Frontiers in Emergency Medicine (E-Journal)
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The Role of Chest CT Scan in Diagnosis of COVID-19
Get PDFAs the number of patients infected by COVID-19 increases worldwide, and in the absence of appropriate therapeutic drugs or vaccines, it is essential to detect patients with COVID-19 pneumonia at its early stages, in order to isolate the patients from healthy population. Computed tomography (CT) scan seems to be promising in detection of COVID-19 as shown in some studies
Clinical Recommendation for Emergency Physicians to Approach to Signs and Symptoms Related to COVID-19; a Preliminary Study
Get PDFIntroduction: There is not enough and comprehensive evidence on signs and symptoms of COVID-19; therefore, it seems too early to provide an appropriate clinical decision-making rule for this newly emerged pandemic viral disease. Objective: We tried to categorize patients’ signs and symptoms from very highly suspected to non-suspected, regarding having COVID-19. Methods: Most recently published English-language articles on COVID-19, were reviewed by the researchers. We considered each complaint, separately, and gathered available data, such as percentage of involved patients and their crude number. Then we considered the pooled and collected results as the final percentage of the occurrence of every specific symptom. We categorized patients’ complaints into six types, based on the data obtained. All extracted complaints were categorized and scored. Results: Twenty-seven articles were reviewed, of which, 12 considered for analysis. The selected papers had reported various numbers of patients, ranging from 16 to 1,099 patients (mean=229 patients per study). In total, nineteen different complaints, with an average of nine complaints per article, had been reported (IQR= 8-11). In terms of overall prevalence, based on the total number of patients, fever and dry cough were reported in more than half of the referred patients. The complaints were categorized in six types with and scored. Conclusions: The patients with score ≥17 are very highly suspected to COVID-19; However, patients with score <5 could be considered as non-suspected 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
Clinical and Epidemiological Features of Hospitalized Patients with COVID-19 in Hospitals of Tehran University of Medical Sciences
Get PDFIntroduction: Since the start of COVID-19 pandemic in December 2019, until mid-April 2020 the total number of cases worldwide exceeded two millions and the death toll exceeded 130000 cases. Objective: The current study conducted to explore the clinical and epidemiological characteristics of COVID-19 patients, fatality of this disease and its mortality risk factors in major hospitals affiliated with Tehran University of Medical Sciences (TUMS). Methods: The data were collected in four major teaching hospitals affiliated with TUMS for all the patients that were admitted between Feb 19th and Apr 15th 2020 and were diagnosed as COVID-19 using reverse transcription polymerase chain reaction (RT-PCR), clinical diagnosis and/or lung computed tomography (CT) scan. The case fatality rate of the disease was estimated by age, sex, symptoms, comorbidities, and type of diagnosis. Logistic regression model was used to examine the associations between different factors and in-hospital deaths. Results: By Apr 15th 2020, a total of 4377 patients were admitted with COVID-19 diagnosis in four selected hospitals and 496 (11.3%) of these patients died in hospital. The case fatality rate of this disease was 28.8% in the ≥80-year age group, which was the highest compared to the other age groups. The case fatality rates were 12.5% and 9.8% among men and women, respectively. The results of multiple logistic regression on the outcome of death indicated that age, sex, cough, myalgia, reduced consciousness at arrival and past history of cancer were significantly associated with in-hospital death. Adjusting the effect of other variables, for each 10-year increase in age, the odds of death due to COVID-19 was 1.61 times greater (adjusted OR 1.61, 95% CI: 1.51 to 1.72, p<0.001). Conclusions: Older age, the male gender, past history of comorbidities (particularly cancer) and reduced consciousness at arrival are among the factors that can significantly increase the odds of in-hospital death in COVID 19 patients. These factors might be helpful in detecting and managing patients with poorer prognosis
A Letter on “Induced Demand after Implementing the Health Reform Plan in Selected Emergency Departments Affiliated to Isfahan University of Medical Sciences: a Cross-Sectional Study”
Get PDFDear Editor in Chief
Advanced Journal of Emergency Medicine
I am writing you to point to an error in the article written by Shahverdi et al. entitled "Induced Demand after Implementing the Health Reform Plan in Selected Emergency Departments Affiliated to Isfahan University of Medical Sciences: a Cross-Sectional Study", which was published in your Journal.
Variables have been proposed to increase the chance of induced demand on both patient and supplier (physicians, service providers and etc.) parts. For example, on the supply-side: "physicians' income, physician/population ratio, price of services, payment methods, consultation time per visit or service, type and size of hospital, and etc." and on the demand-side "patients' insurance coverage and etc.". The study aimed to assess the induced demand after implementing the health reform plan (HRP) in the selected emergency departments, but the findings focus on calculating the percentage of changes in services provided before and after HRP; and it has not been shown that the studied factors have led to induced demand. So, the calculated increases might be due to uncertainty. Furthermore, based on the statistics presented in table1, there is an increase of about 65% in radiographic images, from 0.02 (in 2012-13) to 0.33 (in 2015-2016) image/person, and the mean difference is 0.13. It seems that, there is a miscalculation. The mean difference should be 0.013, and so the increased amount will be 0.033
The Effects of Different Doses of Submucosal vs. Intravenous Ketamine for Conscious-sedation in Children Candidates for Diagnostic-Therapeutic Procedures in Emergency Department
Get PDFIntroduction: Ketamine is a commonly used medicine for reducing pain and stress in patients, including children in emergency department (ED). The intravenous (IV) injection of ketamine is gold standard though difficult in children, but other routes are also possible. Objective: This study was conducted to compare the effects of the submucosal at different doses versus IV injections of ketamine on sedation with proper consciousness in children candidates for diagnostic-therapeutic procedures in ED. Methods: This randomized clinical trial was conducted with 4 groups; groups 1, 2 and 3 respectively received 4, 3 and 2 mg/kg of submucosal ketamine and group four 1.5 mg/kg of IV ketamine. Eligible subjects selected from 46 patients of children’s age as the candidates for subcutaneous wound healing were randomly assigned to the four groups and followed up 5, 10, 15 and 30 minutes after the injection. The Ramsay score was obtained by measuring the heart rate, the breathing rate, the time to start affecting and duration of the effect. The data were ultimately analyzed in SPSS and Excel. Results: The baseline data were matched and confounding variables eliminated included age, gender, weight and hemodynamics. Compared to other doses of submucosal ketamine, 4 mg/kg was found to exert its effect the fastest (4.08±1.01 minutes) (p<0.05) and for the longest duration (23.09±1.12 minutes) (p<0.05). The Ramsay score in groups 1 and 4, i.e. 5.9, was significantly higher than that in groups 2 and 3 (p<0.05). Conclusions: The results showed that 4 mg/kg and 3 mg/kg of submucosal ketamine are appropriate alternatives to IV ketamine. Although the time to start affecting was shorter in the intravenous group compared to in the other groups, the duration of the effect was the longest with 4 mg/kg of submucosal ketamine. Surgeon satisfaction scores were found to be very good and not significantly different between groups 1, 2 and 4. Vomiting was also prevalent with no significant differences between the four groups
MRI Findings in Children with the First Unprovoked Seizure Presenting to the Emergency Department; Does Developmental Delay Suggest the Importance of Brain MRI Evaluation?
Get PDFIntroduction: The first unprovoked seizure (FUS) in children is a convulsive seizure with an unknown cause, which may be due to an underlying neurological disease or a manifestation of epilepsy. Objective: The aim of this study was to evaluate the findings of brain magnetic resonance imaging (MRI) in pediatric patients with FUS, presenting to the emergency department (ED). Methods: In this cross-sectional study, all children with FUS (age: >1month and<14 years), who were referred to the ED of Qaem Hospital, Mashhad, Iran from 2016 to 2019, were investigated. Medical records, brain MRI findings, electroencephalography (EEG) results, and developmental status of children were reviewed retrospectively. Results: The brain MRI findings of 56 children with FUS were reviewed. The mean age of children was 3.92±6.05 years, and the sex distribution was equal. Seventeen (30.4%) patients had abnormal EEG findings, while 13 (23.2%) patients’ had non-specific EEG findings. Neurological examination of 4 (7.1%) children was abnormal. Overall, 6 (10.7%) patients had non-specific abnormal brain MRI findings for seizure, while 3 (5.4%) patients had specific abnormal findings. A significant relationship was observed between the developmental status of children and abnormal MRI findings (P=0.04). However, MRI findings had no significant relationship with EEG or neurological findings (P>0.05). Conclusion: It may be useful to perform brain MRI for children with FUS presenting to ED, especially those who are suspected of developmental disorders
Rationale and Design of a Registry in a Referral and Educational Medical Center in Tehran, Iran: Sina Hospital Covid-19 Registry (SHCo-19R)
Get PDFCoronavirus disease 2019 (Covid-19) is caused by the novel coronavirus resulting in a highly contagious respiratory tract infection with an increased risk of acute respiratory distress syndrome (ARDS), which was first seen in Wuhan, China. Thus far, this virus has spread to many countries worldwide, including Iran. Multiple studies have assessed disease characteristics, viral genetics, and complications of Covid-19 in the Chinese population. However, there is limited data regarding patient characteristics and outcomes of infected cases outside of China. Besides, risk factors of adverse outcomes are poorly identified in different populations. Due to limited data in the Iranian population affected by the virus, we aimed to design a registry of patients with Covid-19 at Sina Hospital in Tehran, Iran [Sina Hospital Covid-19 Registry (SHCo-19R)] in this regard, to assess patient characteristics, imaging features, laboratory findings, management strategies, and adverse outcomes of Iranian patients with Covid-19 and their differences with other populations
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
Consider the Options; Can Decontamination and Reuse be the Answer to N95 Respirator Shortage in COVID-19 Pandemic?
Get PDFHealth care workers (HCWs) are heavily involved in the fight against COVID-19 in all over the world. They have the vital role of treating patients and searching for the proper treatment for the disease, while supporting and protecting their families. It is imperative that the systems should try hard to keep them safe and healthy. World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) have recently published guidelines for keeping HCWs safe and protected. The Personal Protective Equipment (PPE) is the cornerstone of recommendations and contains face mask (air purifying respirator), goggles or face shield, gown, and gloves. There is no doubt that a proper mask (e.g. N95) is the most important element of the protective gear when it comes to transmission of COVID-19