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.

Point-of-care ultrasound use in COVID-19: a narrative review.

Background and Objective: The coronavirus disease 2019 (COVID-19) pandemic that began in early 2020 resulted in significant mortality from respiratory tract infections. Existing imaging modalities such as chest X-ray (CXR) lacks sensitivity in its diagnosis while computed tomography (CT) scan carries risks of radiation and contamination. Point-of-care ultrasound (POCUS) has the advantage of bedside testing with higher diagnostic accuracy. We aim to describe the various applications of POCUS for patients with suspected severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in the emergency department (ED) and intensive care unit (ICU). Methods: We performed literature search on the use of POCUS in the diagnosis and management of COVID-19 in MEDLINE, Embase and Scopus databases using the following search terms: "ultrasonography", "ultrasound", "COVID-19", "SARS-CoV-2", "SARS-CoV-2 variants", "emergency services", "emergency department" and "intensive care units". Search was performed independently by two reviewers with any discrepancy adjudicated by a third member. Key Content and Findings: Lung POCUS in patients with COVID-19 shows different ultrasonographic features from pulmonary oedema, bacterial pneumonia, and other viral pneumonia, thus useful in differentiating between these conditions. It is more sensitive than CXR, and more accessible and widely available than CT scan. POCUS can be used to diagnose COVID-19 pneumonia, screen for COVID-19-related pulmonary and extrapulmonary complications, and guide management of ICU patients, such as timing of ventilator weaning based on lung POCUS findings. Conclusions: POCUS is a useful and rapid point-of-care modality that can be used to aid in diagnosis, management, and risk stratification of COVID-19 patients in different healthcare settings.

Characteristics of migrant workers admitted from the emergency department.

INTRODUCTION: Emergency department (ED) admissions for non-work-related injuries and illnesses in the migrant worker (MW) population in Singapore are not well studied. We aimed to examine ED triage acuity and bills associated with admissions among MW for non-trauma, workplace injury (WI) trauma, and non-workplace injury (NWI) trauma. METHODS: In this retrospective observational study, we included all work permit holders admitted to hospital via the ED of three public hospitals from 1 May 2016 to 31 October 2016. Data obtained from medical records included demographics, triage acuity and bill information. RESULTS: There were 1,750 unique patients accounting for 1,788 admissions. The median age was 33 (interquartile range 27-40) years, with a male predominance of 67%. Trauma accounted for 33% ( n = 595) of admissions, and of these, 73% ( n = 433) were due to WI. Admissions for NWI, as compared to WI, were more likely to present as high acuity P1 cases (43% vs 24%, P < 0.001), be conveyed by ambulance (49% vs 24%, P < 0.001) and result in trauma team activations (29% vs 7%, P < 0.001). More NWI admissions (22%, 36/162) exceeded the insurance claim limit under prevailing healthcare policies, as compared to WI admissions (3%, 13/433). CONCLUSION: Migrant workers are admitted to hospital for non-trauma conditions more frequently than for trauma. Non-workplace injury trauma may be severe. Non-trauma and NWI admissions can result in large bills that exceed mandatory insurance coverage. Recent changes to healthcare policy governing MW to allow copayment of large bills and better access to primary care are timely.

Examining Barriers and Motivations to Speak up on Medical Errors in a Simulated Clinical Emergency: A Mixed-Methods Study.

Phenomenon: Effective communication between team members is essential during the resuscitation of critically-ill patients. Failure of junior doctors to speak up and challenge erroneous clinical decisions made by their senior doctors is a serious communication failure which can result in catastrophic outcomes and jeopardize patient safety. Crisis resource management (CRM) and conflict resolution tools have been increasingly employed in the healthcare setting to reduce communication failure among healthcare providers and improve patient safety during crisis situations. The aims of our study were to: 1) evaluate the factors affecting junior doctors' ability to speak up on medical errors, 2) examine the effectiveness of CRM and conflict resolution tools, and 3) formulate a communication framework directed at training junior doctors in appropriate intellectual questioning of authority. Approach: From January to April 2019, we recruited twenty-five second-year postgraduate junior doctors working in an Emergency Department in Singapore. We provided training in CRM and conflict resolution communication for participants in the intervention arm. Participants underwent a high-fidelity simulated resuscitation scenario which was standardized to include faculty misdirection in the form of erroneous instructions given by a role-played senior doctor. We observed if participants appropriately challenged the erroneous instructions. We subsequently interviewed participants on their response during the simulation to elicit their barriers and motivations toward challenging authority. Video recordings were analyzed by an independent panel of investigators. Findings: Participants employed various non-verbal and verbal approaches when challenging erroneous decisions. We uncovered multiple personal, interpersonal, and situation-based factors influencing the junior doctor's willingness to challenge erroneous decisions made by seniors. From their responses, we conceptualized a theoretical model designed as a "weighing scale" to demonstrate how junior doctor's eventual response is the outcome of a delicate interplay of multiple barriers and motivations. Our intervention did not significantly increase the participants' likelihood of challenging authority (69% in control arm vs 75% in intervention arm, p = 1.00). Insights: Our study provides insights into the mindset of junior doctors when faced with the dilemma of challenging authority on medical errors. Established CRM training may not be effective in addressing the challenges junior doctors face when communicating against the hierarchal gradient. We propose strategies to further develop and optimize CRM training to enhance its value for junior doctors. Drawing from our findings, we formulated a "SAFE" communication tool (State the safety concern, suggest Alternative course of action, Support with Facts, Engage via Enquiry) directed at helping junior doctors in appropriate intellectual questioning of authority.

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.

Perspectives towards End-of-Life Care in the Emergency Department of Tertiary Public Hospitals-A Qualitative Analysis.

Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders' perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients' preferences, families' decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.

Comparing Comorbidity Polypharmacy Score and Charlson Comorbidity Index in predicting outcomes in older trauma patients.

BACKGROUND: The Charlson Comorbidity Index (CCI) and Comorbidity Polypharmacy Score (CPS) may potentially risk-stratify older trauma patients more accurately than traditional trauma severity scores. We aim to evaluate if CCI or CPS are better predictors of mortality and discharge venue in such patients. METHODS: We conducted a retrospective study using registry data from two tertiary trauma centres. Patients aged 65 years and above who presented to the emergency departments (EDs) between January 2011 and December 2015 with traumatic injuries were included. Charts were reviewed for demographics, injury mechanism and severity, discharge outcomes, and types of comorbidities and medications used. Primary outcome was overall mortality; secondary outcomes included ED disposition and hospital discharge venue. Discriminatory power of the score(s) were compared using area under the receiver operating characteristic (AUROC) curve. RESULTS: There were 2,750 patients, with overall female predominance (56.7%, 1,560/2,750) and median age of 78 years (interquartile range [IQR] 72 to 84 years). Median CCI score was 1 (IQR 0 to 2) and median CPS was 8 (IQR 4 to 12). Overall mortality was 9.4% (259/2,750). Every 1-point increase in CCI score resulted in increased odds of death by 16% (adjusted odds ratio 1.16, 95% confidence interval 1.07 to 1.26, p<0.001). Addition of CCI to the Injury Severity Score (ISS) increased the discriminatory power for mortality (AUROC for ISS = 0.832; AUROC for ISS with CCI = 0.843). Every 1-point increase in CCI was significantly associated with decreased odds of admission to a rehab facility by 8%. CPS did not predict mortality and discharge venue. CONCLUSION: CCI, but not CPS, was a predictor of mortality. A higher CCI was associated with decreased odds of discharge to a subacute facility, likely related to underlying rehabilitation potential. Further studies should be undertaken to explore an integrated scoring system that considers injury severity, comorbidities, and polypharmacy.

Epidemiology and outcomes of older trauma patients in Singapore: A multicentre study.

BACKGROUND: An ageing population has caused rising trauma cases amongst older patients. Multiple comorbidities, polypharmacy and limited reserves predispose them to poorer outcomes following a traumatic event. The Comorbidity Polypharmacy Score (CPS) has been found to predict outcomes and mortality in older trauma patients, but has not been studied in Asians. AIM: We aim to describe the epidemiological characteristics of older trauma patients and explore the association of CPS on clinical outcomes. METHODS: We conducted a retrospective observational study using data from the trauma registries of 2 tertiary trauma centres. Patients aged 45 years and above attending the emergency departments (EDs) from January 2011 to December 2015 with traumatic injuries (Injury Severity Score [ISS] of 9 and above) were included. Demographics, clinical data including number of comorbidities and medications used were collected to calculate the CPS. Outcomes of mortality, ED disposition and hospital discharge venue were examined. RESULTS: There were 4,522 patients (median age 70 years; males 53.8%), with majority sustaining Tier 2 injuries (ISS 9 to 15; 68.9%). Falls were the predominant mechanism for those aged above 60 years and above (76%). Median CPS was 6 (interquartile range [IQR] 1 to 11). Amongst patients 75 years and older, 56% comprised the moderate to morbid CPS groups (CPS ≥ 8). Overall mortality was 8.4%; patients above 75 years had longer median length of stay (10 versus 7.1-8.9 days in other ages). Male gender (adjusted odds ratio [aOR] 1.51; 95% confidence interval [CI] 1.12-2.02), increasing age (aOR 1.04; 95% CI 1.03-1.05), injury to abdomen (aOR 3.24; 95% CI 1.93-5.45) and severe CPS category (aOR 1.88; 95% CI 1.23-2.89) were associated with increased odds of death. Increasing age and moderate CPS category increased odds of discharge to a rehabilitation (aOR for age 1.03, 95% CI 1.02-1.04; aOR for moderate CPS 1.72, 95% CI 1.43-2.07) or long-term care facility (aOR for age 1.05, 95% CI 1.03-1.06; aOR for CPS 1.60, 95% CI 1.10-2.32). CONCLUSION: CPS predicted mortality and discharge to a rehabilitation or care facility in this urban, ageing Asian population. Its use may aid future trauma research and needs assessments in such 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.

Improving triage accuracy through a modified nurse-administered emergency department assessment of chest pain score on patients with chest pain at triage (EDACT): A prospective observational study.

BACKGROUND: Chest pain triage in our emergency department (ED) prioritize patients for consultation based on unstructured nursing gestalt. The Emergency Department Assessment of Chest Pain Score (EDACS) identifies patients at low-risk for major adverse cardiac events and may provide standardization for chest pain triage in ED. METHODS: We conducted a prospective observational study, including adult patients with chief complaint of chest pain who were self-conveyed. We aimed to evaluate the overall diagnostic performance of a modified EDACS in triaging these patients. RESULTS: Data was collected over 6 weeks, with 284 patients included in the final analysis. Nursing gestalt had higher sensitivity (97.6%, 95% confidence interval [CI] 87.4% to 99.9% versus EDACS 45.2%, 95% CI 29.8% to 61.3%), while modified EDACS provided higher specificity (76.4%, 95% CI 70.6% to 81.6%, versus nursing gestalt 29.8%, 95% CI 24.1% to 35.9%). EDACS with electrocardiogram had significantly better area under the receiver operating characteristic curve statistic (0.712; 95% CI 0.631 to 0.793) than EDACS alone (0.608; 95% CI 0.528 to 0.689) and nursing gestalt (0.637; 95% CI 0.600 to 0.674) (p = 0.0324). CONCLUSIONS: Further studies should explore if modified EDACS, together with nursing gestalt, can improve triage accuracy for ED patients with chest pain.

Biomarker Rule-in or Rule-out in Patients With Acute Diseases for Validation of Acute Kidney Injury in the Emergency Department (BRAVA): A Multicenter Study Evaluating Urinary TIMP-2/IGFBP7.

Background: Urine tissue inhibitor of metalloproteinases-2/insulin-like growth factor-binding protein 7 (TIMP-2/IGFBP7) (NephroCheck, Ortho Clinical Diagnostics, Raritan, NJ, USA) is a US Food and Drug Administration-approved biomarker for risk assessment of acute kidney injury (AKI) in critically ill adult patients in intensive care units; however, its clinical impact in the emergency department (ED) remains unproven. We evaluated the utility of NephroCheck for predicting AKI development and short-term mortality in the ED. Methods: This was a prospective, observational, five-center international study. We consecutively enrolled ED patients admitted with ≥30% risk of AKI development (assessed by ED physician: ED score) or acute diseases. Serum creatinine was tested on ED arrival (T0), day 1, and day 2 (T48); urine for NephroCheck was collected at T0 and T48. We performed ROC curve and reclassification analyses. Results: Among the 529 patients enrolled (213 females; median age, 65 years), AKI developed in 59 (11.2%) patients. The T0 NephroCheck value was higher in the AKI group than in the non-AKI group (median 0.77 vs. 0.29 (ng/m)2/1,000, P=0.001), and better predicted AKI development than the ED score (area under the curve [AUC], 0.64 vs. 0.53; P=0.04). In reclassification analyses, adding NephroCheck to the ED score improved the prediction of AKI development (P<0.05). The T0 NephroCheck value predicted 30-day mortality (AUC, 0.68; P<0.001). Conclusions: NephroCheck can predict both AKI development and short-term mortality in at-risk ED patients. NephroCheck would be a useful biomarker for early ruling-in or ruling-out of AKI in the ED.

Validation of "Care of the Dying Evaluation" in Emergency Medicine (CODE-EM): pilot phase of end-of-life management protocol offered within emergency room (EMPOWER) study.

BACKGROUND: An increasing number of patients who present to emergency departments are at their end-of-life phase and have significant palliative care needs such as in symptom control for pain and dyspnoea. Evaluating quality of care provided is imperative, yet there is no suitable tool validated in the emergency and Asian settings. We aim to examine the face and construct validity, and reliability of a newly developed questionnaire, Care of the Dying Evaluation - Emergency Medicine, for measuring the quality of end-of-life care in an Asian emergency context. METHODS: A mixed methods pilot study was conducted. Participants composed of the next-of-kin to thirty dying patients who presented to the emergency departments of three public hospitals in Singapore. Qualitative evaluation, using cognitive "think-aloud" interviews, and quantitative analysis were employed. Percentage agreement and κ statistic were measured to evaluate temporal stability of the questionnaire. Cronbach's α and item-total correlations were used to assess internal consistency within the constructs. Confirmatory factor analysis was performed for construct validity. RESULTS: All participants reported clear understanding of the questionnaire with no ambiguity; a minority felt the questions caused emotional distress (7/30, 23.3%). The questions showed moderate to good test-retest reliability. Internal consistencies within the constructs were good for "ENVIRONMENT" and "CARE", and moderate for "COMMUNICATION". Factor loadings range from 0.40 to 0.99. CONCLUSIONS: The Care of the Dying Evaluation - Emergency Medicine questionnaire may be valid and reliable for use in an Asian emergency setting. Our prospective multicentre study using this evaluation tool may provide more insight on the quality of care rendered to dying patients and identify areas for improvement. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03906747).

Health-seeking behaviour of foreign workers in Singapore: Insights from emergency department visits.

INTRODUCTION: Foreign workers (FWs) on work permit face unique health challenges and potential barriers to healthcare. We aimed to examine the epidemiology, attendance patterns, disposition, and adherence to follow-up, by FWs on work permit to two emergency departments (EDs) in Singapore. METHODS: In this retrospective observational study, we included consecutive FWs on work permit who registered at the EDs of two public restructured hospitals from 1 May 2016 to 31 October 2016. Data obtained from electronic medical records included patient demographics, triage acuity, disposition, ED diagnoses and bill information. RESULTS: There were 6,429 individual FWs on work permit who contributed to 7,157 ED visits over the 6-month study period, with male predominance (72.7%, 4672/6429), and median age of 31 (interquartile range 26 to 38) years. A high proportion of these FWs were triaged to low-acuity status compared to the general ED population (66.9% versus 45.9%, P<0.001). Trauma-related injuries contributed to 34.4% of their visits, and were more likely to result in admission compared to non-trauma-related conditions (18.7% vs 15.2%, P<0.001). FWs engaged in shipyard, construction and process industries were more likely to be discharged "against medical advice" (14.8% vs 3.2%, P<0.001), and default their specialist outpatient follow-up (50.1% vs 34.2%, P<0.001) for non-trauma-related conditions compared to trauma-related injuries. CONCLUSION: In Singapore, the EDs of public restructured hospitals provide healthcare safety nets to FWs on work permit. These workers made more low-acuity visits compared to the general population during the study period and may face potential barriers to admission and follow-up.

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.

Emergency airway management in a Singapore centre: A registry study.

INTRODUCTION: Intubations in the emergency department (ED) are often performed immediately without the benefit of pre-selection or the ability to defer. Multicentre observational data provide a framework for understanding emergency airway management but regional practice variation may exist. We aim to describe the intubation indications, prevalence of difficult airway features, peri-intubation adverse events and intubator characteristics in the ED of the National University Hospital, Singapore. METHODS: We conducted a prospective observational study over a period of 31 months from 1 March 2016 to 28 September 2018. Information regarding each intubation attempt, such as indications for intubation, airway assessment, intubation techniques used, peri-intubation adverse events, and clinical outcomes, was collected and described. RESULTS: There were 669 patients, with male predominance (67.3%, 450/669) and mean age of 60.9 years (standard deviation [SD] 18.1). Of these, 25.6% were obese or grossly obese and majority were intubated due to medical indications (84.8%, 567/669). Emergency physicians' initial impression of difficult airway correlated with a higher grade of glottis view on laryngoscopy. First-pass intubation success rate was 86.5%, with hypoxia (11.2%, 75/669) and hypotension (3.7%, 25/669) reported as the two most common adverse events. Majority was rapid sequence intubation (67.3%, 450/669) and the device used was most frequently a video laryngoscope (75.6%, 506/669). More than half of the intubations were performed by postgraduate clinicians in year 5 and above, clinical fellows or attending physicians. CONCLUSION: In our centre, the majority of emergency intubations were performed for medical indications by senior doctors utilising rapid sequence intubation and video laryngoscopy with good ffirst-attempt success.

Label-Free Biophysical Markers from Whole Blood Microfluidic Immune Profiling Reveal Severe Immune Response Signatures.

Disease manifestation and severity from acute infections are often due to hyper-aggressive host immune responses which change within minutes. Current methods for early diagnosis of infections focus on detecting low abundance pathogens, which are time-consuming, of low sensitivity, and do not reflect the severity of the pathophysiology appropriately. The approach here focuses on profiling the rapidly changing host inflammatory response, which in its over-exuberant state, leads to sepsis and death. A 15-min label-free immune profiling assay from 20 µL of unprocessed blood using unconventional L and Inverse-L shaped pillars of deterministic lateral displacement microfluidic technology is developed. The hydrodynamic interactions of deformable immune cells enable simultaneous sorting and immune response profiling in whole blood. Preliminary clinical study of 85 donors in emergency department with a spectrum of immune response states from healthy to severe inflammatory response shows correlation with biophysical markers of immune cell size, deformability, distribution, and cell counts. The speed of patient stratification demonstrated here has promising impact in deployable point-of-care systems for acute infections triage, risk management, and resource allocation at emergency departments, where clinical manifestation of infection severity may not be clinically evident as compared to inpatients in the wards or intensive care units.

Agreement between arterial and venous blood gases in trauma resuscitation in emergency department (AGREE).

INTRODUCTION: Arterial blood gas (ABG) sampling is routinely performed in major trauma patients to assess the severity of hemorrhagic shock. Compared to venous blood gas (VBG), ABG is an additional procedure with risks of hematoma and pain. We aim to determine if pH, base deficit (BD), and lactate from VBG and ABG in trauma patients are clinically equivalent. If proven, the need for ABG and its associated risks can be eliminated. METHODS: This prospective observational study was conducted in the Emergency Department of National University Hospital, Singapore, between February and October 2016. We correlated paired ABG and VBG results in adult trauma patients. VBG and ABG were obtained within 10 min and processed within 5 min using a point-of-care blood gas analyzer. Bland-Altman plot analysis was used to evaluate the agreement between peripheral VBG and ABG in terms of pH, base deficit and lactate. RESULTS: There were 102 patients included, with a median age of 34 (interquartile range 28-46) years and male predominance (90.2%). Majority of patients sustained blunt trauma (96.1%), and had injuries of Tier 1 and Tier 2 severity (60/102, 58.8%). Bland-Altman plot analyses demonstrated that only 72.6% of venous pH and 76.5% of venous BD lie within the pre-defined clinically acceptable limits of agreement, whereas 96.0% of venous lactate was within these limits. CONCLUSION: Venous and arterial pH and BD are not within clinically acceptable limits of agreement, and ABG should be obtained for accurate acid-base status. However, venous lactate may be an acceptable substitute for arterial lactate.