Why COVID-19?

COVID-19 is a highly contagious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an enveloped positive stranded RNA virus and the third member of the family Coronaviridae which has emerged as a zoonotic infection. The predecessor of this new pathogen caused the Severe Acute Respiratory Syndrome (SARS) in 2003 and the Middle East Respiratory Syndrome (MERS) in 2012. Although corona viruses have been known since 1960’s, their familiar species were human pathogens and caused common cold and seasonal flu. SARS-CoV-2 is easily transmitted via respiratory secretions of an infected person, with a reproductive number (the average number of cases to which a single infected person will transmit the virus) of 1.4-2.5. Covid-19 has been estimated to have a case fatality rate of around 3%. As of today, asymptomatic transmission is assumed to be possible during the incubation period, which usually ranges from 2-14 days. The source of infection, animal host, and reservoir are currently unknown. In late December 2019, an outbreak of COVID-19 was reported from Wuhan city, China. The disease soon spread outside China borders and became rapidly prevalent all around the world. The pandemic announcement was officially made by World Health Organization (WHO) on 11 March 2020. Today COVID-19 has affected more than 212 countries and has made billions of people to be quarantined in their houses. Up to now, almost 1500000 confirmed cases of COVID-19 have been reported globally and the death toll has been declared to be 86000. In Iran, we are also facing this unprecedented global public health emergency, with about 65000 confirmed cases and 3993 deaths. This pandemic is beyond an expanding contagious disease and has influenced different features of life. Its enormous social, political, and specifically economic impacts all around the world are undeniable. In low- and middle-income countries this can potentially lead to a huge spike in poverty and collapse. Many vulnerable families have lost their income and access to the essential needs. Education systems have collapsed in many regions. The long-term effect of this global crisis has reduced economic growth even in developed countries. Economic effects of COVID-19 are estimated with dramatic variations. Orlik et al in Bloomberg hypothesized this cost to be $2.7 trillion. The political consequences are even harder to predict but quite significant and devastating, like the heated discussion, criticism and accusation flowing between the leaders of different countries. Since the pandemic is not yet over, the global influence will carry on to happen and make situation even more complicated. While the outbreak is evolving rapidly, health care systems across the world are actively fighting against the new virus. They have encountered many new challenges. Public health measures (such as active case finding, prompt isolation of cases and contacts tracing) to contain the spread of the disease in the society as well as provision of care for the unpredictably high number of people who are infected with the virus have stretched the healthcare system beyond its capacity. At the same time, protecting health care providers’ safety, which often requires provision of sufficient supplies of personal protective equipment, has definitely challenged the system. Societal demand for discovery of a definitive treatment and vaccine has also added to the complexity of the situation that the health care systems are facing. Studies about COVID-19 are increasingly being performed and published; many of them have not yet been fully reviewed and criticized by the academic community. Practitioners often find it difficult to find, appraise and apply the information they need amid the turbulence of their clinical practice. Furthermore, there are still many questions to be answered. The most efficient method for personal protection, methods of viral transmission, most accurate diagnostic approaches, and effective treatment options are yet to be determined. This special issue of the Advanced Journal of Emergency Medicine plans to specifically focus on COVID-19 by gathering the relevant scientific information available. We hope that by publishing high quality papers, this journal can provide its readers with further required information. Appropriate management of patients suffering COVID-19 as well as controlling this pandemic are our ultimate aspirations. We encourage further researches in this field by all scientists and physicians all across the world to be able to eradicate COVID-19 as soon as possible

Hypertonic Saline in the Treatment of Hemorrhagic Shock

Context: The present review discusses different studies about the treatment of hemorrhagic shock (HS) with hypertonic saline (HTS). Evidence acquisition: We have searched the title in the most popular databases containing recent meta-analysis or randomized clinical trials (RCTs). Results: We introduce the hemodynamic effects and mechanisms of action of HTS in HS. Evidence in this field shows controversial results. There are some data supporting the potential benefits of HTS infusion in HS. The goal of research in this field is to identify the best therapy in HS with the least mortality. Conclusion: Our conclusion shows that although HTS can decrease inflammatory response during HS, it can attenuate hypercoagulability and cause complications. There are no data supporting less mortality while treatment with HTS versus other fluids in HS

چگونه به عنوان پرسنل کادر درمانی بخش اورژانس تندرستی خود را حفظ کنیم؟ یک مقاله مروری

Maintaining health is a requirement for having a satisfying job and being efficient. 24-hour activity and working every day of the week leads physicians who work in emergency departments to facing the effects of imbalance in physiological status of the body due to changes in working shifts and working hours. It has been proved that working in shifts leads to decreased quality of sleep, fatigue, mental state disorders, dysfunction in social and family relationships, and problems in providing the mental needs of individuals. With increase in mental and physical tiredness, physicians gradually develop feelings of depersonalization, frustration and emptiness. They develop a negative view towards the patients and their treatment and if the fatigue continues the patient-physician relationship will suffer. The basis of the solution in cases of fatigue is providing a balance in life and looking after oneself and personal health. To improve sanity and mental-physical health in a healthcare system, an array of people are involved, each of whom plays an important role in this major issue.حفظ تندرستی برای داشتن یک شغل رضایت بخش و کارا لازم و ضروری است. فعالیت 24 ساعته و اشتغال در تمامی روزهای هفته موجب می شود پزشکان شاغل در بخش های اورژانس به دلیل تغییر در ساعات کار و فعالیت شیفتی دچار عوارض مرتبط با بهم ریختگی وضعیت فیزیولوژیک بدن شوند. ثابت شده که کار شیفتی منجر به کاهش کیفیت خواب، خستگی، اختلال وضعیت روحی، اختلال در روابط اجتماعی و خانوادگی و بروز اشکال در تامین نیازهای ذهنی افراد می شود. با افزایش خستگی روحی-جسمی به تدریج پزشکان احساس Depersonalization، سرخوردگی و پوچی می کنند. دید منفی نسبت به بیمار و درمان وی پیدا کرده و رفته رفته در صورت تداوم خستگی، رابطه بیمار-پزشک خدشه دار می شود. پایه و اساس راهکار درمانی در موارد بروز خستگی، بر ایجاد تعادل در مدل زندگی و توجه به خود و سلامتی استوار است. در جهت ارتقا بهداشت و سلامت جسم-روان در یک سیستم سلامت مجموعه ای از افراد دخیل هستند که هریک به تنهایی نقش بسزایی در این امر مهم ایفا می کنند

Two Different Endotracheal Tube Securing Techniques: Fixing Bandage vs. Adhesive Tape

Introduction: Emergency physicians should secure Endotracheal tubes (ETT) properly in order to prevent unplanned extubation (UE) and its complications. Despite various available endotracheal tube holders, using bandages or tape are still the most common methods used in this regards. Objective: This study aimed to compare adhesive tape (AT) versus fixing bandage (FB) method in terms of properly securing ETT. Methods: This was an observational longitudinal trial. All patients older than 15-years-old admitted to the ED who had indication for ETT insertion were eligible. Patients were randomly assigned to one of the two groups in which AT or FB was applied. All patients were observed thoroughly in the first 24 hours after intubation. Using a pre-prepared checklist, encountered UE rate and other data were recorded. Results: Seventy-two patients with the mean age of 55.98 ± 18.39 years were finally evaluated of which 38 cases (52.8%) were male. In total, 12% of patients in our study experienced unplanned extubation. Less than 12% of the patients experienced complete UE; there was no statistically significant difference between the two groups (p = 0.24). Comparison of UE with age showed no significant difference (p = 0.89). Male patients experienced more UE, but this was not statistically significant (p = 0.44). Conclusion: It is likely that whether the AT method or FB was applied for securing the ETT in emergency departments, there was no significant difference in rates of unplanned extubation

Emergency Overcrowding Impact on the Quality of Care of Patients Presenting with Acute Stroke

Introduction: Emergency overcrowding is defined as when the amount of care required for patients overcomes the available amount. This can cause delays in delivering critical care in situations like stroke. Objective: The aim of this study was to assess the possible impact of emergency department (ED) crowding on the quality of care for acute stroke patients. Methods: In this cross-sectional prospective study, all patients with symptoms of acute stroke presenting to the ED of educational hospitals were enrolled. All patients were assessed and examined by the emergency medicine (EM) residents on shift and a questionnaire was filled out for them. The amount of time that passed from the first triage to performing the required interventions and delivering health services were recorded by the triage nurse. ED crowding was measured by the occupancy rate. Then, the correlation between all of the variables and ED crowding level were calculated. Results: The average daily bed occupancy rate was 184.9 ± 54.3%. The median time passed from the first triage to performing the interventions were as follows: the first EM resident visit after 34 min, the first neurologic visit after 138 min, head CT after 134 min, ECG after 104 min and ASA administration after 210 min. There was no statistically significant relationship between the ED occupancy rate and the time elapsed before different required health services in the management of stroke patients either throughout an entire day or during each 8-hour interval (p > 0.05). Conclusion: In the current study, the ED occupancy rate was not significantly correlated with the time frame associated with management of admitted acute stroke patients

Nebulized Budesonide vs. Placebo in Adults with Asthma Attack; a Double Blind Randomized Placebo-Controlled Clinical Trial

Introduction: Asthma is one of acute respiratory diseases leading to emergency department (ED) referral. Management of acute attack plays an important role in its outcome. Objective: This trial was designed to evaluate the effectiveness of nebulized budesonide versus placebo in moderate to severe acute asthma attack in adults in the ED. Method: In this clinical trial, we enrolled patients with acute exacerbation of asthma and standard treatment of acute asthma attack was administered to all of them. 41 patients in our study were randomly entered into 2 groups. In one group, we prescribed nebulized budesonide and in the other group nebulized placebo (normal saline) was administered. Patients’ demographic data, vital signs, symptoms’ acuity and the time of symptom relief, patient and physician satisfaction were all recorded and compared between the 2 groups. All cases were followed and disease outcome, readmission, mortality and morbidity rates were documented. Results: In this study, 20 patients were entered the budesonide group and 19 patients were enrolled in the placebo group. The mean age ranges were 55.70±15.30 and 60.32±18.41 years old respectively. Heart rate, respiratory rate and O2 saturation in the first group were improved significantly after the treatment in comparison to the second group (p<0.05). The mean time of recovery and length of hospital stay were better in the first group than the second group but this difference was not significant (p>0.05). Conclusion: The addition of nebulized budesonide to standard asthma treatment might result in more improvement in O2 saturation and less patient’s distress

Haloperidol-Midazolam vs. Haloperidol-Ketamine in Controlling the Agitation of Delirious Patients; a Randomized Clinical Trial

Introduction: Agitation management in delirious patients is crucial in a crowded emergency department (ED) for both patient and personnel safety. Benzodiazepines, antipsychotics, and newly derived ketamine are among the most commonly used drugs in controlling these cases. This study aimed to compare the effectiveness of haloperidol-midazolam with haloperidol-ketamine combination in this regard. Methods: In this double-blind randomized clinical trial, delirious patients with agitation in ED were randomly assigned to a group: group A: haloperidol 2.5 mg IV and midazolam 0.05 mg/kg IV or group B: haloperidol 2.5 mg IV and ketamine 0.5 mg/kg IV. Sedative effects as well as side effects at 0, 5, 10, 15, 30 minutes and 1, 2, 4 hours after the intervention were compared between the 2 groups. Results: We enrolled 140 cases with Altered Mental Status Score (AMSS)≥+2 and mean age of 52.8±19.4 years (78.5% male). Agitation was significantly controlled in both groups (p<0.05). In group B, AMSS score was more significantly and rapidly reduced 5 (p = 0.021), 10 (p = 0.009), and 15 (p = 0.034) minutes after drug administration. After intervention, oxygen saturation was significantly decreased in group A 5 (p = 0.031) and 10 (p = 0.019) minutes after baseline. Time required to the maximum effect was significantly lower in group B versus group A (p=0.014). Less patients in group B had major side effects (p=0.018) and needed physical restraint (p=0.001). Conclusions: Haloperidol-ketamine can control agitation in delirium more rapidly than haloperidol-midazolam. This combination had lower adverse events with lower need for physical restraint

Association of Lymphopenia with Short Term Outcomes of Sepsis Patients; a Brief Report

Introduction: Studies have claimed that low lymphocyte count is independently correlated with 28-day survival of sepsis patients. Therefore, this study aimed to evaluate the value of lymphopenia in predicting the short-term outcome of sepsis patients. Methods: This cross-sectional study was performed on sepsis patients referred to the emergency department during an 8-month period and relationship of lymphopenia with 28-day mortality and probability of septic shock and readmission due to sepsis was assessed. Results: 124 cases with the mean age of 66.12 ± 15.82 (21-90) years were studied (54.8% male). 81 (65.3%) cases had lymphopenia (59.3% male). Lymphopenic patients had a significantly higher mean age (p = 0.003), higher need for ICU admission (p < 0.001), higher prevalence of 28-day septic shock (p < 0.001), higher 28-day mortality (p < 0.001), higher probability of readmission due to sepsis (p = 0.048), and higher SOFA score (p < 0.001). During 28 days of follow up, 57 (46%) patients were expired. They had a higher prevalence of septic shock (p < 0.001) and higher SOFA score (p < 0.001). Multivariate analysis showed that septic shock (OR=364.6; 95% CI: 26.3 to 5051.7; p = 0.001) and lymphopenia (OR=19.2; 95% CI: 1.7 to 211.3; p = 0.016) were the independent predictors of 28-day mortality. Conclusions: Based on the findings, lymphopenia was independently associated with higher 28-day mortality and lymphopenic patients were older than the control group and had a significantly higher need for ICU admission, higher probability of 28-day septic shock and readmission due to sepsis, and higher SOFA score

Affecting Factors on the Quality of Resident Education in Emergency Department; a Cross-Sectional Study

مقدمه: با توجه به تفاوت در زیرساخت های سیستم بهداشت و درمان کشورمان با کشور های پیشرفته، نیاز است که آموزش دستیاری طب اورژانس به گونه ای جهت دهی گردد که ضمن پاسخ دهی به نیازهای درمانی جامعه، اهداف آموزشی مشخص شده برای دستیاران این رشته را نیز با راهنمایی و کمک اعضای هیئت علمی پوشش دهد. شاید اولین قدم در این راه بررسی وضعیت موجود و نظرسنجی از دستیاران و اعضای هیئت علمی فعال در رشته تخصصی طب اورژانس باشد. بنابراین، مطالعه حاضر با هدف بررسی عوامل موثر بر کیفیت آموزش دستیاری در بخش اورژانس طراحی و اجرا گردید. روش کار: ابتدا گروهی متشکل از ۵ عضو هیئت علمی باتجربه نظرات خود را در مورد عوامل مؤثر بر آموزش دستیاری در قالب مصاحبه بیان کردند که منتج به طراحی پرسشنامه ای با 27 سرفصل گردید که در نهایت و بعد از بررسی روایی و پایایی، پرسشنامه ای شامل ۲۳ آیتم تهیه شد. این آیتم ها در سه گروه عوامل فردی، عوامل محیطی و عوامل مربوط به بیماران طبقه بندی شدند. نمونه گیری به روش سرشماری انجام شد و کلیه دستیاران و اعضای هیئت علمی گروه طب اورژانس دانشگاه علوم پزشکی تهران که در محدوده زمانی اجرای این مطالعه در این رشته تخصصی فعالیت داشتند قابلیت ورود به مطالعه را داشتند. نظر سنجی کمی با استفاده از مقیاس لیکرت 5 امتیازی انجام شد. سپس داده ها مورد تحلیل آماری قرار گرفت تا میزان توافق در هر مورد در گروه دستیاران و اعضای هیئت علمی بررسی شود. یافته ها: در مجموع ۵۷ دستیار با میانگین سنی 12/6 ± ۷۵/۳۲ سال و ۲۳ عضو هیئت علمی با میانگین سنی 54/5 ± ۶۵/۳۹ سال در مطالعه شرکت کرده و پرسشنامه ها را تکمیل نمودند. میانگین امتیاز سه دسته از عوامل مورد بررسی شامل عوامل فردی، محیطی و مربوط به بیمار از نظر کلیه شرکت کنندگان به ترتیب برابر با 12/0 ± 17/1، 15/0 ± 09/1 و 22/0 ± 52/1 بود. میانگین این امتیازات به تفکیک سه دسته از عوامل مورد بررسی بین دستیاران و اعضای هیئت علمی رشته طب اورژانس شرکت کننده در مطالعه تفاوت معنی داری نداشت (05/0 &lt; p). از نظر اعضا هیئت علمی کم کردن تعداد شیفت ها باعث بهبود کیفیت آموزش دستیاری نمی شود. ولی ایشان معتقد بودند که شیفت های ۱۲ ساعته، راندهای بالینی در بخش اورژانس و آموزش دستیاران به یکدیگر در بهبود کیفیت آموزش موثر است که اختلاف نظر دستیاران با اعضای هیئت علمی در این موارد معنی دار بود (05/0 &gt; p). نتیجه گیری: اعضای هیئت علمی و دستیاران طب اورژانس نظر یکسانی درباره ساعات کاری و تعداد شیفت های بالینی و تاثیر  آن بر آموزش دستیاری ندارند. اعضای هیئت علمی طب اورژانس معتقد بودند شیفت های ۱۲ ساعته در مقایسه با شیفت های ۸ ساعته امکان آموزش بیشتری را فراهم می کنند و کاهش تعداد شیفت های بالینی کیفیت آموزش را خواهد کاست.Introduction: Considering the differences between the infrastructures of healthcare systems in Iran and advanced countries, there is a need for directing the education of emergency medicine residents in a way that not only meets the treatment needs of the society, but can also cover the determined educational goals for the residents of this specialty with the guidance and help of the faculty members. The first steps might be evaluating the present status and surveying the residents and faculty members who are active in emergency medicine specialty. Therefore, the present study was designed and performed with the aim of evaluating the factors affecting the quality of resident education in emergency department (ED). Methods: Initially, a group that consisted of 5 experienced faculty members expressed their opinions on the factors affecting the quality of resident education in an interview, which resulted in the design of a questionnaire with 27 topics that led to preparation of a 23-item questionnaire after validity and reliability evaluation. These items were classified in 3 groups of personal factors, environmental factors, and patient-related factors. Consecutive sampling was done and all the residents and faculty members of emergency medicine in Tehran University of Medical Sciences who were active in this specialty during the study period were eligible to participate in the study. A quantitative survey was done using 5-point Likert scale. Then the data were statistically analyzed to evaluate the agreement rate of the residents and faculty members in each item. Results: In total, 57 residents with the mean age of 32.75 ± 6.12 years and 23 faculty members with the mean age of 39.65 ± 5.54 years participated in the study and filled out the questionnaires. Mean scores of the 3 categories of evaluated factors, namely personal, environmental, and patient-related factors from the viewpoint of all participants were 1.17 ± 0.12, 1.09 ± 0.15, and 1.52 ± 0.22, respectively. The mean scores calculated for the 3 studied categories were not significantly different between the residents and faculty members of emergency medicine who participated in the study (p &gt; 0.05). In the opinion of faculty members, decreasing the number of shifts does not lead to improvement in the quality of resident’s training. However, they believed that 12-hour shifts, clinical rounds in ED and the residents teaching to each other are effective in improvement of the quality of their education and the opinion of residents and faculty members were significantly different in these cases (p &lt; 0.05). Conclusion: Faculty members and residents of emergency medicine do not share the same opinion on working hours, and the number of clinical shifts and their effect on resident training. The faculty members believed that 12-hour shifts provide more opportunities for education compared to 8-hour shifts and reducing the number of clinical shifts would decrease the quality of education.

How to Maintain our Health as Healthcare Staff of the Emergency Department? a Review Article

Maintaining health is a requirement for having a satisfying job and being efficient. 24-hour activity and working every day of the week leads physicians who work in emergency departments to facing the effects of imbalance in physiological status of the body due to changes in working shifts and working hours. It has been proved that working in shifts leads to decreased quality of sleep, fatigue, mental state disorders, dysfunction in social and family relationships, and problems in providing the mental needs of individuals. With increase in mental and physical tiredness, physicians gradually develop feelings of depersonalization, frustration and emptiness. They develop a negative view towards the patients and their treatment and if the fatigue continues the patient-physician relationship will suffer. The basis of the solution in cases of fatigue is providing a balance in life and looking after oneself and personal health. To improve sanity and mental-physical health in a healthcare system, an array of people are involved, each of whom plays an important role in this major issue