Frontiers in Emergency Medicine (E-Journal)
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The Hexaxial Reference Grid: The emergency ECG interpreter’s most important tool
Get PDFAs emergency physicians, we must all interpret electrocardiograms (ECGs) for time to time. The 12-lead ECG is one of the most frequently ordered tests in the emergency department, often read by physicians with the least formal training in ECG interpretation. Emergency physicians do not have the luxury of waiting one to two days for an official cardiologist’s interpretation; we must know the results immediately. Here is where the process breaks down. I am going to introduce you to the tool that electrocardiographers use that greatly assists with interpretation
A case series of oleander poisoning: challenges faced by emergency physicians in developing countries
Get PDFObjective: 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 potassium and magnesium 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 the management of patients with oleander poisoning. Patients can, however, be managed conservatively following the Advanced Cardiac Life Support (ACLS) algorithm in a setting that lacks the standard treatment of this poison
Performance of CARE rule in ruling out acute coronary syndrome in non-traumatic chest pain: an external validation study
Get PDFObjective: 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. MACE was 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
Incident Reporting Systems: How did we get here and where should we go? a narrative review
Get PDFSince 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.
 
Unusual Esophageal Foreign Bodies in a Schizophrenic Patient: A Case Report
Get PDFIntroduction: The possibility of foreign body ingestion should be considered in psychiatric patients. In some complicated cases, foreign bodies become problematic and require immediate surgical intervention. Case presentation: A 45-year-old man with schizophrenia swallowed razor blades and pieces of glass resulting in esophageal perforation, pneumothorax, pneumomediastinum and urgent need for surgery. He was presented in shock state but successfully passed post-operative period in the intensive care unit and surgical ward and was ultimately transferred to the psychiatric ward. Conclusion: Management of asymptomatic patients depends on the demographic factors of patients as well as the site affected in the gastrointestinal tract
Possible Role of Selective Serotonin Reuptake Inhibitors (SSRIs) in Clinical Outcome of COVID-19 Patients
Get PDFIn February 2020, the World Health Organization officially named the disease caused by the new corona virus as COVID-19 (Corona Virus Disease 2019). For COVID-19 patients, there are usually four phases of the disease. The first one is virus reproduction phase. The second phase is accompanied with mild symptoms and usually includes flu-like symptoms. The third phase is associated with the development of acute respiratory distress syndrome (ARDS) and is characterized by its symptoms. The fourth phase is associated with high fever, systemic inflammatory responses, especially in the lungs, and eventual respiratory failure. COVID-19 is associated with upregulations of inflammatory cytokines. In the acute phase of COVID-19, the function of TCD4+ cells are impaired and the production of interferon-gamma (IFN-γ) and Tumor Necrosis Factor-alpha (TNF-α) in these cells is reduced. With impaired immune function, virus replication continues, and damaged lung cells induce excessive inflammatory responses and overproduction of inflammatory cytokines such as TNF-α, IL-1β, and IL-6 from immune cells. This eventually induce cytokine storm with systemic inflammatory responses and end organ damage. The level of inflammatory cytokines such as IL-1β, IL-6 and IL-10 in COVID-19 patients has been reported to be higher in COVID-19 patients admitted in ICU.
The lack of effective treatment for the severe infection caused by COVID-19 has led scientists and physicians to repurpose popular medications that are indicated for other similar conditions. No effective modality to successful management of this viral disease has yet been identified. Immunosuppressive and anti-inflammatory drugs have been suggested for acute patients with cytokine storms and severe lung involvement.
Recently, due to the anti-inflammatory effects of selective serotonin reuptake inhibitors (SSRIs), their therapeutic effects have been proposed for COVID-19 patients. This group of drugs are usually prescribed to treat depressive disorders. SSRIs have been shown to reduce inflammation and the expression of inflammatory cytokines such as TNF⍺ and IL-1β. The decrease in inflammatory cytokines such as IL-1β and TNF-α in the cerebral tissue has been shown as a result of sertraline administration, indicating the anti-inflammatory effects of this drug. In another study, Fluvoxamine could lower IL-1β, IL-6, and TNFα expression in the striatum in depressed mice. Much attention is paid to sertraline due to its very low anticholinergic activity which is especially desirable for the elderly with coronary heart diseases. Moreover, the anti-inflammatory properties of this compound is attributed to prevention of the expression of pro-inflammatory cytokines.
Recently, it was demonstrated that treatment of patients with major depression with SSRIs could reduce the expression of inflammatory cytokines, such as IL-10, TNF-α, and IL-6 in these patients. The expression of these inflammatory mediators increase in critically ill COVID-19 patients. Therefore, the use of this class of medications in the management of COVID-19 patients could be considered, especially for acute patients with cytokine storms. In a recently published study, the use of antidepressants SSRI and paroxetine and SNRI venlafaxine in hospitalized patients due to COVID-19 reduced the risk of intubation and death. This therapeutic effect on COVID-19 could be attributed to the inhibition of acid sphingomyelinase activity, which prevents epithelial cell from being infection by SARS-CoV2.
It has also been suggested that S1A (σ-1- receptor) agonists can prevent cytokine storms in severe COVID-19. SSRIs, especially fluvoxamine and to a lesser extent sertraline have a moderate to high affinity for this receptor. Antidepressants are associated with decreased plasma levels of pro-inflammatory cytokines which elevate in COVID-19. Furthermore, the antiviral activity of some antidepressants such as fluoxetine has been reported in COVID-19 patients. In a randomized clinical trial on adult outpatients with COVID-19, administration of 100 mg of fluvoxamine reduced the likelihood of clinical deterioration over 15 days. This has been attributed to the high affinity of fluvoxamine for S1R, which reduces the inflammatory responses.
It seems that SSRIs are potential candidates for COVID-19 due to their anti-inflammatory properties. Future clinical studies will determine the exact role of this class of medications in clinical outcomes of COVID-19 patients
Reinfection in COVID-19; Gap Between Theory and Reality
Get PDFAbout 18 months has passed since the first case of coronavirus disease of 2019 (COVID-19) was reported., that caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). There has been some incoherence about various aspects of the disease. A concern has been raised regarding reinfection of patients who have recovered from COVID-19. There are rare reports of cases with suspected COVID-19 “recurrence” or “reactivation”. This could be horrible news for all countries over the world, because the novel virus has a great impact on economy, society, and health. “Retesting Positive for SARS‐CoV‐2” is very attractive and frightening for scientists and has triggered discussions. Retesting positive might be explained in two categories; first, test quality and second, discharge criteria. On the other hand, it has been suggested that there might be a lag in virus clearance in some cases, for example older ones. But the evidence is not sufficient.
Here we report a case of virologically-confirmed COVID-19 patient having experienced a clinically- and virologically-confirmed reinfection of COVID-19. One of our nurses who was a 50-year-old man with history of ischemic heart disease and coronary artery bypass graft was referred to the emergency department with dyspnea and myalgia. He was hospitalized for three days because of his risk factors and positive Reverse transcription polymerase chain reaction (RT-PCR) test for COVID-19. He was discharged and advised to isolate and quarantine. After 6 months, he came back with uncontrolled fever and dyspnea. His O2 saturation was below 80%. He was admitted and hospitalized for 10 days. His RT-PCR test result was positive again for COVID-19. Figure 1 shows his first and second x-ray.
It is important to distinguish reinfection and reactivation of COVID-19, because, in Iran, we permit patients to leave isolation or discharge them from hospital based on clinical recovery without retesting in many cases. While, for example in the Korean approach it has been suggested to label patients as negative after two negative test results in 24 hours. Re-positive RT-PCR test result for SARS-CoV-2 is an emerging global pandemic control challenge. Korea Centers for Disease Control and Prevention (KCDC) reported a high percentage of re-positive cases among asymptomatic patients, most reported cases had mild to moderate symptoms and most of them were asymptomatic. All in all, it is a fact that patients with COVID-19 history might experience re-activation or reinfection. We believe that the criteria for calling patients non-infectious should be reviewed
Efficacy of lacosamide in the treatment of non-convulsive seizure and non-convulsive status epilepticus in septic patients: a narrative review
Get PDFNon-convulsive seizures (NCS) and non-convulsive status epilepticus (NCSE) are of the acute complications of patients admitted to the intensive care unit (ICU), which lead to increased mortality and morbidity. In these cases, immediate treatment with antiepileptic drugs (AEDs) is important to prevent further damage to the brain. AEDs are the first line of treatment, however, most of these medications have many side effects. In the recent years, significant advances have been made in this area and lacosamide is one of the therapeutic options. The intravenous formulation of this drug is most popular due to the lack of drug-drug interaction and properly designed studies which have been conducted in this field. In this review, the latest findings on the effect of lacosamide on acute non-convulsive and generalized-convulsive seizures (G-CS) are evaluated in critically ill patients admitted to the ICU
Simple atrioventricular (AV) dissociation or AV dissociation caused by third degree AV block?
Get PDFOne of the most difficult decisions for many physicians and advanced practice providers occurs when having to distinguish between simple atrioventricular (AV) dissociation and AV dissociation caused by a third degree AV block. Third degree AV block is only one cause of AV dissociation and it is a very infrequent cause. The majority of simple AV dissociations are caused by variations in the balance of sympathetic and parasympathetic inputs from the autonomic nervous system. All of us probably experience an occasional episode of simple AV dissociation while we are asleep. Treatment for simple AV dissociation may be as simple as having the patient get out of bed and walk around the room a few times, while AV dissociation caused by a third degree AV block is going to require an emergent placement of a permanent pacemaker. In order to make this decision properly and confidently, you must have a very clear understanding of the difference. Here, in this educational paper, we aim to discuss more in this regard
Hospital Triage Standards: A Qualitative Study and Content Analysis based on Experts’ Experiences in Iran
Get PDFIntroduction: The lack of a fixed and clear protocol causes confusion for nurses resulting in care performance delay in the emergency room (ER). Given that the purpose of triage is to examine the patient upon arrival in ER for the rapid classification and prioritization of emergency patients in need of treatment, it seems that the development and implementation of hospital triage standards can greatly affect this purpose. Objective: The present study was conducted to review the experiences of experts in hospital triage in terms of determining the standards of hospital ER triage. Methods: This qualitative research was conducted through content analysis method based on Donabedian model. Participants include experts (Politician, Nurse Supervisor, Nurse, Midwife, Faculty of Nursing, Emergency Medicine Specialist) working in educational and private hospitals and single-specialized ERs. Data were collected through in-depth and semi-structured interviews lasting between 25-60 minutes. The main interview questions were: What are the structural standards of a good triage? What are the process standards for a good triage? What are the standards of a good triage? Data analyzed through Content Directed Analysis with Shannon and Hsieh approach. Results: Totally, 21 experts the mean age of 46.9±1.8 (ranged from 30 to 57) years and the mean work experience of 18.9± 8.21 years were participated, of whom 16 (76.2%) persons were male. From the analysis, we extracted 48 codes, 14 subcategories and 3 main categories of "structural standards", "process standards" and "outcome standards". Conclusions: Guidelines are needed so that the nurse in charge of triage can quickly and accurately undertake the important responsibility of patient triage. Additionally, having structure and process and outcome standards improves triage performance