Dividing the Emergency Department into Red, Yellow, and Green Zones to Control COVID-19 Infection; a Letter to Editor.

 COVID-19, in certain respects, can be viewed as a CBRN (chemical, biological, radiological, or nuclear) event due to being a consequence of SARS-CoV2 virus (the "contaminant"). We, thus, reorganized our emergency department (ED) into 3 distinct zones (red, yellow, and green) for the purpose of infection control. Patients with high or medium risk of COVID-19 infection are managed in the red zones. Low-risk patients are managed in the yellow zones. All patients are prohibited to enter the green zones. Green zones are used by healthcare providers (HCPs) for personal protective equipment (PPE) donning, inventory, planning, and dining. Only HCPs who work in the red zones are required to use full level PPE (aerosol precaution). HCPs working in the yellow zones require less PPE (contact and droplet precaution). No PPE is required in the green zones. Establishing red, yellow, and green zones in the ED can be helpful in reducing cross-infections and minimizing demand for PPE.

The suction-assisted laryngoscopy assisted decontamination technique toward successful intubation during massive vomiting simulation: A pilot before-after study.

This study demonstrated a training program of the suction-assisted laryngoscopy assisted decontamination (S.A.L.A.D.) technique for emergency medical technician paramedic (EMT-P). The effectiveness of the training program on the improvements of skills and confidence in managing soiled airway was evaluated.In this pilot before-after study, 41 EMT-P participated in a training program which consisted of 1 training course and 3 evaluation scenarios. The training course included lectures, demonstration, and practice and focused on how to perform endotracheal intubation in soiled airway with the S.A.L.A.D technique. The first scenario was performed on standard airway mannequin head with clean airway (control scenario). The second scenario (pre-training scenario) and the third scenario (post-training scenario) were performed in airway with simulated massive vomiting. The post-training scenario was applied immediately after the training course. All trainees were requested to perform endotracheal intubation for 3 times in each scenario. The "pass" of a scenario was defined as more than twice successful intubation in a scenario. The intubation time, count of successful intubation, pass rate, and the confidence in endotracheal intubation were evaluated.The intubation time in the post-training scenario was significantly shorter than that in the pre-training scenario (P = .031). The pass rate of the control, pre-training, and post-training scenario was 100%, 82.9%, and 92.7%, respectively. The proportion of trainees reporting confident or very confident in endotracheal intubation in soiled airway increased from 22.0% to 97.6% after the training program. Kaplan-Meier analysis revealed that the adjusted hazard ratio of successful intubation for post-training versus pre-training scenario was 2.13 (95% confidence interval of 1.57-2.91).The S.A.L.A.D. technique training could efficiently help EMT-P performing endotracheal intubation during massive vomiting simulation.

Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin.

Acute pulmonary edema due to sympathetic surge and increased peripheral vascular resistance often present to the emergency department (ED) with markedly elevated blood pressure, severe dyspnea, and desaturation. This condition is known as "SCAPE" (sympathetic crashing acute pulmonary edema). We present three SCAPE patients who were successfully treated with high-dose nitroglycerin (NTG) and bilevel positive airway pressure (BiPAP) ventilation. All three patients presented with respiratory failure on arrival but rapidly improved after treatment and did not require endotracheal intubation or admission to the intensive care unit (ICU). SCAPE patients usually present to the ED with extreme respiratory distress associated with diaphoresis, restlessness, and high blood pressure. Emergency physicians must know how to manage SCAPE with high-dose nitrates and NIPPV (noninvasive positive pressure ventilation) because, when treated promptly, one will not only save a life but also obviate the need for endotracheal intubation and ICU admission.

Ultrasound diagnosis of cardiac rupture caused by mechanical chest compression.

A 74-year-old male with chronic kidney disease presented to the emergency department with asystole. Mechanical chest compression was started immediately using a piston-type thumper device. The initial potassium level was 7.7 mEq/L and bedside point-of-care ultrasound (POCUS) revealed no pericardial fluid. With standard resuscitation and anti-hyperkalemia treatment, return of spontaneous circulation (ROSC) was achieved within 10 minutes of compressions. At 15 minutes post-ROSC, the patient went into pulseless electrical activity. A repeated POCUS discovered massive pericardial fluid suggesting the presence of cardiac tamponade. Bedside pericardiotomy was performed followed by open thoracotomy. Laceration of the right ventricular wall adjacent to the fracture site of sternum was found, implicating that it was the complication of mechanical chest compression. After surgical repair and intensive post-operative care, the patient survived with full conscious recovery at day 6 of admission. Our case emphasizes the importance of POCUS in resuscitation, especially when the patient's condition deteriorates unexpectedly.

An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department.

BACKGROUND: The skin, soft tissue, and most parts of the musculoskeletal system are relatively superficial anatomical structures and ideal targets for ultrasound examination in the emergency departments. Soft tissue and musculoskeletal ultrasound applications are relatively underused compared to traditional emergency applications, such as trauma, abdominal aortic aneurysm, and chest and cardiovascular systems. MAIN TEXT: It is important to have knowledge about sonoanatomy and landmarks within the skin, soft tissue, and musculoskeletal systems. Portable machines equipped with high-resolution transducers are now available to fulfill this field of applications in many emergency departments. After needling practice, emergency physicians can not only diagnose and identify pathological findings but also provide interventional procedures and treatments. In this review, we will introduce point-of-care ultrasound (POCUS) applications regarding the soft tissue and musculoskeletal systems: soft tissue infections, joint effusions, foreign bodies, long bone fractures, muscle and tendon injuries, vascular occlusions, and procedures. CONCLUSIONS: With POCUS, emergency physicians can visualize the structures beneath the skin and provide better and safer cares in the emergency departments.

Ultrasound phantoms made of gelatin covered with hydrocolloid skin dressing.

BACKGROUND: Ultrasound-guided invasive procedures, such as central venous catheter insertion, soft-tissue abscess drainage, and foreign-body removal are essential competencies for Emergency Physicians. Such competencies can be trained using ultrasound phantoms. OBJECTIVE: Our aim is to describe ultrasound phantoms that are easily made, inexpensive, reusable, and can withstand multiple punctures. METHODS: Previously recommended gelatin-only ultrasound phantoms have inadequate surface tension resulting in surface disruption, and cannot tolerate multiple punctures when simulating cyst drainage. RESULTS: By covering the gelatin phantom with a hydrocolloid skin dressing, we are able to minimize physical surface disruption (by transducer or needles) and might reduce biological breakdown due to bacterial propagation. CONCLUSIONS: The elements required to construct homemade reusable ultrasound phantoms are inexpensive and can be easily obtained.

Traumatic mediastinal hematoma: a potentially fatal condition that may be overlooked by traditional Focused Assessment with Sonography for Trauma.

Mediastinal hematoma is an uncommon finding in blunt chest trauma. It may be caused by aortic injury, by mediastinal vascular injury such as aortic injury, and by fractures of the sternum and vertebral column. A huge mediastinal hematoma can result in extrapericardial cardiac tamponade by compressing the adjacent organs. Although Focused Assessment with Sonography for Trauma (FAST) can reliably assess the presence of pericardial effusion in the subxiphoid view, it may overlook mediastinal hematoma. We present a 67-year-old male victim of blunt chest trauma complicated with expanding anterior mediastinal hematoma that was undetectable with standard FAST protocol. The large mediastinal hematoma can only be seen in the parasternal long-axis view. When ultrasound is used to assess for anteriorly located mediastinal hematoma, the transducer should be positioned in the parasternal or precordial area to scan into the pericardium and mediastinum. However, these 2 views (parasternal and precordial) are not included in emergency department's traditional FAST examination. The subxiphoid view of FAST can easily miss a mediastinal hematoma. For trauma patients with probable mediastinal injuries, we suggest doing an extended FAST with parasternal long-axis view. Alternatively, one should consider lowering the threshold of thoracic computed tomographic scan in patients with persistent symptoms because a missed mediastinal hematoma could be insidious and fatal.

Comparing the performance of traditional direct laryngoscope with three indirect laryngoscopes: A prospective manikin study in normal and difficult airway scenarios.

OBJECTIVES: The aim of the present study was to evaluate the performance of three indirect laryngoscopes, Truview EVO2 laryngoscope, Clarus Levitan fiberoptic stylet and AirwayScope AWS, in comparison with direct Macintosh laryngoscope (ML) when performed in normal and difficult airway scenarios. METHODS: This prospective comparative study recruited 30 emergency physicians familiar with direct laryngoscopic intubation. Intubations were performed on manikin and were repeated twice for both scenarios. The primary end points were intubation time and rate of failed intubation. Glottis visualization was graded on Cormack and Lehane score and VAS. RESULTS: In normal airway scenario: AWS had shortest intubation time (6.0 s) followed by ML (8.7 s); VAS score of ML and AWS was lower (easier to use) than the other two devices; Cormack and Lehane score was similar for all devices. In difficult airway scenario: AWS had shortest intubation time (5.9 s); VAS score of AWS was lower than the other three devices; TVL, FOS, AWS had better Cormack and Lehane score than ML. Intubation time, rate of failed intubation, and Cormack and Lehane score were similar between attempts in both scenarios. Learning effect was significant in FOS in both scenarios and in TVL in normal airway scenario. CONCLUSIONS: AWS performed best in normal and difficult airways. ML performed better than TVL and FOS in normal airways. Performances of ML, TVL and FOS were similar in difficult airways. Skills with AWS could be mastered rapidly. TVL and FOS required more practice to gain expertise.

The role of emergency ultrasound for evaluating acute pyelonephritis in the ED.

BACKGROUND: Controversy remains over the imaging method of choice for evaluating acute pyelonephritis (APN) in the emergency department (ED). OBJECTIVE: The aim of the study was to determine the efficacy of ultrasound in the diagnosis and management of patients presented to the ED with APN. METHODS: This was a retrospective study of prospectively collected data. A cohort of ED patients diagnosed as APN were prospectively registered, and their medical records were then retrospectively reviewed for the presence of complications (admitted >14 days, admission to intensive care unit, or received invasive procedures), significant abnormalities (hydronephrosis, polycystic kidney diseases, renal abscess, emphysematous pyelonephritis), and mild abnormalities (cysts, stones, swelling). RESULTS: The study included 243 patients. Most of the patients received one or more renal imaging studies (n = 206) and 39.5% of which were considered abnormal. The rates of significant abnormalities on different imaging methods were Kidney-ureter-bladder (KUB), 16.3%; emergency ultrasound (EUS), 39.6%; combination of KUB and EUS, 56.6%; and computed tomography, 58.8%. Factors contributed to complicated APN were elderly, male, a history of preexisting renal diseases, current use of catheters, previous renal calculi, and diabetes mellitus. Significant abnormalities can be identified by EUS in 61% of patients with complicated APN. In fact, the presence of significant sonographic abnormalities effectively diverted 34.3% of patients to receive surgical interventions (percutaneous nephrostomy, abscess aspiration, ureteroscopic stone manipulation, lithotripsy, or nephrectomy). CONCLUSION: Structural abnormalities are not uncommon in ED patients with APN. Early assessment of these patients with EUS is likely to have a great impact on their diagnosis and management.

Ovarian cystic teratoma torsion in pregnancy.

Acute abdominal pain during pregnancy is encountered frequently and the differential diagnosis is extensive. Acute ovarian torsion in a pregnant patient is rare and is difficult to diagnose. Infarction caused by ovarian torsion will result if the twist is not unwound spontaneously or surgically in a timely fashion. The case is described of a 28-year-old primigravida who originally presented to the emergency department with right lower abdominal pain. The patient was ultimately found to have an extremely large cystic teratoma of the right ovary with concomitant torsion. Bedside ultrasonography is a highly accessible tool that can be used in a pregnant woman for screening a mass or ascites. Laparoscopic surgery has now been accepted as a safe modality for definitive diagnosis and therapeutic intervention. Because acute ovarian torsion is not encountered frequently, timely diagnosis is required to prevent mortality and minimise morbidity. It is important to keep ovarian torsion in the differential diagnosis of any pregnant woman with acute abdominal pain. Emergency physicians should be aware of the possibility of acute ovarian torsion in pregnant women and should have a high index of suspicion. Early surgical intervention should be undertaken.

Are new resuscitation guidelines better? Experience of an Asian metropolitan hospital.

INTRODUCTION: Cardiopulmonary resuscitation (CPR) guidelines were revised in 2005 based on new evidence and expert consensus. However, the benefits of the new guidelines remain undetermined and their influence has not been published in Asia. This study aimed to evaluate the impact of implementing the new resuscitation guidelines and identify factors that influence the discharge survival of out-of-hospital cardiac arrest (OHCA) patients in an Asian metropolitan city. MATERIALS AND METHODS: This was an observational cohort study of all OHCA patients seen by the emergency medical service during the period before (Nov 2003 to Oct 2005) and after (May 2006 to Oct 2008) implementing the new resuscitation guidelines. Detailed clinical information was recorded using the Ustein style template. Statistical analysis was done using X2 test or t-test for univariate analysis and the logistic regression model for multivariate analysis. RESULTS: There were 463 patients before and 430 patients after the new guidelines who received resuscitation. The rate of recovery of spontaneous circulation (ROSC), survival-to-intensive care unit (ICU) admission, and survival-to-hospital discharge all showed no benefits regarding the new resuscitation guidelines (ROSC: 42% vs 39%, P = 0.32; Survival-to-ICU admission: 33% vs 30%, P = 0.27; survival-to-hospital discharge: 10% vs 7%, P = 0.09). The rate of ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT), rate of witnessed arrest, and rate of bystander CPR were much lower than in Western studies. After multivariate logistic regression, factors related to discharge survival were witnessed arrest and initial rhythm with VF/pulseless VT. The new resuscitation guidelines did not significantly influence the discharge survival. CONCLUSIONS: We did not observe any improvement in survival after implementing the new guidelines. Independent factors of survival-to-hospital discharge are witnessed arrest and initial rhythm with VF/pulseless VT. Because the rates of VF/pulseless VT and bystander CPR in Asia are low, popularising CPR training programmes and increasing the rate of bystander CPR may be more important for improving OHCA survival rates than frequent guideline changes.

Subcapsular renal hematoma complicating acute pyelonephritis.

Subcapsular renal hematoma (SRH) is an extremely rare complication of acute pyelonephritis (APN). We report a case of SRH complicating APN with a ureteral stone, together with a review of the literature.

Ovarian cyst torsion in a toddler.

Acute abdominal pain in children is encountered frequently, and the differential diagnosis is extensive. Acute ovarian torsion in children is rare, especially at a very young age, and a difficult diagnosis to make. Infarction caused by ovarian torsion will result if the twist is not unwound spontaneously or surgically in a timely fashion. We presented a case of acute ovarian cyst torsion in a 2-year-old girl who originally presented to the emergency department with abdominal pain and vomiting. Ultimately, she was found to have a 2-cm cyst of the right ovary with concomitant torsion. Because acute ovarian torsion in a very young child is not encountered frequently, timely diagnosis is required to prevent mortality and minimize morbidity. It is important to keep ovarian torsion in the differential of any female children with acute abdominal pain. Emergency physicians should be aware that the potential of acute ovarian torsion in a very young child has a high index of suspicion and seek early operative intervention.

Prognostic value of QT parameters in patients with acute hemorrhagic stroke: a prospective evaluation with respect to mortality and post-hospitalization bed confinement.

BACKGROUND: This prospective study was performed to evaluate the prognostic prediction value of QT parameters and clinical characteristics exhibited by patients with acute hemorrhagic stroke at the time of presenting to the emergency department (ED). METHODS: One hundred and sixty-six patients admitted to the ED of Taipei Veterans General Hospital from January 2006 to October 2006 because of acute hemorrhagic stroke were enrolled. Glasgow Coma Scale (GCS) scores between 3 and 8 were taken to indicate severe neurologic deficits. QT parameters (QT max, QT min, QT dispersion, QTc max, QTc min, QTc dispersion) and other pertinent clinical variables were determined on admission. Logistic regression model was applied to evaluate prognostic prediction values. RESULTS: Mortality was higher among stroke patients with low GCS scores (p < 0.01). Leukocyte counts and systolic blood pressures were significantly higher among non-surviving patients (p = 0.04). No association was found between QT parameters and mortality (all p > 0.05). Among survivors, post-hospitalization bed confinement was required for those significantly older (p = 0.01) and those with higher QT max and QTc max values in multivariate analyses (p = 0.04 and p < 0.01, respectively). CONCLUSION: Low GCS scores, increased leukocyte counts, and elevated systolic blood pressures predict increased mortality for subjects with acute hemorrhagic stroke. Advanced age and prolongations in QTc and QT max at the time of stroke predicted poor functional recovery for these subjects.

Acute urinary retention secondary to perforated diverticulitis misdiagnosed as acute prostatitis.

Abdominal abscess resulting from a perforated diverticulitis has never been reported as a cause of acute urinary retention. Our patient is the first case to be reported. Because of the atypical presentation, he was initially misdiagnosed and treated as having acute prostatitis. Emergency physicians should have a high index of suspicion. Detailed history, abdominal sonography, and digital examination are helpful in diagnosing this disease.