METHODS: Non-inferiority randomized, clinical trial involving patients presenting with acute respiratory failure conducted in the ED of a local hospital. Participants were randomly allocated to receive either hCPAP or fCPAP as per the trial protocol. The primary endpoint was respiratory rate reduction. Secondary endpoints included discomfort, improvement in Dyspnea and Likert scales, heart rate reduction, arterial blood oxygenation, partial pressure of carbon dioxide (PaCO2), dryness of mucosa and intubation rate.
RESULTS: 224 patients were included and randomized (113 patients to hCPAP, 111 to fCPAP). Both techniques reduced respiratory rate (hCPAP: from 33.56 ± 3.07 to 25.43 ± 3.11 bpm and fCPAP: from 33.46 ± 3.35 to 27.01 ± 3.19 bpm), heart rate (hCPAP: from 114.76 ± 15.5 to 96.17 ± 16.50 bpm and fCPAP: from 115.07 ± 14.13 to 101.19 ± 16.92 bpm), and improved dyspnea measured by both the Visual Analogue Scale (hCPAP: from 16.36 ± 12.13 to 83.72 ± 12.91 and fCPAP: from 16.01 ± 11.76 to 76.62 ± 13.91) and the Likert scale. Both CPAP techniques improved arterial oxygenation (PaO2 from 67.72 ± 8.06 mmHg to 166.38 ± 30.17 mmHg in hCPAP and 68.99 ± 7.68 mmHg to 184.49 ± 36.38 mmHg in fCPAP) and the PaO2:FiO2 (Partial pressure of arterial oxygen: Fraction of inspired oxygen) ratio from 113.6 ± 13.4 to 273.4 ± 49.5 in hCPAP and 115.0 ± 12.9 to 307.7 ± 60.9 in fCPAP. The intubation rate was lower with hCPAP (4.4% for hCPAP versus 18% for fCPAP, absolute difference -13.6%, p = 0.003). Discomfort and dryness of mucosa were also lower with hCPAP.
CONCLUSION: In patients presenting to the ED with acute cardiogenic pulmonary edema or decompensated COPD, hCPAP was non-inferior to fCPAP and resulted in greater comfort levels and lower intubation rate.
OBJECTIVE: This narrative review describes the technical aspects and clinical indications of helmet continuous positive airway pressure (CPAP). In addition, we explore the advantages and challenges faced using this device at the Emergency Department (ED).
DISCUSSION: Helmet CPAP is tolerable than other NIV interfaces, provides a good seal and has good airway stability. During Covid-19 pandemic, there are evidences it reduced the risk of aerosolization. The potential clinical benefit of helmet CPAP is demonstrated in acute cardiogenic pulmonary oedema (ACPO), Covid-19 pneumonia, immunocompromised patient, acute chest trauma and palliative patient. Compare to conventional oxygen therapy, helmet CPAP had been shown to reduce intubation rate and decrease mortality.
CONCLUSION: Helmet CPAP is one of the potential NIV interface in patients with acute respiratory failure presenting to the emergency department. It is better tolerated for prolonged usage, reduced intubation rate, improved respiratory parameters, and offers protection against aerosolization in infectious diseases.
CASE SUMMARY: A 49-year-old male presented to the emergency department (ED) with acute hypoxemic respiratory failure. He was intubated and treated as pneumonia. Post-intubation, he became hypotensive, requiring fluid resuscitation and inotropic support. Resuscitative transesophageal echocardiography (TEE) showed external compression by a lung mass and an intraluminal thrombus causing SVC obstruction. Computed tomography (CT) angiography was performed, and it confirmed the TEE findings. A provisional diagnosis of lung carcinoma was made, and he underwent endovascular therapy for rapid symptomatic relief.
DISCUSSION: This case report highlights the role of resuscitative TEE in evaluating a hypotensive patient with clinical suspicion of SVCS at the emergency department. TEE performed at the bedside could help to diagnose and demonstrate the pathology causing SVCS in this case. TEE allowed high-quality image acquisition and was able to overcome the limitation of transthoracic echocardiography (TTE). TEE should be considered as an alternative ED imaging modality in the management of SVCS.
METHODS: We conducted a multinational retrospective cohort study involving adult trauma patients admitted to emergency departments in the included countries from 2016 to 2020. Prehospital and hospital data were reviewed from the Pan-Asia Trauma Outcomes Study database. Patients aged ≥18 years transported by emergency medical services were included. Patients lacking data regarding age, sex, physiological criteria, or injury severity scores were excluded. We examined the performance of sFTS in all age groups and fine-tuned physiological criteria to improve sFTS performance in identifying high-risk trauma patients in different age groups.
RESULTS: The sensitivity and specificity of the physiological and anatomical criteria for identifying major trauma (injury severity score ≥ 16) were 80.6% and 58.8%, respectively. The modified sFTS showed increased sensitivity and decreased specificity, with more pronounced changes in the young age group. Adding the shock index further increased sensitivity in both age groups.
CONCLUSIONS: sFTS using only physiological and anatomical criteria is suboptimal for Asian adult patients with trauma of all age groups. Adjusting the physiological criteria and adding a shock index as a triage tool can improve the sensitivity of severely injured patients, particularly in young age groups. A swift field triage process can maintain acceptable sensitivity and specificity in severely injured patients.
OBJECTIVES: To validate the HACOR scale in predicting NIV failure among acute cardiogenic pulmonary oedema (ACPO) patients.
DESIGN, SETTINGS AND PARTICIPANTS: This is a prospective, observational study of consecutive ACPO patients requiring NIV admitted to the ED.
OUTCOME MEASURE AND ANALYSIS: Primary outcome was the ability of the HACOR score to predict NIV failure. Clinical, physiological, and HACOR score at baseline and at 1 h, 12 h and 24 h were analysed. Other potential predictors were assessed as secondary outcomes.
MAIN RESULTS: A total of 221 patients were included in the analysis. Fifty-four (24.4%) had NIV failure. Optimal HACOR score was >5 at 1 h after NIV initiation in predicting NIV failure (AUC 0.73, sensitivity 53.7%, specificity 83.2%). As part of the HACOR score, respiratory rate and heart rate were not found to be significant predictors. Other significant predictors of NIV failure in ACPO patients were acute coronary syndrome, acute kidney injury, presence of congestive heart failure as a comorbid, and the ROX index.
CONCLUSIONS: The HACOR scale measured at 1 h after NIV initiation predicts NIV failure among ACPO patients with acceptable accuracy. The cut-off level > 5 could be a useful clinical decision support tool in ACPO patient. However, clinicians should consider other factors such as the acute coronary and acute kidney diagnosis at presentation, presence of underlying congestive heart failure and the ROX index when clinically deciding on timely invasive mechanical ventilation.
METHOD: We conducted a cross-sectional analysis to compare ChatGPT, Google Bard, and medical students in mass casualty incident (MCI) triage using the Simple Triage And Rapid Treatment (START) method. A validated questionnaire with 15 diverse MCI scenarios was used to assess triage accuracy and content analysis in four categories: "Walking wounded," "Respiration," "Perfusion," and "Mental Status." Statistical analysis compared the results.
RESULT: Google Bard demonstrated a notably higher accuracy of 60%, while ChatGPT achieved an accuracy of 26.67% (p = 0.002). Comparatively, medical students performed at an accuracy rate of 64.3% in a previous study. However, there was no significant difference observed between Google Bard and medical students (p = 0.211). Qualitative content analysis of 'walking-wounded', 'respiration', 'perfusion', and 'mental status' indicated that Google Bard outperformed ChatGPT.
CONCLUSION: Google Bard was found to be superior to ChatGPT in correctly performing mass casualty incident triage. Google Bard achieved an accuracy of 60%, while chatGPT only achieved an accuracy of 26.67%. This difference was statistically significant (p = 0.002).
METHODS/RESULTS: We report a case of a multiple ECG lead misplacement made across two different planes of the heart, resulting in a bizarre series of ECG, mimicking an acute high lateral myocardial infarction. Multiple ECGs were done as there were abrupt changes compared to previous ECGS. Patient was pain free and administration of potentially harmful procedures and treatments were prevented.
CONCLUSION: Our case demonstrated the importance of high clinical suspicion in diagnosing ECG lead misplacement. It is the responsibility of both the healthcare workers who are performing and interpreting the ECG to be alert of a possible lead malposition, to prevent untoward consequences to the patient.
METHODS: This single-centre retrospective study analysed data on consecutive STEMI patients who received thrombolytic therapy from May 2019 to December 2020 (20 months) in a non-PCI capable tertiary hospital. Total population sampling was used in this study. We compared all patients' characteristics and outcomes ten months before and during the pandemic. Regression models were used to assess the impact of COVID-19 pandemic on door-to-needle time (DNT), mortality, bleeding events, and the number of overnight stays.
RESULTS AND DISCUSSION: We analysed 323 patients with a mean age of 52.9 ± 12.9 years and were predominantly male (n = 280, 88.9%). There was a 12.5% reduction in thrombolysis performed during the pandemic. No significant difference in timing from symptoms onset to thrombolysis and DNT was observed. In-hospital mortality was significantly higher during the pandemic (OR 2.02, 95% CI 1.02-4.00, p = 0.044). Bleeding events post thrombolysis remained stable and there was no significant difference in the number of overnight stays during the pandemic.
CONCLUSION: STEMI thrombolysis cases were reduced during the COVID-19 pandemic, with an inverse increase in mortality despite the preserved Emergency Department performance in timely thrombolysis.
METHODS: This retrospective study was conducted in emergency departments of two tertiary hospitals from June 1 to August 31, 2021. Consecutive patients aged >18 years admitted for COVID-19-related HRF (World Health Organization criteria: confirmed COVID-19 pneumonia with respiratory rate > 30 breaths/min, severe respiratory distress, or peripheral oxygen saturation < 90% on room air) requiring NRB + NC or HFNC were screened for enrollment. Primary outcome was improvement of partial pressure arterial oxygen (PaO2) at two hours. Secondary outcomes were intubation rate, ventilator-free days, hospital length of stay, and 28-day mortality. Data were analyzed using linear regression with inverse probability of treatment weighting (IPTW) based on propensity score.
RESULTS: Among the 110 patients recruited, 52 (47.3%) were treated with NRB + NC, and 58 (52.7%) with HFNC. There were significant improvements in patients' PaO2, PaO2/FIO2 ratio, and respiratory rate two hours after the initiation of NRB + NC and HFNC. Comparing the two groups, after IPTW adjustment, there were no statistically significant differences in PaO2 improvement (adjusted mean ratio [MR] 2.81; 95% CI -5.82 to 11.43; p = .524), intubation rate (adjusted OR 1.76; 95% CI 0.44 to 6.92; p = .423), ventilator-free days (adjusted MR 0.00; 95% CI -8.84 to 8.85; p = .999), hospital length of stay (adjusted MR 3.04; 95% CI -2.62 to 8.69; p = .293), and 28-day mortality (adjusted OR 0.68; 95% CI 0.15 to 2.98; p = .608).
CONCLUSION: HFNC may be beneficial in COVID-19 HRF. NRB + NC is a viable alternative, especially in resource-limited settings, given similar improvement in oxygenation at two hours, and no significant differences in long-term outcomes. The effectiveness of NRB + NC needs to be investigated by a powered randomized controlled trial.
OBJECTIVES: This study aimed to compare the outcomes of patients with moderate to severe TBI treated with Sterofundin (SF) versus NS.
DESIGN, SETTINGS AND PARTICIPANTS: A double-blinded randomised controlled trial of patients aged 18 to 65 years with TBI was conducted at the University Malaya Medical Centre from February 2017 to November 2019.
INTERVENTION OR EXPOSURE: Patients were randomly assigned to receive either NS or SF. The study fluids were administered for 72 h as continuous infusions or boluses. Participants, investigators, and staff were blinded to the fluid type.
OUTCOMES MEASURE AND ANALYSIS: The primary outcome was in-hospital mortality. Relative risk (RR) with 95% confidence interval (CI) was calculated.
MAIN RESULTS: A total of 70 patients were included in the analysis, with 38 in the NS group and 32 in the SF group. The in-hospital mortality rate were 3 (7.9%) in the NS group vs. 4 (12.5%) in the SF group, RR = 1.29 (95% CI, 0.64 to 2.59; p = 0.695). No patients developed AKI and required renal replacement therapy. ICP on day 3 was significantly higher in the SF group (18.60 ± 9.26) compared to 12.77 ± 3.63 in the NS group, (95% CI, -11.46 to 0.20; p = 0.037). There were no significant differences in 3-day biochemical parameters and cerebral perfusion pressure, ventilator-free days, length of ICU stay, or Glasgow Outcome Scale-Extended (GOS-E) score at 6 months.
CONCLUSIONS: In patients with moderate to severe TBI, the use of SF was not associated with reduced in-hospital mortality, development of AKI, or improved 6-month GOS-E when compared to NS.