Clinical Recommendation for Emergency Physicians to Approach to Signs and Symptoms Related to COVID-19; a Preliminary Study

Introduction: There is not enough and comprehensive evidence on signs and symptoms of COVID-19; therefore, it seems too early to provide an appropriate clinical decision-making rule for this newly emerged pandemic viral disease. Objective: We tried to categorize patients’ signs and symptoms from very highly suspected to non-suspected, regarding having COVID-19. Methods: Most recently published English-language articles on COVID-19, were reviewed by the researchers. We considered each complaint, separately, and gathered available data, such as percentage of involved patients and their crude number. Then we considered the pooled and collected results as the final percentage of the occurrence of every specific symptom. We categorized patients’ complaints into six types, based on the data obtained. All extracted complaints were categorized and scored. Results: Twenty-seven articles were reviewed, of which, 12 considered for analysis. The selected papers had reported various numbers of patients, ranging from 16 to 1,099 patients (mean=229 patients per study). In total, nineteen different complaints, with an average of nine complaints per article, had been reported (IQR= 8-11). In terms of overall prevalence, based on the total number of patients, fever and dry cough were reported in more than half of the referred patients. The complaints were categorized in six types with and scored. Conclusions: The patients with score ≥17 are very highly suspected to COVID-19; However, patients with score <5 could be considered as non-suspected to COVID-19

A New Formula for Confirmation of Proper Endotracheal Tube Placement with Ultrasonography

Background Endotracheal intubation is an important procedure in critical care and emergency medicine settings. Optimal depth of the tube placement has been a serious concern because of several complications associated with its malposition. Objective: The aim of the current study was to find a new formula to estimate the proper endotracheal tube depth when using ultrasonography or lighted stylet device in order to increase the accuracy of determining Endotracheal tube (ETT) depth and decrease the side effects of ETT misplacement. Method: Patients older than 18 years of age admitted to Imam emergency department who needed tracheal intubation were included. Tube’s length at the angle of the mouth while the tube passed the suprasternal notch, ETT depth after insertion and the distance from ETT’s tip to carina were recorded. Ultrasonography and portable chest x-ray were used as tools for measuring these lengths. Results: A total number of 91 patients including 55 men and 36 women were eligible for inclusion in the study. Not placing the tube at proper depth was considered as failure of intubation. This failure rate was 9.9% in the standard method which would have been 1.1% if our proposed formula was used. Conclusion: The findings of this study suggest that the use of this new formula may help in predicting the proper intubation tube placement. Further studies are warranted to confirm these findings

A 24-year-old Female Traumatic Patient Following a Car Accident

A healthy 24-year-old female presented at the emergency department (ED) after a car accident with ambulance while injured severely after the bus got run over her lower limb. As the trauma team was activated, her primary survey was started: Ac (Airway and cervical collar): She was awake and could talk. Cervical collar was fixed, oxygenation with face mask was started. B (Breathing): Her chest rising was symmetrical without any laceration or abrasion. Chest auscultation was clear and there was no tenderness or crepitation on palpation. No tracheal shift was found. She had normal respiratory rate and O2 saturation of 94% at ambient air. C (Circulation): Two large bore IV lines were inserted and blood samples were obtained. Her vital signs were BP = 60/40 mmHg, PR = 130/min, RR = 12. E-FAST was performed which was negative for free fluid in abdomen, pelvis and thorax, tamponade, and hemopneumothorax. Her pelvis was unstable on examination and pelvic wrapping was performed with sheath. IV fluid therapy with normal saline was started followed by 3 units of packed RBC transfusion. More pack cells and FFP were also requested. D (Disability): She had Glasgow coma scale of 15/15 with normal size and reactive pupil. No neurologic deficit was found except disability of lower extremities due to crush injury. E (Exposure): She had no midline spinal tenderness with normal sphincter anal tone, but there was a laceration in the perineum which extended to the vagina. Portable chest and pelvic x-ray as an adjutant to primary survey were performed which showed type C pelvic fracture. On her secondary survey, she had abrasion on her scalp, 1.5 cm laceration on her right tibia, deformity of her right thigh, and laceration in her genitalia with some vaginal bleeding. Direct pressure was applied and all lacerations were packed. According to negative e-FAST and pelvic fracture and shock, since the angiography was not available, it was decided to fix the pelvis with external fixator in the operation room. After the fixation, and because shock persisted, operative pelvic packing was undertaken. Unfortunately, she suffered cardiorespiratory arrest in the operating room and died

Atypical Presentation of Acute Appendicitis: A 32-year-old Man with Gastroenteritis Symptoms; an Educational Case

Introduction: Appendicitis is a common condition that almost always requires emergency surgery. The diagnosis is clear when the patient presents with classic symptoms. However, presentation may be variable due to variations in the position and length of the appendix. Case presentation: Here, we report a 32-year-old man who presented with diarrhea and lower abdominal pain. Physical examination revealed a generalized abdominal tenderness, more prominent in the lower abdomen, including the right and left quadrants. Abdominal ultrasound failed to show any findings supportive of the diagnosis of appendicitis. Further investigation with abdominopelvic computed tomography (CT) with intravenous and oral contrast revealed retrocecal appendicitis. The patient was discharged home after a non-complicated appendectomy. Conclusion: Emergency physicians should be aware that appendicitis may not always show up with a typical presentation and they should consider the possibility of appendicitis when evaluating an acute abdomen to prevent any delay in diagnosis of atypical presentations

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

Clinical Recommendation for Emergency Physicians to Approach to Signs and Symptoms Related to COVID-19; a Preliminary Study

Introduction: There is not enough and comprehensive evidence on signs and symptoms of COVID-19; therefore, it seems too early to provide an appropriate clinical decision-making rule for this newly emerged pandemic viral disease. Objective: We tried to categorize patients’ signs and symptoms from very highly suspected to non-suspected, regarding having COVID-19. Methods: Most recently published English-language articles on COVID-19, were reviewed by the researchers. We considered each complaint, separately, and gathered available data, such as percentage of involved patients and their crude number. Then we considered the pooled and collected results as the final percentage of the occurrence of every specific symptom. We categorized patients’ complaints into six types, based on the data obtained. All extracted complaints were categorized and scored. Results: Twenty-seven articles were reviewed, of which, 12 considered for analysis. The selected papers had reported various numbers of patients, ranging from 16 to 1,099 patients (mean=229 patients per study). In total, nineteen different complaints, with an average of nine complaints per article, had been reported (IQR= 8-11). In terms of overall prevalence, based on the total number of patients, fever and dry cough were reported in more than half of the referred patients. The complaints were categorized in six types with and scored. Conclusions: The patients with score ≥17 are very highly suspected to COVID-19; However, patients with score <5 could be considered as non-suspected to COVID-19

The Construct Validity and Predictive Validity of In-Training Evaluations of Emergency Medicine Residents in Tehran University of Medical Sciences

Introduction: The evaluation of psychometric indicators in order to evaluate the quality of academic achievement exams is of particular importance. The aim of this study was to investigate the results of the written exams and internal evaluations among the emergency medicine residents in terms of the construct validity and also their ability in predicting resident’s academic success. Methods: In this descriptive correlational study all the emergency medicine residents of Tehran University of Medical Sciences who could enter the emergency medicine residency program within 2009 to 2014 and had participated in the pre-board exam till 2017, were selected through the census method (n=199). The certification exam score was considered as the main variable; then, correlation of written and internal evaluations results were compared with it. The Pearson correlation test was used to determine the correlation between the scores. Results: Finally, the evaluation results of 125 residents were analyzed. The correlation between first and second internal evaluation scores, first and second written scores with the certification exam scores were (p=0.006, r=0.3), (p=0.014, r=0.2), (p=0.202, r=0.1) and (p=0.000, r=0.3), respectively. The mean scores of the first, second and third year residents in written exams were 77.92±12.57, 91.33±8.05, 123.13±8.52 out of 150 in 2014; the mean of these scores were 67.44±8.52, 73.17±23.41, 121.52±6.38 in 2015 and 68.71±28.04, 88.24±14.34 and 118.15±7.73 in 2016, respectively Conclusion: The results of this study showed that in-training evaluations of the emergency medicine residents had acceptable predictive validity in predicting academic success of residents. Also, the ability of the written exams in discriminating between residents of different grades demonstrated the construct validity of these exams

Jejunal Perforation Following Blunt Abdominal Trauma; a Case Report

Introduction: The possibility of intestinal injury for all patients presenting to emergency department (ED) with blunt abdominal trauma, despite minimal physical signs should be considered. To highlight the patient management, hear, we report a case of hollow viscus injuries resulting from blunt abdominal trauma referring to a teaching hospital in Tehran, Iran. Case presentation: A 30-year-old man presented to the ED after “falling into a hole” with his back and had direct blunt abdominal trauma by a heavy bag of cement. In physical examination, there was a mild abdominal tenderness on right upper quadrant. On bedside ultrasonography, there was small free fluid in his Morison’s pouch without hypotension. So abdominal CT scan was performed which revealed free fluid in pelvic, perihepatic, and perisplenic spaces. Mural hematoma of proximal part of jejunum with mural wall hypodensity in mid jejunal loop were also revealed. The patient underwent surgery, and there was damage to the colon serosa and jejunal perforation which was primarily repaired. Conclusion: The presented case highlights the importance of obtaining history and physical exam and paying attention to the nature and mechanism of injury. Emergency physicians should be aware of hollow viscus injury in traumatic patients. Any delay in diagnosis and operative management are associated with an increase in mortality

A New Formula for Confirmation of Proper Endotracheal Tube Placement with Ultrasonography

Background Endotracheal intubation is an important procedure in critical care and emergency medicine settings. Optimal depth of the tube placement has been a serious concern because of several complications associated with its malposition. Objective: The aim of the current study was to find a new formula to estimate the proper endotracheal tube depth when using ultrasonography or lighted stylet device in order to increase the accuracy of determining Endotracheal tube (ETT) depth and decrease the side effects of ETT misplacement. Method: Patients older than 18 years of age admitted to Imam emergency department who needed tracheal intubation were included. Tube’s length at the angle of the mouth while the tube passed the suprasternal notch, ETT depth after insertion and the distance from ETT’s tip to carina were recorded. Ultrasonography and portable chest x-ray were used as tools for measuring these lengths. Results: A total number of 91 patients including 55 men and 36 women were eligible for inclusion in the study. Not placing the tube at proper depth was considered as failure of intubation. This failure rate was 9.9% in the standard method which would have been 1.1% if our proposed formula was used. Conclusion: The findings of this study suggest that the use of this new formula may help in predicting the proper intubation tube placement. Further studies are warranted to confirm these findings