Advanced Journal of Emergency medicine
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Besides other Signs, Can a 6-min Walk Test be Applied as a Criterion for Going to the Hospital with a Diagnosis of COVID-19?
Get PDFRecently the pandemic of Covid-19 challenges countries’ medical health services systems. While some patients experience acute and devastating symptoms, others may only have mild myalgia and fever. Due to the high amounts of hospital referrals, some countries’ health systems have asked patients to stay at home and go to the hospital when they feel that the symptoms are severe. Some symptoms, such as fever, myalgia, diarrhea, and headache, have been offered as Covid-19 symptoms. However, is there any clinical test that helps patients themselves to detect the severity of symptoms? A six-minute walk test is a clinical test to investigate the function of the cardiorespiratory system. In this test, a physician asks a patient to walk for 6 minutes in a 30-meter walking course. Some studies have shown its relation with short term survival, especially in patients who complete less than 300 meters. Based on the walked distance, results can be used in the two following formats. First, the Vo2 max could be estimated via an equation; second, the distance can be compared at different times. Considering that Covid-19 affects the respiratory tract, it seems that it could affect 6-min walk test results. Due to the particular situation, the health system can ask people who have mild symptoms to check their 6-min walk test results for several consecutive days besides the other symptoms. If patients’ walking distance decreased due to breath shortness at this time, they should go to the hospital. Even if their walking distance is less than 300 meters, maybe they need a chest CT scan. With the application of this approach, we can decrease the load of referrals to the hospitals and also prevent patients with mild symptoms from being contacted to the high load of virus in the hospitals
Lung Ultrasound Findings Compared to Chest CT Scan in Patients with COVID-19 Associated Pneumonia: A Pilot Study
Get PDFIntroduction: Lung US has been reported to be as useful as a chest CT scan and much better than a chest x-ray for the evaluation of pneumonia. Objective: This study aimed to compare the findings of lung ultrasound (US) and chest CT scan of patients with COVID-19-associated pneumonia in the Emergency Department (ED). Methods: This retrospective observational pilot study was carried out on confirmed COVID-19 patients in the isolation corona ward of the Imam Hussein Hospital ED from March 15 to March 22, 2020. After obtaining demographic data, the patients underwent a pulmonary bedside US examination, with the patients in the sitting position, turning their back to the examiner. A 10-point lung US was performed. Each lung was divided into two areas: posterior (three zones) and lateral (two zones). The patients’ lung ultrasound and chest CT scan as the standard imaging were blindly reviewed and recorded. The clinical value of ultrasound was evaluated with different severity of lung involvement according to CT severity score. Results: Nineteen patients (38 zones), including 13 males, were evaluated with a mean age of 62.5±16.8 years. B2 lines and consolidation observed in the US examinations were significantly correlated with ground-glass opacity and consolidation observed in CT scan examinations, respectively (p <0.0001). US sensitivity and specificity of finding B2 lines were 90% and 100%, respectively. Also, the sensitivity and specificity of US in identifying consolidation were 82% and 100%, respectively. In the lungs with moderate and severe lobar involvement, US findings were significantly correlated (p <0.05) with CT scan findings. Conclusions: Ultrasound evaluation is a safe, fast, and rapid technique for the evaluation of patients with moderate to severe COVID-19-associated pneumonia. It is a reproducible procedure and can be implemented by the operator after a short course of training
The Primary Angioplasty Registry of Sina (PARS); A Brief Report of Design and Rationale
No full textCardiovascular diseases, especially ST-elevation myocardial infarction (STEMI), are among the major health concerns in Iran. Although primary percutaneous coronary intervention (pPCI) is performed as the treatment of choice in Iranian hospitals, there is limited data on its efficacy, safety, procedural variations, and clinical outcomes after implementation of the new Protocol-247, which transfers patients with STEMI directly to pPCI-capable hospitals. The Primary Angioplasty Registry of Sina (PARS) is an ongoing prospective hospital-based registry enrolling patient with STEMI undergoing pPCI in Sina Hospital, which is a high-volume referral PCI-capable general hospital in Tehran, Iran. This registry aims to gather high-quality data on patient characteristics, hospital-based quality of care, coronary interventions, and in-hospital as well as long-term clinical outcomes of patients undergoing pPCI due to STEMI. In addition, the findings will be used to identify independent predictors of mortality and adverse events and form the basis of future clinical trials and quality improvement strategies
The Role of C-reactive Protein in Diagnosis of Acute Complicated Appendicitis: A Diagnostic Accuracy Study
Get PDFIntroduction: Acute appendicitis is one of the most common emergencies of general surgery. Contrary to simple appendicitis, the complicated cases are associated with higher morbidity and mortality. Except for pathology, no accurate diagnostic test has been found to identify complicated cases. Objective: Here in, we aim to evaluate the serum C-Reactive Protein (CRP) level in both acute simple and complicated appendicitis. Methods: In this diagnostic accuracy study, 199 patients with acute appendicitis were enrolled. The serum CRP level was evaluated in patients. Post-operatively, the patients were divided into simple and complicated appendicitis based on histopathological examination. Eventually, analysis of the CRP level and type of appendicitis was performed. Results: Fifty-three patients were categorized into complicated appendicitis and 146 patients into simple appendicitis. The median of CRP was significantly higher in the complicated group. Additionally, the optimal cutoff point was as follows: [65.0 (25.0) vs 25.0 (51.0); P-value< 0.001]. The optimal cutoff point for CRP was more than 42 with 81.1% sensitivity (95% CI: 68.0 to 90.6), and 67.8% specificity (95% CI: 59.6 to 75.3). The positive (PPV) and negative predictive values (NPV), based on the prevalence of complicated appendicitis (26.6%) for optimal cutoff point, were 47.8% (95% CI: 37.1 to 58.6) and 90.8% (95% CI: 83.8 to 95.5). Conclusion: Our study revealed that evaluation of serum CRP levels could be useful and beneficial in the diagnosis of acute complicated appendicitis
Clinical Features of Patients Newly Admitted to the Emergency Department of a Psychiatric Hospital with an Emphasis on Physical Examination
Get PDFIntroduction: Many medical diseases and their related signs and symptoms are not identified in routine assessments in emergency departments. Objective: We investigated the prevalence of abnormal findings in physical examination of the patients who were newly admitted to emergency department (ED) of a psychiatric hospital. Methods: We studied 200 patients (143 males, 71.5%) who were recently admitted to the ED of a psychiatric university hospital during a 4-month period in 2018. A thorough physical and neurological examination was performed on each subject. Results: Nearly all of the patients (99.3%) had at least one positive finding in physical (non-neurological) examination and 95% had at least one positive neurological finding. We also found at least one problem in gastrointestinal, respiratory or cardiac system of 22.1%, 24% and 33% of the subjects, respectively. The most frequent findings were in cranial nerve I (30%, more common in substance abuse disorder), and visual acuity (52.6%), as well as recent memory (%68.7), attention (%33.7), orientation to time (%29.5), hypokinetic movements (%28.1, more common in females and psychotic patients), akathisia (41.6%), and skin (%85.1, more common in substance abuse and personality disorders). T wave changes were seen in 31.9% and arrhythmia in 16% of the patients. Conclusions: Abnormal findings in examination of the patients admitted to EDs are very prevalent, but most of the abnormalities are not detected or reported in the routine ward examinations. More emphasis should be placed on the examination of olfactory nerve (especially in patients with substance abuse disorder), cognition (especially in older adults), extrapyramidal system, heart, abdomen and skin (especially in patients with personality disorder) during the first week of admission in a psychiatric emergency setting
Necessary Indicators for Developing a Hazmat Response Team of the Iranian Health System
Get PDFIntroduction: Although some countries have set up predetermined programs and specialized teams to deal with hazardous materials (Hazmat) induced events, in other countries including Iran there are many weaknesses in this regard. Objective: We aimed to develop the necessary indicators for the formation of teams to deal with Hazmat accidents in the health system based on existing standards and resources as well as the indigenous conditions of Iran. Methods: This cross-sectional study was carried out in two stages from 2018 to 2020. In the first stage, the literature review was performed and the current guidelines, standards, and models presented in other countries were reviewed and related items were extracted. In the second stage, semi-structured and purposeful interviews by managers and physicians specialized in Hazmat incidents working in Iran, were conducted. The interviews were recorded and later the recordings were transcribed and simultaneously the categorizing and coding of the interviews were performed. Results: In the first stage, searching through the available resources for the present study identified 12 published references through which 10 indicators to develop a Hazmat team were ultimately extracted. In the second stage, a total of 10 interviews were conducted and data saturation occurred. Based on the results of the content analysis for the main indicators of designing and developing teams, 8 categories and 19 sub-categories were developed. Conclusions: By interviewing and localizing the 10 main indicators that were achieved in the first stage, we finally reached the 8 indicators including: Training hazmat team’s members, required equipment for team, response plan, medical surveillance program, hazmat team structure, incident command system, hazmat team qualification of different levels, certification and maintenance of the certificate
Disruption in Medical Care of Non-COVID Patients in COVID-19 Pandemic
Get PDFIn December 2019, a novel coronavirus (2019-nCoV) was detected in Wuhan Hubei province, China. The virus has caused a global concern because of its high potential for transmission, high morbidity and mortality. COVID-19 spreads so rapidly across an increasing number of countries worldwide that it has been found in more than 200 countries so far. The World Health Organization (WHO) has declared COVID-19 a pandemic and public health threat. In general, COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A case fatality rate of approximately 2.3% has been reported for COVID-19. New fever, cough, lymphopenia and bilateral lung infiltrations are characteristic but not diagnostic for COVID-19. Sore throat, dyspnea, myalgia, diarrhea, and abdominal pain are other presentations of COVID-19. We should also be attentive to the probability of atypical presentations in patients who are immunocompromised. While the majority of cases result in mild respiratory tract symptoms like acute bronchitis, severe cases might end in severe pneumonia, acute respiratory distress syndrome (ARDS), septic shock and death due to multiorgan damage, so early recognition of patients with suspected COVID-19 infection is crucial. The burden of the virus is not limited to physical damage, but it also has a significant impact on the mental health of the public. It can lead to generalized anxiety disorders and depression during COVID-19 pandemic. Now many countries are in a state of crisis worldwide. Whenever the living environment changes, people feel unsafe. People's fear of COVID-19 makes them refrain from going to medical centers, which significantly impacts their access to medical care while they require acute treatment. COVID-19 outbreak in countries has pulled essential medical resources away from regular procedures. This has caused complications for patients who need treatment for other medical conditions that require timely and appropriate care. Cancer patients especially still require attention in curative or palliative settings, and women will still be delivering their infants. How can we care for these patients without exposing them to COVID-19
Magnesium Sulfate: A Potential Adjuvant Treatment on COVID-19
Get PDFCOVID-19 has currently become a major global health problem. Due to novelty and high morbidity and mortality, there are some important medical challenges to achieve proper management and treatment of the disease. Different pharmaceutical categories have been candidate for viral or cytokine phase control, and in this regard many clinical trials are underway to obtain evidences and acceptable results. One of these compounds is magnesium (Mg) sulfate which may have potential therapeutic effect on the cytokine phase of COVID-19. Mg compounds have long been used in practice under various indications and purposes as supplemental compounds, electrolyte regulation and also prevention of drugs side effects. In addition, the effectiveness of Mg sulfate in controlling asthma attacks, gynecological cases and pre-natalogical problems has also been proven. Herein we briefly reviewed immunomodulatory and respiratory effects of Mg and its potential benefits in COVID-19 treatment. Mg sulfate can be used both systemically and by inhalation, but nebulizer route has potential effect on rapid onset of action on respiratory system and reduced incidence of systemic side effects. To the best of our knowledge, in COVID-19 patients, as other viral infections, airway hyper-reactiveness can be overrepresented. In this regard ventilation improvement and reducing of airway resistance should be considered. Some bronchodilators, such as β2-agonists and anti-muscarinic agents used to relieve these symptoms. Another option has provided for hospitalized patients, is nebulized Mg sulfate. It has been suggested in the literature that Mg sulfate can cause bronchodilation in asthmatic patients by various mechanisms, including by inhibition of calcium influx into the cytosol, prevention of acetylcholine secretion, inhibition of histamine release; and finally, by β2-receptor affinity enhancement, increases bronchodilator effect of β2-agonists. On the other hand, according to some researches, low Mg level is associated with increased inflammatory response. in vitro studies showed that short-term exposure to Mg sulfate without affecting on viability and function of phagocytes, diminished cytokine gene and protein expression, and consequently could reduce production of TNF-α and IL-6 from neonatal monocytes. Moreover, Mg sulfate can reduce the level of interleukin 1β, that is a potent pro-inflammatory cytokine. Another study of the anti-inflammatory effect of Mg compounds showed that neutralized Mg ions can convert THP-1-derived macrophages to the M2 phenotype (anti-inflammatory macrophages), thereby reduce the production of inflammatory cytokines and enhance the secretion of anti-inflammatory cytokines. As well as, according to in vitro and in vivo studies, Mg sulfate significantly reduces baseline level along with LPS-stimulated cytokine production. Altogether, given that the cytokine phase of COVID-19 plays a very significant role in patient morbidity and mortality, therefore proper management and control of this stage of the disease is important on rescuing patients. It seems that, administration of Mg compounds as an adjuvant treatment may improve this condition of disease. Our preliminary experiences indicated the potential positive effects of Mg sulfate on the improvement process in covid-19. However, in order to achieve more accurate and reliable results, adequate randomized clinical trials are needed. It should be considered that intravenous administration of this drug can be performed only in the intensive care unit (ICU) and or under close observation, but the Inhaler form does not require close monitoring. Moreover, oral Mg supplementation in outpatients may also reduce the inflammatory response in COVID-1
Reteplase versus Streptokinase in Management of ST-segment Elevation Myocardial Infarction; a Letter to the Editor
Get PDFAlthough the ideal treatment route for management of patients with ST-segment elevation myocardial infarction (STEMI) is rapid diagnosis and direct transfer to the catheterization unit and undergoing primary angioplasty, using thrombolytic still has its place in cases that the equipment are not available or there is not enough time for performing angioplasty. Of course these drugs are associated with specific side effects such as probability of gastrointestinal (GI) and cerebral bleeding, allergic reactions and etc. Therefore, finding drugs with fewer side effects and limitations for use has always been interesting in this regard. The drug which has been used all around the world since 1970 and is also traditionally used in Iran for managing patients with STEMI is streptokinase. This drug is a protein extracted from beta hemolytic streptococci, which combines with plasminogen and facilitates transformation of plasminogen to plasmin. However, recently fibrin specific drugs or recombinant tissue plasminogen activators (rtPA) such as alteplase, urokinase, tenecteplase, reteplase and etc. have become available to emergency medicine physicians and cardiologists. Having longer half-lives, fewer side effects, and easier method of use, these drugs have opened a new door for physicians regarding use of thrombolytic drugs in treatment of STEMI and brain stroke. Studies regarding comparison of safety and effectiveness of these drugs are ongoing. In a systematic review and meta-analysis, Tourani et al. showed that the safety and effectiveness of streptokinase and tenecteplase were in the same level. Reteplase is an rtPA peptide, which converts endogenous plasminogen to plasmin. Plasmin causes destruction of the fibrin present in the clot and the clot disappears. In a prospective case-control study in Amiralmomenin Hospital, Tehran, Iran, we divided 152 patients with STEMI and the mean age of 56.41 ± 10.40 (27 – 85) years who were candidates for receiving thrombolytic therapy into 2 groups receiving either streptokinase (from CSL Behring GmbH Co, Germany) or reteplase (from Reliance Life Sciences Co, India) (83.6% male). Then we compared outcomes such as GI bleeding, mortality, hypotension, arrhythmia, and etc. between the 2 groups. The 2 groups were in a similar condition regarding sex (p = 0.331) and age distribution (p = 0.393), blood pressure on admission (p = 0.378), and the rate of positive troponin on admission (p = 0.113). Overall, 61 (40.1%) patients showed at least one of the outcomes that we studied (13 cases in the streptokinase group and 48 cases in the reteplase group; p < 0.0001). In this study, all 20 cases of GI bleeding observed following thrombolytic prescription were in the reteplase group. Additionally, out of the 19 cases of death observed, 14 were in reteplase group and 5 had received streptokinase. One case of arrhythmia and 2 cases of hypotension were seen in streptokinase group. Based on the findings of this study, it seems that despite factors such as longer serum half-life and ease of use, the rate of side effects of this drug should be carefully considered before use. Based on some existing studies, it seems that in the most optimistic scenario, these 2 groups have similar side effects and effectiveness. For a more accurate assessment at least regarding the Iranian race, more accurate studies with larger sample size are required. This topic might have received less attention in developed countries as considering availability of equipment in those countries, treatment protocols are mostly based on angioplasty and not using thrombolytic drugs there. This subject becomes more important when we are aware of the higher treatment costs of these new drugs for patients since insurance does not cover them. Performing cost/benefit studies and evaluating the safety of treatment are suggested for future studies
Intermittent Typical Angina: Remember Wellens’ Syndrome
Get PDFIntroduction: We describe a patient without a history of cardiovascular diseases as an example of Wellens’ syndrome (WS). Case Report: A 65-year-old man presented to emergency department due to intermittent chest pain. Physical examination and chest x-ray were unremarkable. Electrocardiogram (ECG) showed biphasic T-wave in precordial leads V1-V4. Primary cardiac serum biomarkers including high-sensitive cardiac troponin T (hs-cTnT) and CK-MB were slightly elevated, that further assessment did not show any increases; while ECG recorded during a pain period revealed T-wave pseudo-normalization. The patient underwent coronary angiography that revealed a proximal left anterior descending artery lesion. Conclusion: WS is a diagnostic and management challenge and serial ECG evaluation is still essential for a possible acute coronary syndrome. Having knowledge of all subtle features of this syndrome, could avoid improper discharge of high-risk patients. Definitely, accurate risk stratification, and prompting these patients to an early coronary angiogram and treatment are mandatory to avoid development of a massive anterior myocardial infarction