Visual outcome of methanol toxic optic neuropathy after erythropoietin treatment in Riyadh, Saudi Arabia.

PURPOSE: The purpose of this study is to evaluate the visual response of methanol-induced optic neuropathy to management with erythropoietin (EPO) along with conventional therapy. METHODS: This retrospective case series examines the ophthalmological data of patients diagnosed with methanol-induced optic neuropathy between 2020 and 2021 at two centers, Riyadh, Saudi Arabia. Patients' characteristics and the results of initial and final ophthalmological examinations were documented and compared between patients who received EPO in addition to conventional management and those who received only conventional management. RESULTS: A total of nine cases were reviewed, of which eight (88.9%) were males and one was female (11.1%). The mean age was 37.7 years. At presentation, funduscopic examination revealed optic disc edema in four eyes (two patients), and 14 eyes had normal appearance (seven patients). Among the nine patients who received conventional management, 5 (55.6%) additionally received intravenous EPO during the treatment course. There was no clinically or statistically significant difference in terms of visual outcome between the two groups. The mean visual acuity at the final presentation was 1.32 ± 0.79 logarithm of the minimum angle of resolution (LogMAR) in the EPO group and 1.36 ± 0.85 LogMAR in the non-EPO group. Optical coherence tomography indicated that the EPO group had an average retinal nerve fiber layer thickness of 48.13µm (±6.2), at the final assessment. CONCLUSION: Managing the visual impairments in individuals with methanol-induced optic neuropathy using intravenous EPO resulted in similar final visual outcomes compared to conventional management.

Successful management of massive digoxin overdose using DIGIFab and therapeutic plasma exchange: a case report.

BACKGROUND: Despite the efficacy and safety of DIGIFab, it is relatively expensive and has limited availability. In addition, alternative interventions, such as therapeutic plasma exchange, may need to be considered in massive digoxin overdoses. Although few case reports describe its efficacy. CASE PRESENTATION: We report a case of a 17-year-old white male patient brought by family members to our emergency department in Riyadh, Saudi Arabia. After intentionally ingesting 48 mg of digoxin tablets to commit suicide, the patient's initial digoxin serum level was 8.04 ng/mL. The patient was resuscitated in the emergency department. After admission to the intensive care unit, the patient underwent therapeutic plasma exchange, because of insufficient DIGIFab doses. Afterward, the serum digoxin levels drastically decreased, and his symptoms reverted. The patient was successfully managed and discharged 7 days after admission. CONCLUSION: Despite insufficient evidence and a limited number of case reports describing the use of extracorporeal treatment in digoxin overdose, we noted the significant impact of therapeutic plasma exchange on our patient. However, therapeutic plasma exchange's use in routine treatment requires stronger evidence to confirm its benefits.

Two versus Three Infusion Regimens of N-Acetylcysteine for Acetaminophen Overdose.

BACKGROUND: Acetaminophen overdose is a common clinical condition, often leading to liver toxicity. Current treatments involve the three-infusion N-Acetylcysteine (NAC) regimen (FDA-labeled), which may be complex, time-consuming, and need to be changed. An alternative uses two infusions instead, which offers possible advantages regarding simplicity and administration errors. This study sought to compare the respective efficacies and safety outcomes when treating acute acetaminophen overdose among children and adolescents. METHODS: At Montreal Children's Hospital, a retrospective study was conducted comparing pre-2003 FDA-labelled three-infusion NAC therapy with a two-infusion regimen. Information was collected regarding patient demographics, NAC administration details, errors, rates of hepatotoxicity, and adverse reactions, and the statistical test Chi-square test was employed to obtain the results. RESULTS: A total of 126 patients met the inclusion criteria. Of these patients, 65 received a two-infusion regimen, and 61 patients received the FDA-labeled regimen. The two-infusion group experienced significantly fewer administration errors (4 errors vs. 23 errors; p < 0.001), while the rates of hepatotoxicity between them were similar. There were no instances of liver transplantation or mortality due to either regimen. Adverse reactions occurred equally frequently between both regimens with no discernible difference-the meantime to administer NAC was 9 h for the two-infusion regimen and 8.5 h for FDA-labeled regimen groups, respectively. Three cases of hepatitis were successfully treated with timely NAC therapy, and no liver transplantation or mortality occurred. Adverse reactions, including anaphylactoid reactions, were observed in both groups but were resolved when temporarily stopped and restarted at a slower infusion rate. CONCLUSIONS: The two-infusion NAC regimen proved similar efficacy at protecting liver damage and improving patient outcomes compared to its FDA-labeled three-stage counterpart, with significantly fewer administration errors for this version of NAC treatment, suggesting potential advantages in terms of safety and simplicity. Future research should investigate larger cohorts and more variables to validate these results further and optimize the management of acetaminophen overdose cases; further investigation should focus on dosing strategies, personalized approaches, and long-term patient care in this context.

Are We Overusing Coagulation Studies in the Emergency Department?

Methods: This retrospective observational study, conducted in the ED of King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia, during July and August of 2021(2 months) examined coagulation profile requests. Patients' demographic data (age and gender), medical and clinical history (presenting complaint, comorbidities, and diagnosis), the use of antiplatelets or anticoagulant agents and laboratory values for PT, APTT, and INR were collected. We calculated the total cost of unnecessary coagulation profile testing based on the independent assessment of two ED consultants. Results: Of 1,754 patients included in the study, 811 (46.2%) were males and 943 (53.8%) were females, with a mean age of 42.1 ± 18.5 years. There were 29 (1.7%) patients with liver disease and 21 (1.2%) patients had thromboembolic disease. The majority of the patients' results were within normal levels of PT (n = 1,409, 80.3%), APTT (n = 1,262, 71.9%), and INR (n = 1,711, 97.4%). Evidence of active bleeding was detected in 29 patients (1.7%). Among patients with bleeding only one had an abnormal INR (3.01) and was on warfarin. Forty-six (2.6%) patients had elevated INR level. Cohen's kappa between the two consultants was recorded at 0.681 (substantial agreement) in their assessment of the appropriateness of coagulation tests requests and both consultants believed that 1,051 tests (59.9%) were not indicated and were unnecessary. The expected annual cost saving if the unnecessary tests were removed would be around SAR 1,897,200 (approximately US$ 503,232) which is about SAR 180000 (US$ 48000)/1000 patients. Conclusion: This study showed that coagulation tests are overused in the ED. More than half of coagulation profile tests in our study population were deemed unnecessary and associated with significant cost. Targeted testing based on specific patient presentation and medical history can guide physicians in wisely choosing who needs coagulation studies.

Prognostic accuracy of qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients presenting with suspected infection to the emergency department (PASSEM) Multicenter prospective external validation cohort study protocol.

BACKGROUND: Early identification of a patient with infection who may develop sepsis is of utmost importance. Unfortunately, this remains elusive because no single clinical measure or test can reflect complex pathophysiological changes in patients with sepsis. However, multiple clinical and laboratory parameters indicate impending sepsis and organ dysfunction. Screening tools using these parameters can help identify the condition, such as SIRS, quick SOFA (qSOFA), National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS). We aim to externally validate qSOFA, SIRS, and NEWS/NEWS2/MEWS for in-hospital mortality among adult patients with suspected infection who presenting to the emergency department. METHODS AND ANALYSIS: PASSEM study is an international prospective external validation cohort study. For 9 months, each participating center will recruit consecutive adult patients who visited the emergency departments with suspected infection and are planned for hospitalization. We will collect patients' demographics, vital signs measured in the triage, initial white blood cell count, and variables required to calculate Charlson Comorbidities Index; and follow patients for 90 days since their inclusion in the study. The primary outcome will be 30-days in-hospital mortality. The secondary outcome will be intensive care unit (ICU) admission, prolonged stay in the ICU (i.e., ≥72 hours), and 30- as well as 90-days all-cause mortality. The study started in December 2021 and planned to enroll 2851 patients to reach 200 in-hospital death. The sample size is adaptive and will be adjusted based on prespecified consecutive interim analyses. DISCUSSION: PASSEM study will be the first international multicenter prospective cohort study that designated to externally validate qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients with suspected infection presenting to the ED in the Middle East region. STUDY REGISTRATION: The study is registered at ClinicalTrials.gov (NCT05172479).

The Prevalence of Simultaneously Ordering Amylase and Lipase for Diagnosing Pancreatitis.

Background: The simultaneous measurement of serum amylase and lipase levels in the diagnosis of pancreatitis was deemed unnecessary in several studies. We aim at evaluating the prevalence of the simultaneous co-ordering of serum amylase and lipase. Methods: This retrospective chart review was conducted at King Saud University Medical City in Riyadh, Saudi Arabia, between January 2021 and January 2022. We examined requests for serum amylase or serum lipase levels that had been sought for suspected pancreatitis within the electronic health system (EHS). Results: A total of 9,617 requests for serum amylase and serum lipase levels for 5,536 patients were made in a year; 6,873 (71.5%) were made for serum lipase alone; 1,672 (17.4%) were made for co-ordered serum lipase and amylase; 322 (3.3%) were made for amylase alone; and 750 (7.8%) were made for repeated amylase testing. Four hundred and thirteen tests (4.3%) yielded a diagnosis of pancreatitis. The estimated cost reduction when serum amylase was removed if serum lipase was co-ordered was 108,680 SAR (approximately US$28,960). Conclusion: Serum amylase and lipase were co-ordered for about 17.4% of pancreatitis diagnostic tests, all of which were unnecessary. Eliminating serum amylase testing for any patient who receives a test of their lipase levels would exert a significant impact on institutional costs and savings.

Emergency Medicine Personnel's Preparation, Performance and Perception of Their Night Shifts: A Cross-Sectional Study from Saudi Arabia.

PURPOSE: This study aimed to investigate the perceptions and habits of different emergency department (ED) workers (nurses, residents, and attending physicians) and their pre- or post-shift routines. The study also examined the effect of night shifts on personal life, social life, and health. PATIENTS AND METHODS: An anonymous, online, cross-sectional, multiple-choice, self-rating (5-point Likert scale) survey was administered to the participants. All analyses were performed using the SPSS version 22.0. Ethical approval was obtained from the Institutional Review Board (IRB) of King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia. RESULTS: Thirty-three nurses, 51 residents, and 39 attending physicians participated in the survey (response rates of 21%, 100%, and 100%, respectively). A significant difference was noted in the need to use physical sleeping aids between the three groups (P < 0.003), with more nurses using humidifiers as a sleeping aid (21.2%) than residents or attending physicians. However, there was no difference in the use of pharmacological aids between the three groups. All groups utilized coffee as the preferred stimulant, especially residents (76.5%, P <0.032). Nurses and attending physicians wake up 2 hours before their shift, while residents prefer 3 hours (P <0.001). Attending physicians reported the highest accident rates post-night shifts of 17.9% (P < 0.001). Residents reported satisfaction while working night shifts and were least in agreement with night shifts reducing life span. Attending physicians were more in agreement with the increasing risk of drug/alcohol misuse and the incidence of depression in relation to night shifts. CONCLUSION: Participants shared many commonalities, yet residents were less likely to use sleeping aids and enjoy night shifts more than the other groups. All groups consumed coffee for stimulation. Attending physicians reported the highest accident rates post night shifts.

Emergency Medicine Physicians' Views on Providing Unnecessary Management in the Emergency Department.

Purpose: To assess the views of emergency medicine physicians (EMPs) on the practice of providing unnecessary medical management in the emergency department. Methods: All EMPs in Saudi Arabia were approached to participate in this cross-sectional study. A self-administered online survey that collected the participants' demographic information and opinions regarding the unnecessary management provided by EMPs in Saudi Arabia was conducted between December 2020 and February 2021. SPSS 22.0 was used to analyze the data. Results: A total of 181 EMPs returned the questionnaire. More than 80% of the participants believed that EMPs order unnecessary tests or procedures at least a few times per week. The major reasons for ordering unnecessary medical tests or procedures were "concern about malpractice issues" (60.8%), "not having enough time with a patient for meaningful discussion" (47%), and "just to be safe" (46.4%). More than 55% of the respondents also believed that EMPs are in the best position to address the problem of unnecessary testing. Conclusion: Most of the EMPs who participated in this study recognized that ordering unnecessary tests is a serious problem that happens on a daily basis. Many factors and reasons were described by the participants, and multiple possible solutions were suggested to help overcome the issue. Evaluating physicians' perspectives on the issue is a key step in addressing the problem and implementing appropriate interventions.

Pediatric tizanidine toxicity reversed with naloxone: a case report.

BACKGROUND: Tizanidine, an α-2 adrenoceptor agonist, is widely prescribed for the management of spasticity in adults. Case reports on pediatric tizanidine overdose are limited. Here, we report a case of pediatric tizanidine toxicity that was reversed with naloxone. CASE PRESENTATION: A 3-year-old male presented to the emergency department with lethargy, bradycardia, and bradypnea after accidental ingestion of multiple tizanidine tablets. Improvements in the level of consciousness and respiratory and heart rates were observed after two intravenous administrations of naloxone at a dose of 0.05 and 0.1 mg/kg, respectively. CONCLUSIONS: This case report provides further evidence regarding the use of naloxone as a viable antidote for centrally acting α-2 receptor agonists and presents additional epidemiologic data on childhood tizanidine poisoning.

Methylene Blue Infusion to Treat Severe Dapsone-Induced Methemoglobinemia in a Pediatric Patient.

Dapsone overdose is a well-known potent cause of methemoglobinemia and hemolytic anemia. We discuss a case of a two-year-old male who developed severe persistent methemoglobinemia treated with multiple doses of methylene blue (MB), multidose activated charcoal, and vitamin C. Methylene blue infusion (rather than bolus dosing) aided in controlling this patient's methemoglobin (MetHb) levels and symptoms and may reduce the total needed dose.

Use of ultrasound guidance in central venous catheter placement by emergency physicians in Saudi Arabia.

OBJECTIVES: To determine the ultrasound guidance for central venous catheter (USG-CVC) placement rate of emergency physicians (EPs) in Kingdom of Saudi Arabia. METHODS: A cross-sectional survey study regarding the respondents' demographic profiles, formal and informal training in USG-CVC placement, experiences, and attitudes towards the procedure was emailed to all EPs registered with the Saudi Commission for Health Specialties (SCFHS) between October and December 2018. RESULTS: In total, 234/350 SCFHS-registered EPs completed the survey; the response rate was 66.9%. Most respondents (70.5%) were board-certified in emergency medicine (EM). Ninety percent indicated that US device for CVC placement assistance was available. Most EPs (78.2%) had performed USG-CVC placement; the US usage rate correlated significantly with recent graduation from residency (p=0.048). In total, 83.3% received formal training during residency. Of the 234 respondents, 53.8% felt extremely comfortable with CVC placement with USG and 19.7% without USG (p less than 0.01). Nevertheless, most respondents desired further USG-CVC training. CONCLUSION: Despite existing evidence and a consensus on its superiority over the landmark technique, USG-CVC placement has not been adopted by a small proportion of EPs into clinical practice. Formal training, education, and institutional provision of permanent onsite US machines may address any barriers.

Acute lamotrigine overdose: a systematic review of published adult and pediatric cases.

CONTEXT: Lamotrigine is a broad-spectrum anticonvulsant commonly used to treat seizure and bipolar mood disorders. Evidence from case series and retrospective studies indicate that lamotrigine overdose is usually benign. However, there are reported cases of cardiac arrest and mortality following lamotrigine overdose. We undertook a systematic review of the literature on lamotrigine overdoses to better understand the clinical severity, the relevance of serum concentrations, and therapeutic interventions for overdose. OBJECTIVES: To characterize manifestations of acute lamotrigine overdose, determine if serum concentrations predict poisoning severity, and evaluate the effectiveness of overdose management interventions. METHODS: We performed a literature search across eight databases, including Medline, EMBASE, and the Cochrane Library, from database inception to April 2014. Major bibliographic databases were updated on 31 May 2017. Articles were eligible if they described acute or acute on chronic lamotrigine overdose. At least one serum lamotrigine concentration had to be reported for inclusion. Reports on chronic poisoning, studies describing adverse effects of therapeutic use, and animal studies were excluded. RESULTS: We retrieved 6238 records; 48 (51 cases) met the inclusion criteria. Cases primarily involved adults (70.6%). Potentially life-threatening symptoms of overdose included seizures (55%), Glasgow Coma Scale ≤8 (20%), hypotension (12%), and wide complex tachycardia (WCT) and cardiac arrest (6%). Among the 25 cases exposed to lamotrigine alone (13 adult; 12 pediatric), 2 adult fatalities occurred (4 g and 7.5 g ingested) and 8 pediatric cases experienced seizures (all children ≤3.5-years-old, 75% without an underlying seizure disorder, ≥ 525 mg ingested). The lowest seizure-associated serum concentration was 3.8 mg/L and 25.6 mg/L for pediatric and adult patients, respectively, suggesting children may be more susceptible to CNS toxicity. Cardiovascular toxicities occurred primarily in adult patients (threshold >25 mg/L). Overdose interventions included benzodiazepines (53%), propofol or barbiturates (14%), NaHCO3 (20%), lipid therapy (12%), and extracorporeal elimination (10%). NaHCO3 yielded no response in four of nine cases with conduction delays; however, two of the four cases subsequently responded with lipid therapy. CONCLUSIONS: Most cases reporting lamotrigine exposures observed mild or no toxicity; however, large exposures were associated with severe CNS depression, seizures, cardiac conduction delays, wide complex tachycardia, and death. In adults with a serum concentration >25 mg/L, severe toxicity may occur. In patients ≤3.5 years of age, ingestions of ≥525 mg may produce severe CNS depression and seizures.

Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study.

OBJECTIVES: To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture. DESIGN: A substudy of a prospective multicenter cohort study. SETTING: 12 Canadian academic emergency departments, from November 2000 to December 2009. PARTICIPANTS: Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage. MAIN OUTCOME MEASURE: Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death. RESULTS: Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with >1 × 10(6)/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000 × 10(6)/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%). CONCLUSION: No xanthochromia and red blood cell count <2000 × 10(6)/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache.