A Simple Strategy for the Sterile Use of Reusable Laryngoscope Blades in Resource Limited Countries

The laryngoscope blade has a potential role for crossinfection due to its contamination with bacteria, blood,and microorganisms. Cleaning the laryngoscope bladehas various methods in different countries. Most operatingrooms have no guidelines for laryngoscope disinfectionafter each usage (1). Some use tap water for cleaningwhich is an inadequate method while others add disinfectantto tap water which is more effective for the controlof infection, but this may result in the emergence ofresistant bacteria. There are so many disinfectants likealdehyde-free biguanide and Chlorine dioxide or chlorhexidinewithout any international guideline for commonpractice. Cleaning with most of these disinfectants istime consuming and needs at least 10 minutes for disinfection(2). In some centers, anesthesiologists use disposableblade laryngoscopes which brings, sometimes, difficultyin airway management especially in the emergencysituations compared to standard laryngoscopes, becauseof the shape of the blade or light carrying capacity. Most ofthe single-use laryngoscopes tested were significantly inferiorto the standard Macintosh blade. This raises concernover their use in clinical practice, particularly if intubationis difficult (3). The cost of disposable blades for laryngoscopesis almost 5 to 10 dollars

The Role of Respiratory System Surface Area and Ventilation Volume in Severity and Mortality of COVID-19 Infection

According to epidemiologic and analytic studies of different countries during coronavirus disease 2019 (COVID-19) pandemic, high prevalence of the disease, more hospitalization, getting a more severe form of the disease, diffused peripheral distribution of opacities, more need to receiving ICU care, poor prognosis, and high mortality rate in men compared with women were obtained. The causes of the above gender differences in subsequent studies were attributed to several factors including behavioral use of masks or handwashing, as well as genetic, hormonal, and immunological factors. Also in the past epidemiologic studies, a higher prevalence of severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS) among men was shown than women. Despite the lack of accurate statistical studies, some evidence shows high severe COVID-19 incidence and mortality rate in athlete’s society compared with non-athletes. Respiratory sex-related differences in women include smaller lung volumes, smaller-diameter conducting airways, smaller radial rib cage dimensions, shorter diaphragm, and fewer lung function parameters such as ventilation volume. Originally and typically, athletes have high lung volumes and capacities such as forced expiratory volume in 1 second (FEV1), especially high ventilation volume. It is well-known that in COVID-19 infection, the main route of transmission is respiratory droplets and direct contact with infected people. Hence, this hypothesis is raised that higher lung ventilation volume ratio of men than women and athletes than non-athletes may be the major reason for the difference of COVID-19 infection based on sex. In other words, in the same condition, men expose more viral load than women, also athletes receive more viral load than non-athletes. Viral load is a critical parameter in the severity and mortality of COVID-19 infection. The offered hypothesis may recognize a potential approach in future studies and investigations of COVID-19 infection. Confirmation of this theory in comer studies may update health advice and improve precaution recommendations between athletes and non-athletes as well as men and women based on the surface area of the respiratory system

Family Members’ Attitudes Regarding Family Presence During Resuscitation of Adults: A Systematic Review and Meta Analysis

Context: Family presence during resuscitation (FPDR) is a controversial debate throughout the world. Experts believe that FPDRis a cultural and ethnical issue and that countries have different views regarding this matter. The aim of this study is a systematicreview and meta-analysis of all available studies assessing patient families’ views regarding their presence during resuscitation.Evidence Acquisition: Studies reported attitudes of the patients’ relatives toward FPDR were eligible for inclusion. Case reports,letters, opinion pieces, and reviews were excluded from the study. A systematic search was conducted in Medline, Embase, CINAHL,Cochrane library,Web of Science, SCOPUS, PsycInfo, and other related databases based on selected keywords. The qualities of studieswere assessed using Critical Appraisal Skills Programme (CASP) and STROBE statement. Comprehensive meta-analysis (version-2)was used for data analysis. Heterogeneity was assessed using the Cochrane Q-statistic and the I2 statistic. Publication bias was detectedthrough funnel plot.Results: A total of 18 studies were selected, including 10 cross-sectionals and 8 control trials. The results were categorized in threeitems: tendency for being present, satisfaction, and coping. A meta-analysis was done for 9 descriptive cross-sectional studies. Theevent rate of being present was 0.73 (95% CI: 0.60 - 0.83), which was statistically significant (P = 0.001), whereas the event rate ofcoping was 0.62 (95% CI: 0.48 - 0.73) and was not statistically significant.Conclusions: The results of this study showed that the patients’ families tend to be present during resuscitation and believe thatsome rules should support FPDR. In terms of anxiety disorders and PTSD, when there were more intervals, family’s presence andtheir emotional supports had a positive effect on them. However, the role of the medical staff cannot be ignored in this regard

Using Ketamine and Propofol for Procedural Sedation of Adults in the Emergency Department: A Systematic Review and Meta-Analysis

Purpose: Ketamine-propofol combination (ketofol) is being used to provide a safe and effective procedural sedation (PS) in emergency department (ED) and may theoretically have beneficial effects since using lower doses of each drug may result in a reduction of the adverse events of both agents while maintaining optimal conditions for performing procedures. This systematic review was conducted to evaluate the efficacy, advantages and disadvantages of these two drugs for PS. Methods: The PRISMA statement was used for this systematic review. We searched the databases of PubMed, Scopus, ProQuest, Medline (Ovid) from 1990 to August 2017 for randomized clinical trials (RCTs) in which the study population aged ≥18 and was referred to ED. Full-texts of the studies performed in adults that were published in English were reviewed for inclusion. Both authors independently evaluated all studies. Five articles were eligible for the meta-analysis based on their common outcomes. Results: The total number of subjects was 1250, of which 635 were treated with propofol and 615 were treated with ketofol. Although two of the five studies showed a better quality of sedation with ketofol, the other three did not find any significant difference between propofol and ketofol. This systematic review found a lower incidence of respiratory adverse effects in ketofol group than propofol group. Conclusion: Ketamine/propofol mixture (ketofol) has less respiratory adverse effects than propofol alone in ED procedural sedation

Role of anesthesiology curriculum in improving bag-mask ventilation and intubation success rates of emergency medicine residents: a prospective descriptive study

<p>Abstract</p> <p>Background</p> <p>Rapid and safe airway management has always been of paramount importance in successful management of critically ill and injured patients in the emergency department. The purpose of our study was to determine success rates of bag-mask ventilation and tracheal intubation performed by emergency medicine residents before and after completing their anesthesiology curriculum.</p> <p>Methods</p> <p>A prospective descriptive study was conducted at Nikoukari Hospital, a teaching hospital located in Tabriz, Iran. In a skills lab, a total number of 18 emergency medicine residents (post graduate year 1) were given traditional intubation and bag-mask ventilation instructions in a 36 hour course combined with mannequin practice. Later the residents were given the opportunity of receiving training on airway management in an operating room for a period of one month which was considered as an additional training program added to their Anesthesiology Curriculum. Residents were asked to ventilate and intubate 18 patients (Mallampati class I and ASA class I and II) in the operating room; both before and after completing this additional training program. Intubation achieved at first attempt within 20 seconds was considered successful. Successful bag-mask ventilation was defined as increase in ETCo₂to 20 mm Hg and back to baseline with a 3 L/min fresh gas-flow and the adjustable pressure limiting valve at 20 cm H₂O. An attending anesthesiologist who was always present in the operating room during the induction of anesthesia confirmed the endotracheal intubation by direct laryngoscopy and capnography. Success rates were recorded and compared using McNemar, marginal homogeneity and paired t-Test tests in SPSS 15 software.</p> <p>Results</p> <p>Before the additional training program in the operating room, the participants had intubation and bag-mask ventilation success rates of 27.7% (CI 0.07-0.49) and 16.6% (CI 0-0.34) respectively. After the additional training program in the operating room the success rates increased to 83.3% (CI 0.66-1) and 88.8% (CI 0.73-1), respectively. The differences in success rates were statistically significant (P = 0.002 and P = 0.0004, respectively).</p> <p>Conclusions</p> <p>The success rate of emergency medicine residents in airway management improved significantly after completing anesthesiology rotation. Anesthesiology rotations should be considered as an essential component of emergency medicine training programs. A collateral curriculum of this nature should also focus on the acquisition of skills in airway management.</p

Determination of the Predictive Value of Serum Bilirubin in Patients with Ischemic Stroke: A Prospective Descriptive Analytical Study

Purpose: In all types of ischemic stroke, especially in the acute phase, excessive oxidative stress causes structural and functional damage to the brain. This may play a major role in the pathophysiology of the brain damage. Higher serum levels of bilirubin have therapeutic effects in oxidative stress-induced stroke. Nevertheless, role of increased serum levels of bilirubin in the acute phase of ischemic stroke is controversial. Methods: This study was a cross-sectional prospective descriptive study conducted in the Emergency Department (ED) of Imam Reza hospital, Tabriz University of Medical Sciences, Tabriz, Iran, throughout six months. 275 ischemic stroke patients were evaluated based on their brain CT scan infarct size, NIHSS, MRS, and serum levels of bilirubin. Later, data were analyzed using SPSS software. Results: Total, direct and indirect bilirubin levels were significantly higher in expired patients (p< 0.0001). Total (p< 0.0001), direct (p< 0.0001) and indirect (p< 0.0001) bilirubin levels, NIHSS score (p< 0.0001), and ischemic area (p< 0.0001) significantly predicted the outcome in these patients. Conclusion: Total, direct and indirect bilirubin levels was significantly associated with mortality in the acute phase of ischemic stroke patients

Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department

Abstract Background Despite the fact that numerous medications have been introduced to treat renal colic, none has been proven to relieve the pain rapidly and thoroughly. In this study, we aimed at comparing the effects of intravenous lidocaine versus intravenous morphine in patients suffering from renal colic. Methods In a prospective randomized double-blind clinical trial performed in the emergency department of Imam Reza educational hospital of Tabriz, Iran, we studied 240 patients, 18–65 years old, who were referred due to renal colic. Patients were divided into two groups. In group I (120 people) single-dose intravenous lidocaine (1.5 mg/kg) was administered and in group II (120 people) single-dose intravenous morphine (0.1 mg/kg) was administered slowly. Visual Analogue Pain Scale (VAS) was recorded while admission, 5, 10, 15 and 30 minutes after injection. Statistical data and results were studied using descriptive statistics as percentage and Mean ± SD. To compare the response to treatment, Mann–Whitney U-test was used in two groups. Consequently, the data were analyzed using the SPSS16 software. Results Pain score measured in two groups five minutes after the injection of lidocaine and morphine were 65 % and 53 % respectively (95% CI 0.60 - 0.69, CI 0.48 – 0.57, p = 0.0002).108 (90 %) patients (95 % CI 0.84 – 0.95) from group I and 84 (70%) patients (95 % CI 0.62 - 0.78) from group II responded appropriately at the end of the complete treatment. The difference was statistically significant (p = 0.0001). Conclusions Changing the smooth muscle tone and reducing the transmission of afferent sensory pathways, lidocaine causes a significant reduction in pain. Trial registration Clinical Trials IRCT138901042496N3</p