increased troponin and change of the electrocardiogram (ECG) in these patients confirm myocarditis and help us to calibrate our care for the heart complaints sooner and more effectively. This approach might provide better prognosis for these patients.
Recommendation
We suggest adding heart ultrasound to lung ultrasound in triaging the patients suspicious of COVID-19 or at least in the first doctor visit even if CT scan is available because myocarditis with pneumonia exists in some patients at the same time. Furthermore, we found that E-Point to Septal Separation (EPSS), as a reliable indicator of global hypokinesea in heart, can be used effectively instead of evaluating through eyeballing because eyeballing needs a high level of expertise and may be more operator-dependent and obtaining a four-chamber view in supine critically ill patients is difficult when the operator lacks expertise
Prognostic Value of Routine Biochemistry Profile of Liver Transplant Patients Admitted to the Emergency Department with a Suspected Infection
No full textIntroduction: Since patients who have undergone liver transplantation should take immunosuppressants for life, the prevalence of systemic infections after this procedure is very high. These infections are associated with increased mortality and morbidity. Objective: This study aimed to investigate the prognostic value of routine biochemistry profile and its relationship with mortality in liver transplant patients admitted to the emergency department (ED) with a suspected infection. Methods: Patients who had undergone liver transplantation were included in the study. The patients were divided into three groups of culture-negative, culture-positive and control. White blood cell (WBC) count, hemoglobin (Hb), platelet (Plt), international normalized ratio (INR), creatinine (Cr), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values as well as vital sign findings were comparatively evaluated in terms of their ability to show the presence of any infection and their correlation with mortality. Results: Totally, 142 patients were enrolled and were divided into the following three groups: 41 cases in culture-negative group, 30 cases in culture-positive group, and 71 cases in control group. There was not any significant difference between study groups in terms of age and sex ratio (p>0.05). The Hb and Plt values of the culture-positive patients were significantly lower, and their INR was significantly higher compared to those in control group (p<0.05). Fever, Hb, Plt, INR, AST and ALT values were factors that had a significant correlation with mortality in patients with an infection whethere culture-positive or culture-negative ones (p<0.05). Conclusions: In patients admitted to the ED with a history of liver transplantation, we recommend the evaluation of vital signs and Hb, PLt, and INR values to determine whether there is an infection or not. We can also state that mortality risk is higher in cases with low Hb and Plt levels and high INR, ALT, and AST values
Epidemiological Characteristics, Clinical Features, and Outcome of COVID-19 Patients in Northern Tehran, Iran; a Cross-Sectional Study
No full textIntroduction: Following the widespread pandemic of the novel coronavirus diseases (COVID-19), this study has reported demographic and laboratory findings and clinical outcomes of patients with COVID-19 admitted to a tertiary educational hospital in 99 days in Iran. Objective: We aimed to investigate in-hospital death risk factors including underlying diseases and describe the signs, symptoms, and demographic features of COVID-19 patients. Methods: All confirmed COVID-19 cases admitted from 22 February to 30 May 2020 were extracted from hospital records. A follow-up telephone survey was conducted 30 days after discharge to acquire additional data such as survival status. Distribution of demographic and clinical characteristics was presented based on survival status during hospitalization. All analyses were performed using STATA version 14 with a level of significance below 5%. Results: Among 1083 recorded patients, the rate of survival and death was 89.2% (n=966) and 10.8% (n=117), respectively. 62% of the cases (n=671) were male. The mean recovery time was 1.90 (3.4) days in survived cases, which was significantly lower than that in deceased cases 4.5 (5.2) days, p<0.001). A significantly higher rate of death was observed among patients above the age of 60 years (24.8%, p<0.001), cases with hypertension (25.4%, P<0.001) and cases without cough (17 %, p=0.002) but with shortness of breath (16.5%, p=0.001). Conclusions: Our study emphasized the significant effect of different underlying conditions as mortality factors among COVID-19 patients, namely older age spectrum, hypertension, and ischemic heart disease. By acknowledging the epidemiologic pattern and mortality factors, we have more tools to prioritize and make better judgments, and more lives can be saved
Life Threatening Transverse-Lying Vegetable Foreign Body in the Larynx; A Case Report
No full textIntroduction: Foreign body (FB) in throat is one of the common presentations in emergency departments (ED). The foreign body may be stuck in the neck region through ingestion or due to iatrogenic injury. FB ingestion is rare in adults but still occurs. The ED treatment plan for patients suspected to have ingested a foreign body depends on the type and location of the FB, as well as the patient’s condition. In adults, the most common FBs ingested are chicken bone and fishbone. The ingested FB often gets lodged in the oropharynx and cricopharyngeal muscle regions. Case presentation: We report a 15-year-old female patient who presented with a foreign body in the throat. Lateral neck radiograph (LNR) revealed a radio-dense vegetable foreign body in the supraglottic region, lying transversely above the vocal cord. This is an unusual clinical and radiological presentation. A 4-cm long piece of beetroot was removed successfully via direct laryngoscopy under safe procedural sedation. Post-procedure, the patient recovered well, discharged within a few hours. Conclusion: Even though foreign body in throat is a common presentation, we report this case due to its anatomical position, type, size, and the unusual radiological appearance of the FB
Conventional Radiograph Is Still Advised in the Diagnostic Work-up of a Shoulder Dislocation; a Letter to the Editor
Get PDFDear editor:
A shoulder dislocation is a common diagnosis at the emergency department, showing an incidence of 23.9 per 100,000 person-years. In the current diagnostic work-up, a radiograph is often used to confirm the dislocation. As radiographs are associated with radiation exposure, the ultrasound has been proposed as an alternative. Therefore, the study by Entezari et al is of great importance in evaluating the applicability of the ultrasound. However, the authors suggest that the ultrasound can be used as an alternative to the radiograph. In our opinion, an important advantage of the radiograph has not been discussed and we question some decisions that were made in terms of methodology. Therefore, we think that this study has to be seen in the light of these remarks
Incidental Findings of COVID-19 Pneumonia in Chest CT scan of Trauma Patients; a Case Series
Get PDFIntroduction: COVID-19 is an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a strain of coronavirus. The first cases were reported in Wuhan, China, in December 2019, later was officially recognized as a pandemic on March 11th, 2020. Case presentation: Here we report five trauma cases admitted to our hospital, not for COVID-19 related symptoms, but chest computed tomography (CT) scan findings were suspicious of COVID-19 infection. Real-time reverse-transcription polymerase chain reaction (RT-PCR) assays for COVID-19 were reported as positive in these cases. Conclusion: COVID-19 usually manifests with mild respiratory and constitutional symptoms, even some cases are asymptomatic