Point-of-care Hemoglobin Measurement in Comparison with Hematology Analyzer: A Cross-sectional Study in Emergency Department

Introduction: Point-of-care hemoglobin testing devices can help emergency physicians to make their clinical decisions in a timelier manner.  They can also improve the patient care process by decreasing the length of stay and costs. Although different devices are available now, their diagnostic accuracy remains still uncertain. Objective: This study compares the results of hemoglobin levels measured by a point-of-care hemoglobin testing device and central lab auto-analyzer. Methods: Hemoglobin level was measured both by a point-of-care device (Mission® Plus Hb) and the central laboratory auto-analyzer (Sysmex KX-21N™) in medical cases presenting to emergency department (ED) and requiring hemoglobin (Hb)/hematocrit (Hct) level measurement. The agreement of Hb and Hct between the two methods was assessed based on intraclass correlation coefficient (ICC), Bland-Altman analysis and the Mountain plots. Also, time gap between point-of-care testing and preparation of central lab results was measured. Results: Hb and Hct were measured in 86 cases mostly presented because of gastrointestinal bleeding. We found a good agreement between the two methods for hemoglobin (ICC=0.985) and hematocrit levels (ICC=0.991). The bias was 0.09 and 95% limits of agreement (LoA) were -0.89 to 1.07 for Hb level. Mean of time delay between point-of-care testing and preparation of central lab results was 207.31 minutes (SD=93.66) and this delay was clinically significant (p=0.001). Conclusion: Point-of-care measurement of Hb level provides proper quantitative results in ED patients. It significantly decreases laboratory turnaround time and may be used to improve the patient throughput by decreasing the length of stay in most clinical settings

Point-of-care Hemoglobin Measurement in Comparison with Hematology Analyzer: A Cross-sectional Study in Emergency Department

Introduction: Point-of-care hemoglobin testing devices can help emergency physicians to make their clinical decisions in a timelier manner.  They can also improve the patient care process by decreasing the length of stay and costs. Although different devices are available now, their diagnostic accuracy remains still uncertain. Objective: This study compares the results of hemoglobin levels measured by a point-of-care hemoglobin testing device and central lab auto-analyzer. Methods: Hemoglobin level was measured both by a point-of-care device (Mission® Plus Hb) and the central laboratory auto-analyzer (Sysmex KX-21N™) in medical cases presenting to emergency department (ED) and requiring hemoglobin (Hb)/hematocrit (Hct) level measurement. The agreement of Hb and Hct between the two methods was assessed based on intraclass correlation coefficient (ICC), Bland-Altman analysis and the Mountain plots. Also, time gap between point-of-care testing and preparation of central lab results was measured. Results: Hb and Hct were measured in 86 cases mostly presented because of gastrointestinal bleeding. We found a good agreement between the two methods for hemoglobin (ICC=0.985) and hematocrit levels (ICC=0.991). The bias was 0.09 and 95% limits of agreement (LoA) were -0.89 to 1.07 for Hb level. Mean of time delay between point-of-care testing and preparation of central lab results was 207.31 minutes (SD=93.66) and this delay was clinically significant (p=0.001). Conclusion: Point-of-care measurement of Hb level provides proper quantitative results in ED patients. It significantly decreases laboratory turnaround time and may be used to improve the patient throughput by decreasing the length of stay in most clinical settings

Lung Ultrasound Findings Compared to Chest CT Scan in Patients with COVID-19 Associated Pneumonia: A Pilot Study

Introduction: Lung US has been reported to be as useful as a chest CT scan and much better than a chest x-ray for the evaluation of pneumonia. Objective: This study aimed to compare the findings of lung ultrasound (US) and chest CT scan of patients with COVID-19-associated pneumonia in the Emergency Department (ED). Methods: This retrospective observational pilot study was carried out on confirmed COVID-19 patients in the isolation corona ward of the Imam Hussein Hospital ED from March 15 to March 22, 2020. After obtaining demographic data, the patients underwent a pulmonary bedside US examination, with the patients in the sitting position, turning their back to the examiner. A 10-point lung US was performed. Each lung was divided into two areas: posterior (three zones) and lateral (two zones). The patients’ lung ultrasound and chest CT scan as the standard imaging were blindly reviewed and recorded. The clinical value of ultrasound was evaluated with different severity of lung involvement according to CT severity score. Results: Nineteen patients (38 zones), including 13 males, were evaluated with a mean age of 62.5±16.8 years. B2 lines and consolidation observed in the US examinations were significantly correlated with ground-glass opacity and consolidation observed in CT scan examinations, respectively (p <0.0001). US sensitivity and specificity of finding B2 lines were 90% and 100%, respectively. Also, the sensitivity and specificity of US in identifying consolidation were 82% and 100%, respectively. In the lungs with moderate and severe lobar involvement, US findings were significantly correlated (p <0.05) with CT scan findings. Conclusions: Ultrasound evaluation is a safe, fast, and rapid technique for the evaluation of patients with moderate to severe COVID-19-associated pneumonia. It is a reproducible procedure and can be implemented by the operator after a short course of training

Baseline Characteristics of Fall from Height Victims Presenting to Emergency Department; a Brief Report

Introduction: Trauma due to accidents or fall from height is a major cause of disability and mortality. The present study was designed aiming to evaluate the baseline characteristics of fall from height victims presenting to emergency department (ED).Methods: This prospective cross-sectional study evaluates the baseline characteristics of fall from height cases presenting to EDs of three educational Hospitals, Tehran, Iran, during one year. Data were analyzed using SPSS 21 and presented using descriptive statistics.Results: 460 patients with the mean age of 27.89 ± 20.95 years were evaluated (76.5% male). 191 (41.5%) falls occurred when working, 27 (5.9%) during play, and 242 (52.6%) in other times. Among construction workers, 166 (81.4%) had not used any safety equipment. Fracture and dislocation with 180 (39.1%) cases and soft tissue injury with 166 (36.1%) were the most common injuries inflicted. Mean height of falling was 3.41 ± 0.34 (range: 0.5 – 20) meters. Finally, 8 (1.7%) of the patients died (50% intentional) and 63% were discharged from ED. A significant correlation was detected between mortality and the falls being intentional (p < 0.0001) as well as greater height of fall (p < 0.0001).Conclusion: Based on the findings, most fall from height victims in the present study were young men, single, construction workers, with less than high school diploma education level. Intentional fall and greater height of falling significantly correlated with mortality

Workplace Violence against Residents in Emergency Department and Reasons for not Reporting Them; a Cross Sectional Study

Introduction: Due to the stressful nature of emergency Department (ED), residents in ED are at risk of violence from patients or their associates. This study aimed to determine the prevalence of workplace violence against ED residents and the reasons for not reporting them. Methods: This cross-sectional study was conducted on ED residents of three educational hospitals, Tehran, Iran, during 2015. The national questionnaire about workplace violence was used for data gathering. In addition, prevalence of reporting the violence and the reasons for not reporting them were determined. Results: 280 questionnaires were analyzed. The mean age of residents was 32.2 ± 4.6 years (58.4% female). 224 (80%) residents stated that they had not passed any educational courses on violence management. The most prevalent type of violence was verbal (90.7%) and patients’ associates (85.4%) were the most common source of aggression. The frequency of physical violence was higher in male aggressors (p = 0.001), resident age > 30 years (p = 0.044), aggressor age > 30 years (p = 0.001), and night shift (p = 0.001). The same trend was observed regarding verbal and racial-ethnic violence. There was no significant relationship between residents’ sex, resident's specialty, and presence of security and police with frequency of violence. 214 (76.4%) residents did not report the violence, and the main reasons for not reporting from their viewpoint were uselessness of reporting (37.4%) and insignificance of the violence (36.9%). Conclusion: Based on the findings of the present study more than 90% of ED residents had experienced at least one type of verbal, physical, or racial-ethnic violence during their shifts. It is necessary for residents in EDs to be trained about violence control and also report and follow these issues through legal channels

Rare presentation of COVID-19 in 6-year-old girl: myocarditis with severe restrictive diastolic dysfunction

Since the emergence of COVID-19 in late December 2019, patients were presented at the hospitals with different symptoms, including cardiac manifestations. Recent records of coronavirus infection in children and adolescents have been accompanied by multisystem inflammatory syndrome (MIS-C). Here, we describe a 6 -year-old girl with no history of cardiac disease, infected with COVID-19 and presented at the emergency department with fever and cardiac manifestations. Her echocardiography findings favored myocarditis with restrictive (severe) diastolic dysfunction, a rare manifestation of COVID-19 among children. Unfortunately, despite standard treatment of myocarditis and supportive care, the patient passed away. Therefore, it seems necessary to develop a guideline for the recent cardiac consequences of the pandemic among children and follow their presentations carefully

Acute Physiology and Chronic Health Evaluation (APACHE) III Score Compared to Trauma-Injury Severity Score (TRISS) in Predicting Mortality of Trauma Patients

Introduction: More than 50 scoring systems have been published for classification of trauma patients in the field, emergency room, and intensive care settings, so far. The present study aimed to compare the ability of trauma injury severity score (TRISS) and acute physiology and chronic health evaluation (APACHE) III in predicting mortality of intensive care unit (ICU) admitted trauma patients. Methods: This prospective cross-sectional study included ICU admitted multiple trauma patients of Imam Hossein and Hafte-Tir Hospitals, Tehran, Iran, during 2011 and 2012. Demographic data, vital signs, mechanism of injury and required variables for calculating APACHE III score and TRISS were recorded. The accuracy of the two models in predicting mortality of trauma patients was compared using area under the ROC curve. Results: 152 multiple trauma patients with mean age of 37.09 ± 14.60 years were studied (78.94% male). 48 (31.57%) cases died. For both APACHE III and TRISS, predicted death rates significantly correlated with observed death rates (p < 0.0001). The mean age of dead patients was 37.21 ± 14.07 years compared to 37.03±14.96 years for those who survived (p = 0.4). The area under ROC curve was 0.806 (95% CI: 0.663-0.908) for TRISS and 0.797 (95% CI: 0.652-0.901) for APACHE III (p = 0.2). Conclusion: Based on the results of this study, both TRISS and APACHE models have the same accuracy in predicting mortality of ICU admitted trauma patients. Therefore, it seems that TRISS model would be more applicable in this regard because of its easier calculation, consideration of trauma characteristics, and independency of patient care quality

Characteristics of Methadone Intoxicated Children Presenting to Emergency Department; a Cross Sectional Study

Introduction: Each year a large number of patients present to emergency departments (EDs) following accidental or intentional poisoning with methadone. This study was designed with the aim of demographic evaluation of methadone poisoning in children presenting to ED and proposing preventive measures to parents and the healthcare system. Methods: This cross sectional study was carried out on children under the age of 12 years presenting to ED of a poisoning referral center. Demographic characteristics of the child and parents, cause of poisoning, form of drug consumed, dose consumed, the symptoms of the child on admission, clinical examination, laboratory findings, and final outcome were recorded and reported using descriptive statistics. Results: 179 cases were studied (59.2% boys). Cause of consumption was accidental in 175 (97.8%) cases and consumed drug dose was unknown in 53 (53.6%) cases. On admission 6 cases were in deep coma, 133 (74.3%) had miotic pupils, and 52 (29.1%) were affected with respiratory apnea and cyanosis. In 132 (73.8%) cases drugs were obtained from unapproved stores and form of drug consumed was syrup in 146 (81.6%) cases. 177 (98.9%) cases were discharged after 2 or3 days and 2 (1.1%) cases died. Conclusion: Based on the results of the present study, most cases of methadone poisoning were accidental, in children residing in poor and middle-class areas, with parents who had a low level of education and had obtained the drug from unapproved stores and stored it in improper containers or at improper places. Only 64.8% of the parents were educated regarding drug storage

Review of Unusual Presentations of COVID-19

The world has faced the coronavirus disease 2019 (COVID-19) pandemic since the H1N1 influenza pandemic in 1918. The symptoms of this disease are spreading rapidly and affect almost all systems of the body. In addition to the common symptoms of the virus, numerous reports of rare symptoms of the virus have also been published. These atypical presentations can result in difficulty in diagnosing the disease. The aim of this work is to summarize “uncommon atypical presentations”, which have not received enough attention in descriptions of the disease presentation to date and the authors specifically discuss the important uncommon atypical presentations of COVID-19

Low-Dose Fentanyl, Propofol, Midazolam, Ketamine and Lidocaine Combination vs. Regular Dose Propofol and Fentanyl Combination for Deep Sedation Induction; a Randomized Clinical Trial

Introduction: Need for procedural sedation and analgesia (PSA) is felt in emergency department (ED) more and more each day. This study aimed to compare the effectiveness of low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination with regular dose of propofol and fentanyl combination for induction of deep sedation.Methods: In this single-blind clinical trial, candidate patients for sedation and analgesia aged more than 15 and less than 60 years old, with pain score ≥6 were allocated to one of the groups using block randomization and were compared regarding onset of action, recovery time, and probable side effects.Results: 125 patients with the mean age of 37.8 ± 14.3 years were randomly allocated to each group. 100% of the patients in group 1 (5 drugs) and 56.5% of the patients in group 2 (2 drugs) were deeply sedated in the 3rd minute after injection. The 2 groups were significantly different regarding onset of action (p = 0.440), recovery time (p = 0.018), and treatment failure (p < 0.001).Conclusion: Low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination was more successful in induction of deep sedation compared to regular dose of propofol and fentanyl combination. Recovery time was a little longer in this group and both groups were similar regarding drug side effects and effect on vital signs