Serious outcomes among emergency department patients with presyncope: A systematic review.

BACKGROUND: Syncope is transient loss of consciousness, and in presyncope, patients experience same prodromal symptoms without losing consciousness. While studies have extensively reported the risk of serious outcome among emergency department (ED) syncope, the outcome for patients with presyncope and their management are not well studied. We undertook a systematic review to assess the occurrence/identification of short-term (30-day) serious outcomes among ED patients with presyncope. METHODS: ED studies that enrolled patients with presyncope and reported any short-term serious outcome were included. Studies that enrolled patients without presyncope (e.g., hypoglycemia, seizure, and stroke) were excluded. We restricted our study to only English publications and searched the MEDLINE, Embase, Scopus, and Web of Science from the inception date to July 2023. We used SIGN 50 tool for assessment of risk of bias. RESULTS: In total, 1788 articles were screened by two reviewers and 32 articles were selected for full-text assessment. Five (four prospective and one retrospective) studies with 2741 presyncope patients were included. Four studies were from North America and the fifth one was from Europe. Included studies had weaknesses due to risk of bias, but all had acceptable quality. The prevalence of overall adverse outcome varied 4.4%-26.8% for all adults and 5.5%-18.7% among older patients; arrhythmia was the most prevalent (17.4% in one study), followed by anemia/hemorrhage as reported in different studies. Among older patients, myocardial infarction was the third most common serious outcome reported in one study. CONCLUSIONS: The prevalence of short-term serious outcomes varies from 4% to 27% among ED patients with presyncope in our review, with arrhythmia being the most common serious outcome. Our review indicates that presyncope may carry a similar risk to syncope, and hence, the same level of caution should be exercised for ED presyncope management as syncope.

External validation of the bedside score for the diagnosis of acute cholecystitis.

Objective: Acute cholecystitis usually presents with right upper quadrant (RUQ) abdominal pain. However, there are other conditions with similar findings which make the diagnosis difficult. The objective of this study is to prospectively validate the performance of the bedside score for the diagnosis of cholecystitis in patients presenting to the emergency department (ED) with possible acute cholecystitis. Study design: We performed a prospective observational study of a convenience sample of patients with RUQ pain admitted to the ED of three academic hospitals. Symptoms (post prandial symptoms), physical signs (RUQ tenderness, murphy's sign) and ultrasound findings (Murphy's sign, gallstone, and gallbladder thickening) were scoring system items. The final diagnosis of cholecystitis was confirmed with a surgical pathology and/or discharge diagnosis of the patient in a 30-day follow-up. The treating physicians' clinical gestalt of acute cholecystitis was also assessed by 5-point Likert scale. Results: One hundred thirty patients were followed up and were included in the analysis. 42 patients (32 %) had cholecystitis. The bedside clinical score of less than 4 had a sensitivity of 100 % (CI95 %: 91.60 %-100 %), negative predictive value (NPV) of 100 % (CI 95 %: 41.35 %-63 %), and negative likelihood ratio (-LR) of 0. Score of 6 and above had a specificity of 90.91 % (CI 95 %: 82.87 %-95.99 %), positive predictive value (PPV) of 83.67 % (CI 95 %: 72.55 %-90.86 %), and positive likelihood ratio (+LR) of 10.74 (CI95 %: 5.54-20.83). Physicians' clinical gestalt at the scale of 4 and 5 showed a specificity of 95.45 % (CI 95 %: 88.77 %-98.75 %), PPV of 90.91 % (CI 95 %: 79.29 %-96.31 %), and +LR of 20.95 (CI95 %: 8.02-54.71). At the same time at the scale of 1 and 2, the sensitivity was 95.24 % (CI 95 %: 83.84 %-99.42 %), NPV was 97.22 % (CI 95 %: 90.01 %-99.27 %), and the -LR was 0.06 (CI 95 %: 0.02-0.423). The area under the curve of bedside clinical score was not significantly higher than clinical gestalt (97.58 (CI 95 %: 95.31-99.85) vs. 95.37 (CI 95: 99.24-100))(p-value = 0.35). Conclusion: This study showed while the bedside score would be helpful to rule out and rule in acute cholecystitis, physicians' gestalt had similar diagnostic performance.

The performance of HEAR score for identification of low-risk chest pain: a systematic review and meta-analysis.

Chest pain is one of the most common presentations to the emergency department (ED) and HEART score (history, ECG, age, risk factors, and cardiac troponin) is recommended for risk stratification. It has been proposed that the sum of four items with no troponin (HEAR score) below 2 can be used safely to lower testing and reduce length of stay. To assess the performance of the HEAR score in hospital and prehospital settings, we performed a systematic review and meta-analysis. English studies on the performance of the HEAR score in patients with acute chest pain were included. They were excluded if data are inaccessible. MEDLINE, Embase, Evidence-Based Medicine Reviews, Scopus, and web of science were searched from 1946 to July 2021. The quality of studies was assessed using Quality Assessment of Diagnostic Accuracy Studies version 2. Acute coronary syndrome or major adverse cardiac events prediction were outcomes of interest. The performance indices with 95% confidence intervals (CIs) were extracted. Inverse variance and the random-effects model were used to report the results. Of the 692 articles on the HEAR score, 10 studies were included in the analysis with 33 843 patients. Studies were at low to moderate risk of bias. Three studies were in prehospital and three were retrospective. The pooling of data on the HEAR score showed that the sensitivity at the HEAR<2, <3, and <4 cutoffs in the ED were 99.03% (95% CI, 98.29-99.77), 97.54% (95% CI, 94.50-100), and 91.80% (95% CI, 84.62-98.98), respectively. The negative predictive values (NPVs) for the above cutoffs were 99.84% (95% CI, 99.72-99.95), 99.75% (95% CI, 99.65-99.85), and 99.57% (95% CI, 99.11-100), respectively. Of note, for the HEAR<2, negative likelihood ratio was 0.07 (95% CI, 0.02-0.12). In the prehospital, at the HEAR<4 cutoff, the pooled sensitivity and NPV were 85.01% (95% CI, 80.56-89.47) and 91.48% (95% CI, 87.10-95.87), respectively. This study showed that in the ED, the HEAR score<2 can be used for an early discharge strategy. Currently, this score cannot be recommended in prehospital setting. Prospero (CRD42021273710).

Ultrasonography indicators for predicting difficult intubation: a systematic review and meta-analysis.

BACKGROUND: Ultrasonography (US) is recently used frequently as a tool for airway assessment prior to intubation (endotracheal tube (ETT) placement), and several indicators have been proposed in studies with different reported performances in this regard. This systematic review and meta-analysis reviewed the performance of US in difficult airway assessment. METHODS: This systematic review and meta-analysis was conducted according to the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane book. All the studies that had carried out difficult airway assessments using US, had compared the indicators in difficult and easy groups, and had published the results in English by the time we conducted our search in April 28, 2020, were included. RESULTS: In the initial search, 17,156 articles were retrieved. After deleting the duplicate articles retrieved from multiple databases, 7578 articles remained for screening based on the abstracts and titles. Finally, the full text of 371 articles were assessed and the data from 26 articles were extracted, which had examined a total of 45 US indicators for predicting difficult intubation. The most common US index was the "thickness of anterior neck soft tissue at the vocal cords level". Also, "skin to epiglottis" and "anterior neck soft tissue at the hyoid bone level" were among the most common indicators examined in this area. CONCLUSION: This systematic review showed that US can be used for predicting difficult airway. Of note, "skin thickness at the epiglottis and hyoid levels", "the hyomental distance", and "the hyomental distance ratio" were correlated with difficult laryngoscopy in the meta-analysis. Many other indicators, including some ratios, have also been proposed for accurately predicting difficult intubation, although there have been no external validation studies on them.

Comparing Diazepam Plus Fentanyl With Midazolam Plus Fentanyl in the Moderate Procedural Sedation of Anterior Shoulder Dislocations: A Randomized Clinical Trial.

BACKGROUND: The reduction of shoulder dislocation requires adequate procedural sedation and analgesia. The mixture of midazolam and fentanyl is reported in the literature, but long-acting benzodiazepines in conjunction with fentanyl are lacking. STUDY OBJECTIVE: Our aim was to compar e IV diazepam with IV midazolam in moderate procedural sedation (based on the classification of the American Society of Anesthesiologists) for the reduction of shoulder dislocation. METHODS: This was a randomized controlled clinical trial conducted from April 2019 to December 2019 in the emergency department of a university-affiliated hospital in Tehran, Iran. Participants were adult patients (aged 18-65 years) with anterior shoulder dislocation. Group A (n = 42) received diazepam 0.1 mg/kg plus fentanyl 1 µg/kg IV and group B received midazolam 0.1 mg/kg plus fentanyl 1 µg g/kg IV. Main outcomes measured were onset of muscle relaxation, time taken to reduction, total procedure time, number of the reduction attempts, patient recovery time, the occurrence of the adverse effects, amount of the pain reported by the patients using visual analog scale, and patients and physicians overall satisfaction with the procedure using a Likert scale question. RESULTS: Eighty-one patients were included. The mean ± standard deviation time of the onset of the muscle relaxation and time taken to reduction was shorter in the diazepam plus fentanyl group (p = 0.016 and p = 0.001, respectively). Adverse effects and pain relief were not statistically different between the two groups. Patient recovery time and total procedure time was shorter in the midazolam plus fentanyl group (p = 0.008 and p = 0.02, respectively). The overall satisfaction of patients and physicians was higher in the diazepam plus fentanyl group. CONCLUSIONS: As compared with midazolam plus fentanyl, diazepam plus fentanyl was superior in terms of the onset of the muscle relaxation, patient and physician satisfaction, and time taken to reduction.

Comparison of intravenous ketorolac at three doses for treating renal colic in the emergency department: A noninferiority randomized controlled trial.

BACKGROUND: Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug (NSAID) that is extensively used for the management of renal colic in the emergency department (ED). It has been proposed that ketorolac is used at doses above its analgesic ceiling with no more advantages and increased risk of adverse effects. In this study, we compared the analgesic effects of three doses of intravenous ketorolac in patients with renal colic. METHODS: This noninferiority, randomized, double-blind clinical trial evaluated the analgesic efficacy of three doses of intravenous ketorolac (10, 20, and 30 mg) in adult patients presenting to the ED with renal colic. Exclusion criteria consisted of age > 65 years, active peptic ulcer disease, acute gastrointestinal hemorrhage, renal or hepatic insufficiency, NSAID hypersensitivity, pregnancy or breastfeeding, unstable vital signs, and patients who had received analgesics in the past 24 hours. Pain was recorded every 15 minutes from baseline up to 60 minutes, and the primary outcome was pain reduction at 30 minutes. If patients still required additional pain medications at 30 minutes, they would receive 0.1 mg/kg intravenous morphine sulfate as a rescue analgesic. RESULTS: A total of 165 subjects enrolled in this study, 55 in each group. The median visual analog scale score in 30 minutes was improved from 90 at baseline to 40 among subjects who were randomized to 30-mg group. This improvement was 40 and 50 mm in 20- and 10-mg ketorolac treatment arms, respectively, with no significant difference between the three doses (p < 0.05). Secondary outcomes showed similar rescue analgesic administration and adverse effects. There was no serious adverse event. CONCLUSION: Ketorolac at 10-, 20-, and 30-mg doses can produce similar analgesic efficacy in renal colic.

Clinical Characteristics and Outcomes of 905 COVID-19 Patients Admitted to Imam Khomeini Hospital Complex in the Capital City of Tehran, Iran.

BACKGROUND: We studied the clinical characteristics and outcomes of 905 hospitalized coronavirus disease 2019 (COVID-19) patients admitted to Imam Khomeini Hospital Complex (IKHC), Tehran, Iran. METHODS: COVID-19 patients were recruited based on clinical symptoms and patterns of computed tomography (CT) imaging between February 20 and March 19. All patients were tested for the presence of COVID-19 RNA. The Poisson regression model estimated the incidence rate ratio (IRR) for different parameters. RESULTS: The average age (± standard deviation) was 56.9 (±15.7) years and 61.77% were male. The most common symptoms were fever (93.59%), dry cough (79.78%), and dyspnea (75.69%). Only 43.76% of patients were positive for the RT-PCR COVID-19 test. Prevalence of lymphopenia was 42.9% and more than 90% had elevated lactate dehydrogenase (LDH) or C-reactive protein (CRP). About 11% were severe cases, and 13.7% died in the hospital. The median length of stay (LOS) was 3 days. We found higher risks of mortality in patients who were older than 70 years (IRR = 11.77, 95% CI 3.63-38.18), underwent mechanical ventilation (IRR = 7.36, 95% CI 5.06-10.7), were admitted to the intensive care unit (ICU) (IRR = 5.47, 95% CI 4.00-8.38), tested positive on the COVID-19 test (IRR = 2.80, 95% CI 1.64-3.55), and reported a history of comorbidity (IRR = 1.76, 95% CI 1.07-2.89) compared to their corresponding reference groups. Hydroxychloroquine therapy was not associated with mortality in our study. CONCLUSION: Older age, experiencing a severe form of the disease, and having a comorbidity were the most important prognostic factors for COVID-19 infection. Larger studies are needed to perform further subgroup analyses and verify high-risk groups.

Peripheral Cytotoxic T Cell Lymphoma of the Appendix Presenting as Acute Appendicitis.

INTRODUCTION: Lymphoma of the appendix is a rare cause of acute appendicitis; however, acute appendicitis is a common first manifestation of appendiceal lymphomas. Cytotoxic peripheral T cell lymphoma (PTCL) is a type of aggressive non-Hodgkin lymphoma that portends a generally poor outcome. Cytotoxic PTCL of the appendix is extremely rare with few cases reported in the literature. Case Presentation. This is the report of a 23-year-old man who had experienced lower abdominal pain for three months before presenting to the emergency department with severe right lower abdominal pain, nausea, vomiting, and anorexia since the day prior to admission. The patient was diagnosed with acute appendicitis, and the pathology report confirmed cytotoxic PTCL of the appendix. CONCLUSION: Patients with appendiceal PTCL commonly present with signs and symptoms of acute appendicitis due to luminal obstruction by the tumor. Therefore, appendiceal tumors such as PTCL should be considered in the differential diagnosis of patients presenting as acute appendicitis. In addition, since there is no standard chemotherapy regimen for cytotoxic PTCL, this and other case reports hopefully help in providing the clinical evidence needed for establishing appropriate treatment guidelines.

Accuracy of Ultrasonography in Diagnosis of Shoulder Dislocation: A Systematic Review.

CONTEXT: This systematic review of clinical trials was conducted to compare the diagnostic accuracy of ultrasound in comparison to plain radiography in shoulder dislocation. EVIDENCE ACQUISITION: MEDLINE, Cochrane Database of Systematic Reviews, clinicaltrials.gov, Google scholar, and Scopus were searched for clinical trials. Diagnosis of shoulder dislocation and confirmation of shoulder reduction were the outcomes of interest. Sensitivity, specificity, positive predictive value and negative predictive value of included clinical trials were calculated. RESULTS: Seven studies met our inclusion criteria and were analyzed. All included studies except two had a sensitivity and specificity of 100% for ultrasound (one with a sensitivity of 54% and one with a specificity of 60%). CONCLUSION: It can be suggested that ultrasound can be used as a reliable alternative diagnostic method for detection of both dislocation and reduction in shoulder joint. This may decrease the delay in treatment, cost, radiation exposure, and need for repeated sedation.

Acute Gastric Dilation Following Trauma: A Case Report.

INTRODUCTION: Acute gastric dilation following trauma is an unusual event that can occur in different settings, and can cause gastric necrosis as a rare though fatal condition. The present report involves a case of acute gastric dilation following multiple traumas, which caused gastric necrosis and total gastrectomy. CASE PRESENTATION: A 19-year-old morbid obese male presented to the emergency department (ED) following a motor vehicle accident.He had a left lower extremity crash injury. In his serial examinations, he was complaining of upper abdominal pain with epigastric tenderness. After nasogastric tube (NGT) reinsertion, due to detecting coffee ground secretions in the drained fluid, the patient was transferred to the operating room.A midline laparotomy was performed that revealed dilation and discoloration of the stomach. Gastric decompression was performed. All the discoloration then disappeared except for that of certain suspicious areas, which necessitated evaluations. On the following day, given the lack of improvement in the patient`s condition, he was transferred to the operating room for a second laparotomy. CONCLUSION: The present report emphasized on the importance of NGT insertion in multiple-trauma patients, which is, however, neglected in many cases. Moreover, acute gastric dilation is recommended to be considered in the differential diagnosis of patients with multiple or abdominal trauma and complaints of vomiting or abdominal pains.

Application of decision rules on diagnosis and prognosis of renal colic: a systematic review and meta-analysis.

Renal colic is a prevalent emergency department presentation resulting from urolithiasis. Clinical decision rules for the diagnosis of urolithiasis were developed to help clinicians with better judgment. In this systematic review, we assessed the performance of prediction rules on urolithiasis diagnosis and prognosis. MEDLINE, Embase, Web of Science, and Scopus were searched for studies on the performance of a clinical decision tool for diagnosis or prognosis of urolithiasis. Performance and accuracy of the rules were the key outcomes of interest. Databases were searched from inception to March 2019. Of the 4980 articles reviewed, 28 studies were included in the present analysis. Twenty-one studies were on urolithiasis diagnosis (including eight studies on STONE rule), and 10 studies reported urolithiasis outcomes. Studies were at low to moderate risk of bias. The pooling of data on STONE showed that the prevalence of urolithiasis in low, moderate, and high risk groups were: 12% (95% confidence interval 9%-15%), 53% (95% confidence interval 43%-62%), and 83% (95% confidence interval 75%-91%), respectively. In the high risk score group, prevalence of clinically important alternative diagnosis was 1% (95% confidence interval 0%-2%) and 11% (95% confidence interval 8%-13%) of patients needed intervention. STONE scoring system is useful in estimating the prevalence of urolithiasis but high heterogeneity among the studies makes it unsuitable for application. Other decision tools were poorly studied and cannot be recommended for clinical use.

How much change in pain score does really matter to patients?

OBJECTIVE: The goal of this study was to determine the minimal change in pain score recognized by patients as meaningful known as minimal clinically important difference (MCID). METHODS: Pain was recordedupon admission, 30 and 60 min later and patients were asked todescribe the extent of pain change on a 5-point Likert scale ranging from "much better" to "much worse". Patients reported their pain by two common pain scales comprising numeric rating scale (NRS) and visual analog scale (VAS). We used receiver operating characteristiccurve to assess the accuracy of pain scales. We then calculated the mean change in pain scores among patients who reported their pain change as "a little better" or "a little worse" and also analyzed regression to evaluate the MCID. RESULTS: A total of 150 patients and 253 pain changes were recruited. The MCID ±â€¯SD (95% CI) was 1.65 ±â€¯1.58 (1.32-1.97) for NRS and 16.55 ±â€¯17.53 (12.96-20.15) for VAS. The area under the curve by NRS and VAS were 0.86 and 0.89. For linear regression, the line slope and the y-intercept were 17.56 and 1.88, for VAS; these values were 1.73 and 0.31 for NRS, respectively. CONCLUSIONS: Recognizing the extent of change in pain score that really matters to patients is crucial for the evaluation of treatment effect. Patients perceived a change of 1.65 points on NRS and 16.55 on VAS in their pain severity as meaningful. This value was not different whether the pain was perceived alleviated or aggravated.

Developing a Checklist for Cardiopulmonary Resuscitation (CPR) Quality Control in Emergency Department; a Qualitative Study.

INTRODUCTION: Monitoring the quality of cardiopulmonary resuscitation (CPR) could help in achieving favorable outcomes, decreasing mortality, and preventing post-CPR neurologic sequels. This study aimed to generate a user-friendly checklist for CPR quality control in emergency department (ED). METHOD: A qualitative study was performed between January and December 2018. In the first step, two emergency medicine specialists searched currently available databases and extracted the factors related to CPR quality. Afterward, two sessions of focus group discussions were held. The participants included four emergency medicine specialists, two ED managers, one anesthesiologist, and one cardiologist. Subsequently, 20 medical specialists, consisting of 10 emergency medicine specialists, six anesthesiologists, and four cardiologists, were invited to a Delphi panel in order to rate the extracted items from the prior group discussions. RESULTS: During the two rounds of focus group discussions, 38 items related to the quality of CPR were identified. A Delphi panel evaluated the items; 31 items with at least 75% agreement were selected. These 31 items were included in the final checklist and after a pilot study and adjustment of its content they were sorted in 10 categories as follows: 1. chest compression, 2. airway, 3. bag-mask ventilation, 4. cardiac monitoring, 5. defibrillation, 6. intravenous (IV) drug delivery, 7. Medications, 8. Advanced airway, 9. CPR sequence, and 10. Reversible causes. CONCLUSION: Our study provides a checklist for monitoring the quality of CPR in ED, but it is still necessary to include other factors related to the ED environment on this checklist.

Desmopressin/indomethacin combination efficacy and safety in renal colic pain management: A randomized placebo controlled trial.

INTRODUCTION: Renal colic is a prevalent cause of abdominal pain in the emergency department. Although non-steroidal anti-inflammatory drugs and opioids are used for the treatment of renal colic, some adverse effects have been reported. Therefore, desmopressin -a synthetic analogue of vasopressin- has been proposed as another treatment choice. In the present study, indomethacin in combination with nasal desmopressin was compared with indomethacin alone in the management of renal colic. METHODS: Included in the study were 124 patients with initial diagnosis of renal colic and randomized to receive indomethacin suppository (100 mg) with either desmopressin intranasal spray (4 puffs, total dose of 40 micrograms) and or placebo intranasal spray. RESULTS: All the included patients were finally diagnosed with renal colic. There was no difference between the two groups in pain at the baseline (p = 0.4) and both treatments reduced pain successfully (p < 0.001). There was no significant difference between the two groups in pain reduction (p = 0.35). CONCLUSIONS: While there was significant pain reduction in both patients groups, pain reduction of NSAIDs (e.g. indomethacin) in renal colic, does not significantly improve when given in combination with desmopressin.