Headache in the Emergency Department: A Multicenter Observational Study from Singapore.

Background and Objectives: There is scarce data about the epidemiology, clinical features, investigations, diagnosis, treatment, and outcome in patients attending Singapore emergency departments (EDs) with nontraumatic headache. We sought to describe these characteristics of adult patients presenting to the ED with a primary complaint of headache. Materials and Methods: We performed a cross-sectional study on adult patients with nontraumatic headache over 4 consecutive weeks from 18 March 2019 to 14 April 2019 across four EDs in Singapore. Exclusion criteria were history of head trauma within 48 h of presentation, missing records, interhospital transfers, representation with the same headache as a recent previous visit and headache as an associated symptom. Results: During the study period, 579 patients (representing 1.8% of the total ED census) comprising 55.3% males and with a median age of 36 years presented to the four Singapore EDs with a primary complaint of nontraumatic headache. Paracetamol (41.5%), non-steroidal anti-inflammatory drugs (34.4%) and tramadol (31.5%) were the three commonest analgesics used either singly or in combination. Prochlorperazine (22.9%) and metoclopramide (17.4%) were frequent anti-emetic adjuncts. One-third of patients had computed tomography of the brain performed, which found abnormalities among 20.9% of them. ED diagnoses of primary headache conditions were made in 73.6% of patients. Conclusions: Primary headaches constituted most ED headache diagnoses. ED imaging of selected patients yielded a relatively high pick-up rate for significant intracranial abnormalities. Opioid use for symptomatic relief of headaches in the ED was found to be high, underscoring the need for improvement in headache analgesia relief practices in the ED.

Responding to COVID-19: how an academic infectious diseases division mobilized in Singapore.

BACKGROUND: On January 30, COVID-19 was declared a Public Health Emergency of International Concern-a week after Singapore's first imported case and 5 days before local transmission. The National University Hospital (NUH) is Singapore's third largest hospital with 1200 beds, heavy clinical workloads, and major roles in research and teaching. MAIN BODY: With memories of SARS still vivid, there was an urgent requirement for the NUH Division of Infectious Diseases to adapt-undergoing major reorganization to face rapidly changing priorities while ensuring usual essential services and standards. Leveraging on individual strengths, our division mobilized to meet the demands of COVID-19 while engaging in high-level coordination, strategy, and advocacy. We present our experience of the 60 days since the nation's first case. During this time, our hospital has managed 3030 suspect cases, including 1300 inpatients, 37 confirmed cases, and overseen 4384 samples tested for COVID-19. CONCLUSION: Complex hospital adaptations were supported by an unprecedented number of workflows and coordination channels essential to safe and effective operations. The actions we describe, aligned with international recommendations and emerging evidence-based best practices, may serve as a framework for other divisions and institutions facing the spread of COVID-19 globally.

Impact of the COVID-19 pandemic on hyperacute stroke treatment: experience from a comprehensive stroke centre in Singapore.

The Coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving and affecting healthcare systems across the world. Singapore has escalated its alert level to Disease Outbreak Response System Condition (DORSCON) Orange, signifying severe disease with community spread. We aimed to study the overall volume of AIS cases and the delivery of hyperacute stroke services during DORSCON Orange. This was a single-centre, observational cohort study performed at a comprehensive stroke centre responsible for AIS cases in the western region of Singapore, as well as providing care for COVID-19 patients. All AIS patients reviewed as an acute stroke activation in the Emergency Department (ED) from November 2019 to April 2020 were included. System processes timings, treatment and clinical outcome variables were collected. We studied 350 AIS activation patients admitted through the ED, 206 (58.9%) pre- and 144 during DORSCON Orange. Across the study period, number of stroke activations showed significant decline (p = 0.004, 95% CI 6.513 to - 2.287), as the number of COVID-19 cases increased exponentially, whilst proportion of activations receiving acute recanalization therapy remained stable (p = 0.519, 95% CI - 1.605 to 2.702). Amongst AIS patients that received acute recanalization therapy, early neurological outcomes in terms of change in median NIHSS at 24 h (-4 versus -4, p = 0.685) were largely similar between the pre- and during DORSCON orange periods. The number of stroke activations decreased while the proportion receiving acute recanalization therapy remained stable in the current COVID-19 pandemic in Singapore.

Can non-invasive cardiac hemodynamics and fluid content system (NICaS) parameters predict Acute Heart Failure outcomes in Caucasian and Asian patients in the emergency department?

PURPOSE: Acute heart failure (AHF) is a serious condition that requires prompt diagnosis and management. To optimize patient care, clinicians need a reliable, non-invasive method to assess hemodynamic parameters and total body congestion. Currently, no standardized technology is widely used for this purpose. However, NICaS technology, which measures hemodynamic parameters based on regional bioimpedance, has shown promise in monitoring AHF patients in a non-invasive and reliable manner. In this study, researchers aimed to evaluate the usefulness of NICaS technology in predicting patients' outcome in Caucasian and Asian AHF patients presenting to the emergency department (ED). PATIENTS AND METHODS: The study included 40 Caucasian patients from Italy (group A) and 71 Asian patients from Indonesia and Singapore (group B) with a diagnosis of AHF in the ED. The study compared data from NICaS parameters, clinical findings, laboratory, and radiological results with short-term events. RESULTS: In group A, NICaS data at ED arrival significantly predicted 30-day cardiovascular mortality and rehospitalization. At discharge, a value of cardiac output obtained using NICaS was a significant predictor for 30-day rehospitalization. In group B, NICaS variables, total peripheral resistance index on admission and during 48-72 â€‹h had prominent AUC compared to clinical congestion score and NT-proBNP in predicting mortality and rehospitalization. CONCLUSIONS: The results indicate that NICaS technology offers a simple, non-invasive, and reliable method of assessing cardiac hemodynamics and congestion in AHF patients. These measurements may enhance diagnosis, tailor management plans, stratify risk, and predict outcomes in both Caucasian and Asian patients.

Pre- and apnoeic high-flow oxygenation for rapid sequence intubation in the emergency department (the Pre-AeRATE trial): A multicentre randomised controlled trial.

INTRODUCTION: Evidence regarding the efficacy of high-flow nasal cannula (HFNC) oxygenation for preoxygenation and apnoeic oxygenation is conflicting. Our objective is to evaluate whether HFNC oxygenation for preoxygenation and apnoeic oxygenation maintains higher oxygen saturation (SpO2) during rapid sequence intubation (RSI) in ED patients compared to usual care. METHODS: This was a multicentre, open-label, randomised controlled trial in adult ED patients requiring RSI. Patients were randomly assigned 1:1 to either intervention (HFNC oxygenation at 60L/min) group or control (non-rebreather mask for preoxygenation and nasal prongs of at least 15L/min oxygen flow for apnoeic oxygenation) group. Primary outcome was lowest SpO2 during the first intubation attempt. Secondary outcomes included incidence of SpO2 falling below 90% and safe apnoea time. RESULTS: One hundred and ninety patients were included, with 97 in the intervention and 93 in the control group. Median lowest SpO2 during the first intubation attempt was 100% in both groups. Incidence of SpO2 falling below 90% was lower in the intervention group (15.5%) compared to the control group (22.6%) (adjusted relative risk=0.68, 95% confidence interval [CI] 0.37-1.25). Post hoc quantile regression analysis showed that the first quartile of lowest SpO2 during the first intubation attempt was greater by 5.46% (95% CI 1.48-9.45%, P=0.007) in the intervention group. CONCLUSION: Use of HFNC for preoxygenation and apnoeic oxygenation, when compared to usual care, did not improve lowest SpO2 during the first intubation attempt but may prolong safe apnoea time.

Virtual reality mobile application to improve videoscopic airway training: A randomised trial.

INTRODUCTION: Flexible bronchoscopic intubation (FBI) is an important technique in managing an anticipated difficult airway, yet it is rarely performed and has a steep learning curve. We aim to evaluate if the integration of virtual reality gaming application into routine FBI training for emergency department doctors would be more effective than traditional teaching methods. METHODS: We conducted a randomised controlled trial to compare self-directed learning using the mobile application, Airway Ex* in the intervention group versus the control group without use of the mobile application. All participants underwent conventional didactic teaching and low-fidelity simulation with trainer's demonstration and hands-on practice on a manikin for FBI. Participants randomised to the intervention arm received an additional 30 minutes of self-directed learning using Airway Ex, preloaded on electronic devices while the control arm did not. The primary outcome was time taken to successful intubation. RESULTS: Forty-five physicians (20 junior and 25 senior physicians) were enrolled, with male predominance (57.8%, 26/45). There was no difference in time taken to successful intubation (median 48 seconds [interquartile range, IQR 41-69] versus 44 seconds [IQR 37-60], P=0.23) between the control and intervention groups, respectively. However, the intervention group received better ratings (median 4 [IQR 4-5]) for the quality of scope manipulation skills compared to control (median 4 [IQR 3-4], adjusted P=0.03). This difference remains significant among junior physicians in stratified analysis. CONCLUSION: Incorporating virtual reality with traditional teaching methods allows learners to be trained on FBI safely without compromising patient care. Junior physicians appear to benefit more compared to senior physicians.

Comparison of Reusable Models in Pericardiocentesis Simulation Training.

INTRODUCTION: Pericardiocentesis is a potentially life-saving procedure. We compared two low-cost models-an agar-based model and a novel model, Centesys-in terms of ultrasound image quality and realism, effectiveness of the model, and learners' confidence and satisfaction after training. METHODS: In this pilot randomised 2x2 crossover trial stratified by physician seniority, participants were assigned to undergo pericardiocentesis training either with the agar-based or Centesys model first, followed by the other model. Participants were asked to rate their confidence in performing ultrasound-guided pericardiocentesis, clarity and realism of cardiac structures on ultrasound imaging, and satisfaction on a 7-point Likert scale before and after training with each model. RESULTS: Twenty participants with median postgraduate year of 4 (interquartile range [IQR] 3.75-6) years were recruited. Pre-training, participants rated themselves a median score of 2.5 (IQR 2-4) for level of confidence in performing pericardiocentesis, which improved to 5 (IQR 4-6) post-training with Centesys (P=0.007). Centesys was recognised to be more realistic in simulating cardiac anatomy on ultrasound (median 5 [IQR 4-5] versus 3.5 [IQR 3-4], P=0.002) than the agar-based model. There was greater satisfaction with Centesys (median 5 [IQR 5-6] versus 4 [IQR 3.75-4], P<0.001). All 20 participants achieved successful insertion of a pericardial drain into the simulated pericardial sac with Centesys. CONCLUSION: Centesys achieved greater learner satisfaction as compared to the agar-based model, and was an effective tool for teaching ultrasound-guided pericardiocentesis and drain insertion.

Pre- and Apnoeic high flow oxygenation for RApid sequence intubation in The Emergency department (Pre-AeRATE): study protocol for a multicentre, randomised controlled trial.

BACKGROUND: Maintaining adequate oxygenation during rapid sequence intubation (RSI) is imperative to prevent peri-intubation adverse events that can lead to increased duration of hospital and intensive care unit stay, or a prolonged vegetative state requiring long-term institutionalisation. Despite employing current best practices during RSI, desaturation during intubation still occurs. High-flow nasal cannula (HFNC) oxygenation may potentially improve oxygenation during pre- and apnoeic oxygenation to allow a longer safe apnoeic time for RSI. OBJECTIVE: We aim to test the hypothesis that the use of humidified high-flow oxygenation via nasal cannula at 60 L/min maintains higher oxygen saturation compared with current usual care of non-rebreather mask and standard nasal cannula at an oxygen flow rate of 15 L/min for pre- and apnoeic oxygenation. METHODS: This is a multi-centre randomised controlled trial enrolling adult patients aged 21 years and older who require rapid sequence intubation due to medical, surgical, or traumatic conditions in the Emergency Departments (EDs) of the National University Hospital and the Ng Teng Fong General Hospital. Eligible patients will undergo randomisation at an equal ratio into intervention or control arms. The primary endpoint will be the lowest oxygen saturation achieved during the first intubation attempt from time of administration of paralytic agent until quantitative end-tidal carbon dioxide is detected if the first intubation attempt is successful, or until the start of the second attempt if it is not. DISCUSSION: Prolongation of safe apnoea time through maintenance of oxygen saturation above 90% using HFNC oxygenation during RSI could potentially change current clinical practice, improve standard of care, and translate to better outcomes for patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03396094 . Registered on 10 January 2018.

Arterial puncture using insulin needle is less painful than with standard needle: a randomized crossover study.

OBJECTIVES: Arterial punctures are important procedures performed by emergency physicians in the assessment of ill patients. However, arterial punctures are painful and can create anxiety and needle phobia in patients. The pain score of radial arterial punctures were compared between the insulin needle and the standard 23-gauge hypodermic needle. METHODS: In a randomized controlled crossover design, healthy volunteers were recruited to undergo bilateral radial arterial punctures. They were assigned to receive either the insulin or the standard needle as the first puncture, using blocked randomization. The primary outcome was the pain score measured on a 100-mm visual analogue scale (VAS) for pain, and secondary outcomes were rate of hemolysis, mean potassium values, and procedural complications immediately and 24 hours postprocedure. RESULTS: Fifty healthy volunteers were included in the study. The mean (±standard deviation) VAS score in punctures with the insulin needle was lower than the standard needle (23 ± 22 mm vs. 39 ± 24 mm; mean difference = -15 mm; 95% confidence interval = -22 mm to -7 mm; p < 0.001). The rates of hemolysis and mean potassium value were greater in samples obtained using the insulin needle compared to the standard needle (31.3% vs. 11.6%, p = 0.035; and 4.6 ±0.7 mmol/L vs. 4.2 ±0.5 mmol/L, p = 0.002). Procedural complications were lower in punctures with the insulin needle both immediately postprocedure (0% vs. 24%; p < 0.001) and at 24 hours postprocedure (5.4% vs. 34.2%; p = 0.007). CONCLUSIONS: Arterial punctures using insulin needles cause less pain and fewer procedural complications compared to standard needles. However, due to the higher rate of hemolysis, its use should be limited to conditions that do not require a concurrent potassium value in the same blood sample.