Subcutaneous fast-acting insulin analogues, alone or in combination with long-acting insulin, versus intravenous regular insulin infusion in patients with diabetic ketoacidosis: protocol for an updated systematic review and meta-analysis of randomised trials.

INTRODUCTION: Diabetic ketoacidosis (DKA) is traditionally managed using intravenous regular insulin infusion (RII) in intensive care unit (ICU)/high dependency unit (HDU). Subcutaneous fast-acting insulin analogues (FAIAs) may help to manage DKA outside ICU/HDU. Furthermore, combining subcutaneous long-acting insulin (LAI) with subcutaneous FAIAs may accelerate ketoacidosis resolution. The latest (2016) Cochrane review was inconclusive regarding subcutaneous FAIAs versus intravenous RII in DKA. It was limited by small sample sizes, unclear risk of bias (RoB) in primary trials and did not examine subcutaneous FAIAs with subcutaneous LAI versus intravenous RII in DKA. We report the protocol for an updated meta-analysis on the safety and benefits of subcutaneous FAIAs with/without subcutaneous LAI versus intravenous RII in DKA. METHODS AND ANALYSIS: We will search Medline, Embase, CINAHL and Cochrane Library, from inception until December 2022, without language restrictions, for randomised trials on subcutaneous FAIAs with/without subcutaneous LAI versus intravenous RII in DKA. We also search ClinicalTrials.gov, ClinicalTrialsRegister.eu and reference lists of included trials. Primary outcomes include all-cause in-hospital mortality, time to DKA resolution, in-hospital DKA recurrence and hospital readmission for DKA post-discharge. Secondary outcomes include resource utilisation and patient satisfaction. Safety outcomes include important complications of DKA and insulin. Reviewers will extract data, assess overall RoB and quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation. We will assess statistical heterogeneity by visually inspecting forest plots and the I2 statistic. We will synthesise data using the random-effects model. Predefined subgroup analyses are: mild versus moderate versus severe DKA; age <20 vs ≥20 years; pregnant versus non-pregnant; infective versus non-infective DKA precipitating cause; subcutaneous FAIAs alone versus subcutaneous FAIAs and subcutaneous LAI; and high versus low overall RoB. We will also perform trial sequential analysis for primary outcomes. ETHICS AND DISSEMINATION: Ethics board approval is not required. Results will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42022369518.

Rare case of Torsades de Pointes in severe hypothyroidism: literature review and challenges in management.

BACKGROUND: Hypothyroidism can manifest as several important cardiac abnormalities. There are few reports of ventricular dysrhythmias (VDs) in hypothyroidism. We described a rare case of VDs in severe hypothyroidism and reviewed the literature behind its management. CASE PRESENTATION: A 67-year-old gentleman, with poor compliance to treatment for Hashimoto's thyroiditis, presented with palpitations to the Emergency Department. He had runs of non-sustained ventricular tachycardia (NSVT). He was treated with intravenous (IV) amiodarone and admitted to the intensive care unit for observation. He then developed recurrent Torsades de Pointes (Tdp) despite treatment with several anti-arhythmics. He required electrical cardioversion and eventual transvenous overdrive pacing (OP). VT recurred while he was on OP. VT resolved and he was weaned off OP only after adequate thyroid hormone replacement. CONCLUSIONS: VDs, including NSVT, Tdp, and VT, are rare and potentially lethal in hypothyroidism. Our case demonstrates important challenges in the management of severe hypothyroidism. Here, VDs are often refractory to treatment with drugs and electrical means. The choice(s) of anti-arrhthymics requires careful consideration and can be difficult before thyroid function tests are known. Amiodarone use should be cautioned as it is associated with thyroid dysfunction and QT interval prolongation. There is no literature to guide thyroid hormone replacement in this disease. Aggressive replacement is associated with adverse cardiovascular effects. Our case showed a fine balance between the risk of rapid thyroid hormone replacement and the urgency to terminate VDs. Its administration should be carefully monitored amidst bridging strategies like electrical cardioversion and OP to manage life-threatening VDs.

Benefits and safety of transdermal glyceryl trinitrate in acute stroke: A systematic review and meta-analysis of randomized trials.

BACKGROUND: Transdermal glyceryl trinitrate (GTN) has potential beneficial properties in acute stroke including intracerebral hemorrhage (ICH) and possible clinical benefits suggested in ultra-early stroke (≤6 h). Our meta-analysis updated the evidence on its safety and benefits in acute stroke. METHODS: We searched major electronic databases for randomized trials comparing transdermal GTN versus placebo/control in acute stroke. Primary outcomes were mortality, 90-day modified Rankin Scale (mRS), and blood pressure (BP) effects. Secondary outcomes included early, late, resource utilization, and surrogate outcomes. Safety outcomes were adverse events. Reviewers identified studies, extracted data, and assessed risk of bias (RoB) using a modified Cochrane RoB instrument and quality of evidence (QoE) using GRADE. We also performed a priori subgroup and trial sequential analyses (TSA) on primary outcomes. These subgroup analyses were ICH versus ischemic stroke, minor (NIHSS ≤5) versus major (NIHSS >5) ischemic stroke, ischemic stroke with versus without thrombolysis, prehospital versus non prehospital settings, time from stroke to randomization ≤6 h versus >6 h, and high versus low overall RoB studies. RESULTS: Seven eligible primary trials enrolled 5363 patients. GTN reduced BP (mean difference [MD] = -4.74 mm Hg, 95% confidence interval [CI] = -6.03 to -3.45 mm Hg] and diastolic BP (MD = -2.94 mm Hg, 95% CI = -3.74 to -2.13 mm Hg) 24 h posttreatment but did not affect 4- to 10-day mortality (relative risk [RR] = 1.11, 95% CI = 0.82 to 1.49), 90-day mortality (RR = 0.96, 95% CI = 0.77 to 1.19), and 90-day mRS >2 (RR = 0.98, 95% CI = 0.93 to 1.03) compared to control/placebo. The QoE was high for primary outcomes with no subgroup effects detected. GTN did not affect secondary outcomes and increased risk of headache and hypotension. TSA generally supported our conclusions regarding primary outcomes. CONCLUSIONS: Transdermal GTN reduces BP in acute stroke but does not alter clinical outcomes even in ultra-early stroke (≤6 h).

Benefits and safety of transdermal glyceryl trinitrate in acute stroke: a systematic review and meta-analysis of randomised trials (protocol).

INTRODUCTION: High blood pressure (BP) in acute stroke has adverse outcomes. Transdermal glyceryl trinitrate (GTN) has beneficial properties in controlling BP. The 2016 meta-analysis and 2017 Cochrane review showed that transdermal GTN was beneficial in a small patient subgroup with stroke onset ≤6 hours. Larger studies focusing on this patient subgroup have since been conducted. We report the protocol for an updated systematic review and meta-analysis on the safety and benefits of transdermal GTN in acute stroke. METHODS AND ANALYSIS: We will search Medline, Pubmed, Embase, CINAHL and Cochrane Library from inception until June 2020 for randomised trials that report the efficacy and safety of transdermal GTN versus placebo/control therapy among adult patients with acute stroke. Primary outcomes include in-hospital mortality, BP lowering and late functional status. Secondary outcomes include early, late, resource utilisation and surrogate outcomes. Safety outcomes include reported adverse events. Reviewers will first screen titles and abstracts, and then full texts, to identify eligible studies. Independently and in duplicate, they will extract data, assess risk of bias (RoB) using a modified Cochrane RoB tool and quality of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Disagreement will be resolved by discussion and consultation with an external reviewer if necessary. Using a random-effects model, we will report effect sizes using relative risks and 95% CIs. We will perform predefined subgroup analyses: intracerebral haemorrhage versus ischaemic stroke; minor (NIHSS (National Institutes of Health Stroke Scale) ≤five) versus major (NIHSS >five) ischaemic stroke; ischaemic stroke with versus without thrombolysis; prehospital versus non-prehospital settings; time from stroke to randomisation ≤6 versus >6 hours and high versus low overall RoB studies. We will also perform trial sequential analysis for the primary outcomes. ETHICS AND DISSEMINATION: Ethics board approval is unnecessary. PROSPERO registration has been obtained. The results will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42020173093.

Long-term effect of hyperoxemia during chronic obstructive pulmonary disease exacerbation managed by emergency medical service and emergency department: a prospective, exploratory study.

OBJECTIVE: Long-term effects of hyperoxemia during acute exacerbation of chronic obstructive pulmonary disease (AECOPD) remained unknown. We aimed to explore these effects of hyperoxemia during AECOPD. METHODS: This was an exploratory follow-up study of a cohort with AECOPD managed by Emergency Medical Service and two emergency departments (EDs). Patients were classified as hyperoxemic (PaO2 > 65 mmHg) or nonhyperoxemic (PaO2 ≤ 65 mmHg). Patients discharged from ED/inpatient care were followed up prospectively for 1 year. The primary outcome was 1-year all-cause mortality in hyperoxemic vs. nonhyperoxemic groups. Secondary outcomes were 3-month all-cause mortality and median number of repeat AECOPD hospitalizations within 1 year. We generated Kaplan-Meier curves and compared them using log-rank test. The primary outcome was also analyzed using Cox proportional-hazards model. We reported crude and adjusted hazard ratios, their 95% confidence intervals (CIs) and P values. We adjusted for two a priori predictors of delayed mortality; age ≥ 70 years and repeat AECOPD hospitalizations. RESULTS: A total of 231 patients were analyzed. One-year mortality rates in hyperoxemic vs. nonhyperoxemic groups were 26/137 (19.0%) and 12/94 (12.8%), respectively (P = 0.693). Although Kaplan-Meier curves showed divergent courses favoring nonhyperoxemic group, log-rank test was not statistically significant (P = 0.203). The crude and adjusted hazard ratios (reference: nonhyperoxemic group) were 1.55 (95% CIs, 0.78-3.08; P = 0.207) and 1.57 (95% CIs, 0.79-3.13; P = 0.196), respectively. Secondary outcomes did not differ. CONCLUSIONS: Our study reported no effect on 1-year all-cause mortality associated with hyperoxemia during AECOPD. Further studies are needed to prove/disprove our findings.

Effect of oxygen therapy on the risk of mechanical ventilation in emergency acute pulmonary edema patients.

OBJECTIVE: We investigated the effects of hyperoxemia on morbidity and mortality in acute cardiogenic pulmonary edema (ACPE). METHODS: We conducted a retrospective cohort study of patients in our emergency department (ED) with ACPE who received arterial blood gases. Patients were classified based on the first PaO2 as hypoxemic (<75 mmHg), normoxemic (75-100 mmHg) and hyperoxemic (>100 mmHg). The primary outcome was the rates of mechanical ventilation (MV). We also reported adjusted odds ratios (AOR) and their 95% confidence intervals (CI) of the primary outcome after adjusting for predictors of MV determined a priori. Secondary outcomes were median hospital length of stay (LOS) and in-hospital mortality. RESULTS: We recruited 335 patients; 34.0% had hyperoxemia. The rates of normoxemia and hypoxemia were 27.5% and 38.5%, respectively. The rates of MV were: hypoxemic 60/129 (46.5%) vs. normoxemic 41/92 (44.6%) vs. hyperoxemic 50/114 (43.9%); P = 0.62. The AORs for MV for the hyperoxemic and hypoxemic groups (reference: normoxemic group) were 0.98 (95% CI: 0.53-1.79) and 1.38 (95% CI: 0.77-2.48), respectively. Intubation rates for the groups were: hypoxemic 15/129 (11.6%) vs. normoxemic 6/92 (6.5%) vs. hyperoxemic 12/114 (10.6%); P = 0.43. The secondary outcomes were comparable among the groups. In-hospital mortality rates were: hypoxemic 6/129 (4.7%) vs. 6/92 (6.5%) vs. 10/114 (8.8%); P = 0.42. CONCLUSION: Our exploratory study did not report effects on mechanical ventilation, median hospital LOS and in-hospital mortality from hyperoxemia compared to hypoxemic and normoxemic ED patients with ACPE. Further studies are warranted to prove or disprove our findings.

Most impactful predictors for hyperoxaemia in exacerbation of chronic obstructive pulmonary disease managed by Emergency Medical Services and Emergency Department.

INTRODUCTION: Hyperoxemia in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) leads to adverse outcomes. It remains prevalent in the pre-hospital Emergency Medical Services (EMS) and Emergency Department (ED). OBJECTIVE: To determine the key predictors for hyperoxemia in AECOPD in EMS and ED. METHODS: This was a prospective observational study of AECOPD patients in EMS and two EDs. Hyperoxemia was defined as PaO2 > 65 mm Hg (corresponds to SpO2 > 92%). We determined apriori candidate factors in Patient, Organization and Staff domains. Primary outcomes were the key predictors for hyperoxemia. Secondary outcomes were in-hospital mortality and mechanical ventilation rates in hyperoxemic versus non-hyperoxemic groups. We generated a logistic regression model for each domain. We reported the adjusted odds ratios (AORs), 95% CIs and p values. We selected the output factors using AOR ≥2.0 and ≥2.5 for modifiable and non-modifiable factors, respectively. These selected factors were fed into a final model with eventual factors selected based on: threshold AORs as stated above and/or 95% CIs including these AORs. RESULTS: Three hundred and twenty-six patients were analysed; 60.7% had hyperoxemia. We found three eventual modifiable factors; first, ED SpO2 > 95% [AOR 2.62 (95% CIs: 1.61-4.33); P < 0.001], EMS non-rebreathing mask [AOR 2.01 (95% CIs: 1.06-3.97); P = 0.04]; and ED nasal cannula [AOR 1.69 (95% CIs: 1.05-2.72); P = 0.03]. Secondary outcomes did not differ between groups. CONCLUSION: We identified three key modifiable predictors. We intend to conduct an interventional study using them to reduce hyperoxemia rate in AECOPD.

Effectiveness of a post-emergency department discharge multidisciplinary bundle in reducing acute hospital admissions for the elderly.

OBJECTIVE: We evaluated the effectiveness of the Subacute Ambulatory care for the Functionally challenged and Elderly (SAFE) programme, a post-emergency department (ED) discharge intervention for elderly and functionally challenged patients, in reducing acute hospital admissions. METHODS: This study was a 32-month retrospective quasi-experimental study comparing patients with at least one of six diagnostic classifications who underwent SAFE intervention with those who were eligible but declined and received usual ED care (control). The primary outcomes were rates of first acute hospital admission at 30 and 60 days post-ED discharge. Secondary outcomes were 20-day withdrawal rate and 60-day mortality. The difference in primary outcome between the two groups was compared using a Cox proportional hazards model. We reported adjusted hazard ratios (HRs) with their 95% confidence intervals (CIs) adjusting for predefined factors of age, sex, triage risk assessment tool scores and baseline ED utilization and acute hospital admission rates in the past year. RESULTS: There were 438 and 209 patients in the intervention and control groups, respectively. The intervention group had reduced risk of first acute hospital admission at 30 days (10 vs. 27%, HR=0.34, 95% CI: 0.22-0.52) and 60 days (18 vs. 33%, HR=0.48, 95% CI: 0.34-0.69) compared with the control. The 20-day withdrawal rate was 3.2%. Both groups did not differ in 60-day mortality rates. CONCLUSION: The SAFE programme was effective in reducing first acute hospital admissions in selected elderly and functionally challenged patients after ED discharge at 30 and 60 days compared with usual ED discharge care.

Peri-mortem caesarean section after traumatic arrest: Crisis resource management.

Peri-mortem caesarean section (PMCS) is a very rare procedure performed to improve the chances of survival for both mother and fetus following cardiorespiratory arrest. Non-obstetricians including Emergency Physicians (EPs) are often called upon to perform this procedure under challenging and suboptimal circumstances. We reported a case of PMCS performed timely after traumatic cardiorespiratory arrest that resulted in fetal survival. A 25-year-old primigravida female and six-month pregnant presented to the Emergency Department (ED) of an adult tertiary hospital. She experienced traumatic cardiorespiratory arrest for nearly 27 min following a high-speed motor vehicle crash. Upon ED arrival, she was in pulseless electrical activity. She was immediately intubated with continuation of cardiopulmonary resuscitation. She received bilateral tube thoracostomies as well as intravenous (IV) transfusion of blood products, adrenaline and tranexamic acid. Her fundal height was two centimeters above the umbilicus on palpation. The EP performed a PMCS via a midline laparotomy 3-4 min upon ED arrival. The baby was bradycardic and cyanosed with no spontaneous respiration at birth and was resuscitated by a second EP. She was intubated and the EP gained IV access using a cannula introduced into the umbilical vein. Neonatal hypothermia was avoided using cling wrap. The baby was transported to a nearby neonatal intensive unit. She survived and is currently one year old. The mother, however, did not respond to our resuscitation and succumbed to her multiple injuries. We reviewed the limited literature regarding this potentially life-saving emergency procedure and highlighted the challenges facing our resuscitation team.

Traumatic diaphragmatic injuries: a retrospective review of a 12-year experience at a tertiary trauma centre.

INTRODUCTION: Traumatic diaphragmatic injuries (TDIs) are clinically challenging. We aimed to review TDIs treated at a tertiary trauma centre over a 12-year period. METHODS: This was a single-centre retrospective review of adult patients with TDIs treated between 1 January 2003 and 31 December 2014. Primary outcomes were mortality rates and Injury Severity Scores (ISS) associated with each TDI subtype. Secondary outcomes included proportions of TDIs diagnosed radiologically, operatively or during autopsy. We compared the TDI subtypes with respect to mechanism of injury, mortality rates and median ISS. Data was analysed using descriptive statistics. RESULTS: Among 46 patients studied, the TDI subtypes noted were acute diaphragmatic herniation (n = 14, 30.4%), tears (n = 22, 47.8%) and contusions (n = 10, 21.7%). Patients with these TDI subtypes had a mortality rate of 35.7%-100%, while the ISS ranges for survivors and deaths were 22.0-34.0 (interquartile range [IQR] 6.5-23.0) and 53.5-66.0 (IQR 16.0-28.5), respectively. TDIs were identified via chest radiography (n = 2/33, 6.1%) and computed tomography (n = 6/13, 46.2%). All survivors (n = 21) and deaths (n = 25) underwent open surgery or autopsy, respectively, which confirmed TDIs. Blunt traumas and penetrating traumas were more frequently associated with acute herniation/contusions and tears, respectively. There were statistically significant differences among the TDI subtypes in their mechanism of injury, mortality rate and median ISS of survivors. CONCLUSION: TDIs showed varying injury patterns with blunt versus penetrating mechanisms of injury, and were associated with significant mortality rates. Preoperative imaging had limited diagnostic use.

Outcomes of warfarinized patients with minor head injury and normal initial CT scan.

OBJECTIVES: We investigated delayed outcomes of patients with minor head injury, warfarin, and a normal initial head computer tomographic (CT) scan finding. METHODS: We conducted a single-center, retrospective study on such patients who were admitted. A second CT was not mandatory. International normalized ratios were classified into subtherapeutic, therapeutic, and supratherapeutic ranges. We traced them 2 weeks after discharge for delayed intracranial hemorrhage (ICH). Primary outcomes were proportions with ICH on second CT, fresh-frozen plasma (FFP) and/or vitamin K administration, and neurosurgical intervention. Secondary outcomes were hospital length of stay and the proportion with ICH 2 weeks after discharge. We explored differences in proportions of ICH during hospital stay among different strata (age ≥65 years, antiplatelet therapy, supratherapeutic international normalized ratio ranges, and FFP administration). Data were analyzed using descriptive statistics. P values less than .05 were considered statistically significant. RESULTS: We recruited 298 patients. Of admissions (N = 295), 11 (3.7%) had a second CT, with one (0.3%) abnormality. There were 7 (2.4%) and 8 (2.7%) patients who received FFP and vitamin K, respectively. One patient (0.3%) required neurosurgical intervention. The median hospital length of stay was 3 (interquartile range, 2) days. No patients reattended 2 weeks after discharge. There were no statistically significant differences in the proportions of ICH during hospital stay among the 4 strata. CONCLUSIONS: Delayed ICH was rare with no predictive factors. Clinical monitoring before deciding on second CT was safe. The optimal period and mode of observation had yet to be determined.

Do emergency nurses and doctors agree in their triage assessment of dyspneic patients?

OBJECTIVES: This study investigated the inter-observer agreement (IOA) between doctors and nurses on triaging adult ED dyspneic patients. METHODS: This was a prospective observational study comparing eight trained ED nurses with doctors. Each patient was assessed by a nurse and two doctors (1 and 2) who decided on four-point Patient Acuity Category (PAC) and triage management steps. The primary outcome was the proportion of resuscitation room escalations from consult. Secondary outcomes included proportions and IOA of assigned PAC and steps in triage management. The investigators reported IOA as the k statistic (95% CIs) and percent agreement. DATA/RESULTS: There were 22/302 (7.3%) escalations; one from clinical deterioration. Proportions of assigned PAC status by nurses, Drs 1 and 2 were: PAC 1: 20.2-24.2%; PAC 2: 71.5-72.8%; PAC 3: 4.3-7.0%; PAC 4: 0.0-0.7%. The IOA was at least fair to moderate [k: 0.33 (0.22-0.43) to 1.00] in all steps of management except for electrocardiogram [k: 0.19 (0.10-0.27) to 0.45 (0.35-0.55)] ordering. The percent agreement ranged from 81 to 100% for all management steps except for chest Xray (66-73%) and electrocardiogram (61-71%) ordering. CONCLUSION: Trained ED nurses were safe and managed adult dyspneic patients as well as doctors at triage.

Survey of factors affecting health care workers' perception towards institutional and individual disaster preparedness.

INTRODUCTION: Health care institutions constantly must be prepared for disaster response. However, there are deficiencies in the current level of preparedness. The aim of this study was to investigate the factors affecting the perception of health care workers (HCWs) towards individual and institutional preparedness for a disaster. METHODS: A survey on disaster incident preparedness was conducted among doctors, nurses, and allied health workers over a period of two months in 2010. The survey investigated perceptions of disaster preparedness at the individual and institutional level. Responses were measured using a five-point Likert scale. The primary outcomes were factors affecting HCWs' perception of institution and individual preparedness. Secondary outcomes were the proportions of staff willing to participate and to place importance on disaster response training and their knowledge of access to such training. Data was analyzed using descriptive statistics. Logistic regression was performed to determine the factors that influenced the HCWs' perception of their individual and institutional readiness. Odd ratios (ORs) of such factors were reported with their 95% confidence intervals (CIs). RESULTS: Of 1700 HCWs, 1534 (90.2%) completed the survey. 75.3% (1155/1534) felt that the institution was ready for a disaster incident, but only 36.4% (558/1534) felt that they (as individuals) were prepared. Some important factors associated with a positive perception of institution preparedness were leadership preparedness (OR = 13.19; 95% CI, 9.93-17.51), peer preparedness (OR = 6.11; 95% CI, 4.27-8.73) and availability of training opportunities (OR = 4.76; 95% CI, 3.65-6.22). Some important factors associated with a positive perception of individual preparedness were prior experience in disaster response (OR = 2.80; 95% CI, 1.99-3.93), institution preparedness (OR = 3.71; 95% CI, 2.68-5.14), peer preparedness (OR = 3.49; 95% CI, 2.75-4.26), previous training in disaster response (OR = 3.48; 95% CI, 2.76-4.39) and family support (OR = 3.22; 95% CI, 2.54-4.07). Most (80.7%, 1238/1534) were willing to participate in future disaster incident response training, while 74.5% (1143/1534) felt that being able to respond to a disaster incident constitutes part of their professional competency. However, only 27.8% (426/1534) knew how to access these training opportunities. CONCLUSIONS: This study demonstrated that HCWs fare poorly in their perception of their individual preparedness. Important factors that might contribute to improving this perception at the individual and institution level have been identified. These factors could guide the review and implementation of future disaster incident response training in health care institutions.

Comparing triage evaluation of adult dyspneic patients between emergency nurses and doctors using simulated scenarios.

OBJECTIVE: Although registered nurses frequently perform triaging in many emergency departments (EDs), little is known regarding the agreement between nurses and doctors in triaging dyspneic patients. The aim of our study was to compare the effectiveness of trained ED nurses with doctors in the evaluation of dyspneic patients at triage using the SimMan 3G simulator. METHODS: We compared eight nurses who underwent a structured training/accreditation program with eight doctors. Two assessors evaluated them through seven common and/or important cardiorespiratory simulated scenarios. Each scenario had an evaluation instrument that scored participants on triage assessment and management. Each nurse was also surveyed over a six-point Likert scale (0-5) on their confidence in triaging dyspneic patients after the study. Data was analyzed using descriptive statistics with statistical significance set at p<0.05. DATA/RESULTS: There were no statistically significant differences between the mean assessment or management scores across all scenarios between doctors versus nurses (p ranging from 0.070 to 0.798). Six nurses felt they could evaluate ED dyspneic patients alone (score of 4) and the remainder with supervision (score of 2-3). CONCLUSION: Trained ED nurses; when compared to doctors; could triage and evaluate dyspneic patients effectively on a simulator.

Severe chlorate poisoning successfully treated with methylene blue.

BACKGROUND: Chlorate poisoning as a cause of methemoglobinemia is regarded in current literature to be resistant to treatment by methylene blue due to the oxidizing and denaturing properties of the chlorate anion, and often leads to severe renal and hematological complications with a high mortality rate. Recent case studies suggest practitioners have eschewed the use of methylene blue in such situations. OBJECTIVES: This report describes a case of chlorate poisoning presenting as severe methemoglobinemia successfully treated with methylene blue alone, believed to be a first in reported literature. CASE REPORT: A 34-year-old male construction worker presented 4 h after accidental ingestion of an industrial chemical, with giddiness and breathlessness. Physical examination did not reveal any abnormal cardiorespiratory findings, although arterial blood gas analysis and pulse oximetry revealed an "oxygen saturation gap." Methemoglobin levels were found to be severely elevated at 66.8% 6 h after ingestion, and the patient was promptly treated with methylene blue. Clinical examination and laboratory tests suggested the absence of hemolysis at the time of treatment. The patient was discharged after a brief and uneventful hospital stay. Subsequent tests revealed the chemical ingested to be sodium chlorate. CONCLUSION: The successful outcome in our case suggests that a window of opportunity as long as 6 h may exist during which treatment of chlorate poisoning with methylene blue may be of clinical value. We postulate that the absence of significant hemolysis and hematological alterations at the time of antidote administration may be a necessary prerequisite for treatment success.

Nationwide improvement of door-to-balloon times in patients with acute ST-segment elevation myocardial infarction requiring primary percutaneous coronary intervention with out-of-hospital 12-lead ECG recording and transmission.

STUDY OBJECTIVE: Reducing door-to-balloon times for acute ST-segment elevation myocardial infarction (STEMI) patients has been shown to improve long-term survival. We aim to reduce door-to-balloon time for STEMI patients requiring primary percutaneous coronary intervention by adoption of out-of-hospital 12-lead ECG transmission by Singapore's national ambulance service. METHODS: This was a nationwide, before-after study of STEMI patients who presented to the emergency departments (ED) and required percutaneous coronary intervention. In the before phase, chest pain patients received 12-lead ECGs in the ED. In the after phase, 12-lead ECGs were performed by ambulance crews and transmitted from the field to the ED. Patients whose ECG showed greater than or equal to 2 mm ST-segment elevation in anterior or greater than or equal to 1 mm ST-segment elevation in inferior leads for 2 or more contiguous leads and symptom onset of less than 12 hours' duration were eligible for percutaneous coronary intervention activation before arrival. RESULTS: ECGs (2,653) were transmitted by the ambulance service; 180 (7%) were suspected STEMI. One hundred twenty-seven patients from the before and 156 from the after phase met inclusion criteria for analysis. Median door-to-balloon time was 75 minutes in the before and 51 minutes in the after phase (median difference=23 minutes; 95% confidence interval 18 to 27 minutes). Median door-to-balloon times were significantly reduced regardless of presentation hours. Overall, there was significant reduction in door-to-activation, door-to-ECG, and door-to-cardiovascular laboratory times. No significant difference was found pertaining to adverse events. CONCLUSION: This study describes a nationwide implementation of out-of-hospital ECG transmission resulting in reduced door-to-balloon times, regardless of presentation hours. Out-of-hospital ECG transmission should be adopted as best practice for management of chest pain.

A meta-analysis on the utility of peripheral venous blood gas analyses in exacerbations of chronic obstructive pulmonary disease in the emergency department.

The objective of this case-based review is to identify and summarize the relevant evidence for the clinical utility of peripheral venous blood gas (pVBG) analyses in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) treated in the emergency department. Relevant studies were identified using the Cochrane Library, Medline, Embase, and CINAHL databases and by hand searching of references of published articles. Included studies were prospective trials comparing arterial and pVBG results in patients with COPD or respiratory distress that reported at least average differences and/or limits of agreement between the two results in English. Outcomes of interest were agreement between arterial and pVBG values for pH, pCO2, pO2, and HCO3. Eighty-nine studies were identified of which six were relevant. The weighted average difference for pCO2 was 5.92 mmHg, whereas those for pH, pO2, and HCO3 were 0.028, 18.65 mmHg, and 1.34 mEq/l, respectively. Using Bland-Altman analysis, the 95% limits of agreement were in the range of -0.10 to 0.08, -17 to 26 mmHg and, -3.5 to 3.5 mEq/l for pH, pCO2, and HCO3, respectively. Reported cutoff pVBG pCO2 values for screening of arterial hypercarbia ranged from 30 to 46 mmHg. No studies investigated the role of pVBG analysis in treatment alteration or clinical outcomes. Available evidence suggests that there is good agreement for pH and HCO3 values between arterial and pVBG results in patients with COPD, but not for pO2 or pCO2. Widespread clinical use is limited because of the lack of validation studies on clinical outcomes.