Evaluating ED Nurses' Knowledge, Self-reported Competencies & Attitude in Sepsis by an Education Program
Bing Yin LEE
,
Sun Fei LI
,
Kathleen ROTHERAY
Year:
2026
Sepsis has been regarded as one of the cardinal causes of death across the globe. Its significance and time-critical nature accounted for 20% of worldwide deaths, according to a 2024 WHO study. As for the Hong Kong condition, Ling et al. have documented a 21% surge in incidence and 1-in-4 deaths from 2009 – 2018 in the Intensive Care Unit of Hong Kong, leading to a major health burden to society. Emergency Department (ED) Nurses as the ‘gatekeeper’ for various life-threatening diseases, while it appears not to be the case in the ‘Hour-1-Sepsis Bundle', judging by its low compliance rate. Nevertheless, various studies focused on Sepsis management instead of reviewing knowledge, attitude, and self-reported competencies of ED Nurses towards Sepsis screening, or implementing educational programs prompting early identification of Sepsis in the ED This is a single-center interventional study conducted in the ED of Kwong Wah Hospital. 70 eligible ED...
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KID THAT DO METH CASE REPORT ON PEADIATRIC METHHEMOGLOBINEMIA
Sifrah Isaac
,
Nitin Jagasia
Year:
2026
Methemoglobinemia is a rare but life-threatening hematologic condition where hemoglobin is oxidized from the ferrous (Fe2+) to the ferric (Fe3+) state, impairing oxygen delivery to tissues. While congenital forms exist, acquired methemoglobinemia often triggered by medications or chemical exposures is more common. Prevalence in pediatric populations is estimated at approximately 0.0015%. Case Presentation: A 6-year-old male presented to the Apollo Hospitals Navi Mumbai Emergency Department with fever, abdominal pain, vomiting, epistaxis, and acute breathlessness. Physical examination revealed central and peripheral cyanosis with an SpO2 of 88% on room air, which only improved to 92% despite high-flow oxygen (10L). Notably, the patient had a history of exposure to a watch repair solution and prior consumption of "outside food." Diagnostic Workup: Venous Blood Gas (VBG) analysis confirmed methemoglobinemia with a level (FMetHb) of 31.0% and respiratory alkalosis. Laboratory results showed mild thrombocytopenia (Platelets: 89,000) and a normal hemoglobin (15.5 g/dL)....
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The 3Ps Framework (Physiology–Profile–Plan): A Physiology-Based, Ultrasound-Guided Approach to Individualized Shock Resuscitation
Abdolghader Pakniyat
,
Sabrina Berdouk
,
Shahryar Lahouti
,
Rasha Buhumaid
Year:
2026
Abstract: Background: shock is a complex condition where similar vital signs at the bedside can actually reflect very different underlying physiology. While protocol-driven management helps stabilize early, it can sometimes mismatch treatment to the patient’s actual physiology, especially in undifferentiated shock. This can lead to avoidable harm, such as fluid overload or using the wrong vasoactive medications. Objective: To introduce a practical, physiology-based framework that uses bedside ultrasound to help tailor early assessment and treatment for patients in shock. Methods/Framework: After reviewing the subject, we introduce the Physiology–Profile–Plan (3Ps) framework, a quick, repeatable clinical process that complements ABC resuscitation. The first step, Physiology, is to identify the main cause of shock, such as pump failure, vasodilation (pipe failure), volume loss, obstruction, or a combination of these. Profile creates a real-time picture of the patient’s hemodynamics by combining clinical exams with various types of monitoring, with a focus on...
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A Novel Trajectory-Based, Anticipatory Model for the Management of Emergency, Intensive Care, and Chronic Conditions, Exemplified by Hypertension
abdulatif Aljaili Aljaili Mohamed
Year:
2026
TITLE A Novel Trajectory-Based, Anticipatory Model for the Management of Emergency, Intensive Care, and Chronic Conditions, Exemplified by Hypertension AUTHOR Abdulatif Aljaili Mohammed ABSTRACT Background:Conventional hypertension management relies on fixed diagnostic thresholds, most commonly 140/90 mmHg. This threshold-based approach is inherently reactive and often permits silent vascular injury to progress for years before intervention is initiated. Such delays may contribute to irreversible cardiovascular, cerebrovascular, and renal complications that ultimately present as emergencies, increasing emergency department (ED) visits and intensive care unit (ICU) admissions. Objective:To introduce the Progressive Serial Incremental Change (PSIC) Model, a novel trajectory-based framework that reconceptualizes hypertension as a dynamic process rather than a static threshold, enabling earlier identification of pathological blood pressure evolution and anticipatory intervention. Methods / Conceptual Framework:Serial blood pressure measurements can demonstrate gradual, progressive increases over time—such as readings evolving from 110 mmHg to 114 mmHg, 117 mmHg, and 119 mmHg...
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Evaluating ED Nurses' Knowledge, Self-reported Competencies & Attitude in Sepsis by an Education Program
BING YIN LEE
,
Sun Fei LI
,
Kathleen ROTHERAY
Year:
2026
Sepsis has been regarded as one of the cardinal causes of death across the globe. Its significance and time-critical nature accounted for 20% of worldwide deaths, according to a 2024 WHO study. As for the Hong Kong condition, Ling et al. have documented a 21% surge in incidence and 1-in-4 deaths from 2009 – 2018 in the Intensive Care Unit of Hong Kong, leading to a major health burden to society. Emergency Department (ED) nurses are the ‘gatekeepers’ for various life-threatening diseases, while it appears not to be the case in the ‘Hour-1-Sepsis Bundle', judging by its low compliance rate. Nevertheless, various studies focused on Sepsis management instead of reviewing knowledge, attitude, and self-reported competencies of ED Nurses towards Sepsis screening, or implementing educational programs prompting early identification of Sepsis in the ED This is a single-center interventional study conducted in the ED of Kwong Wah Hospital. 70 eligible ED...
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Fatal Metformin Overdose Leading to MALA and Abdominal Compartment Syndrome: A Case Report
Ryu John Mori-Iwatate
,
Hitoshi Koga
,
Hideaki Yoshihara
,
Takahito Hayashi
Year:
2026
Background: Metformin-associated lactic acidosis (MALA) is a well-recognized adverse effect of metformin, which can rapidly progress to severe clinical features including altered mental status, respiratory failure, circulatory failure, and multiple organ dysfunction syndrome. While MALA is known, fatal cases resulting from intentional metformin overdose for suicide are comparatively rare, posing unique management challenges. Case Presentation: A 56-year-old male with a history of hypertension and diabetes mellitus was found unconscious in a bathtub with multiple wrist lacerations. A suicide note and empty blister packs of prescription medication were discovered nearby, including a total of 162 hypoglycemic tablets containing 10,500 mg of metformin. He was initially transported to a local hospital, where he received fluid resuscitation and bicarbonate therapy for severe lactic acidosis (pH 7.186, lactate 16.0 mmol). However, the acidosis remained uncorrected, and transfer to our facility was arranged due to the lack of continuous hemodiafiltration (CHDF) capabilities at the referring...
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Delayed Non-Cardiogenic Pulmonary Edema After Amlodipine Overdose: A Case Highlighting Atypical Complications
KAM HANG LEONG
,
HOI IP LEONG
,
Tam Fei Chang
Year:
2026
Introduction: Calcium channel blocker (CCB) overdose typically presents with early hypotension and bradycardia. This case highlights an unusual delayed complication in a 21-year-old female with iron deficiency anemia, depression, and connective tissue disease who intentionally ingested 100 mg of amlodipine. Case Presentation: The patient presented 2 hours post-ingestion with dizziness, hypotension (98/57 mmHg), tachycardia (HR 103 bpm), and mild fever (37.7°C). Initial management included IV calcium gluconate and hydration. Unexpectedly, 20 hours later, she developed acute hypoxemia and dyspnea. Imaging revealed bilateral pulmonary infiltrates, pleural effusions, atelectasis, and B-lines on ultrasound, with preserved ejection fraction. NT-proBNP escalated sharply (46 → 1701 → 2002 pg/mL). She was managed with diuretics, steroids, and high-flow nasal cannula (HFNC) oxygen, with suspected non-cardiogenic pulmonary edema. Key Learning Points: Atypical Delayed Complication: CCB overdose may precipitate late-onset non-cardiogenic pulmonary edema despite initial hemodynamic stabilization. Role of Biomarkers & Imaging: Rising NT-proBNP with preserved...
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The 3Ps Framework (Physiology–Profile–Plan): A Physiology-Based, Ultrasound-Guided Approach to Individualized Shock Resuscitation
Abdolghader Pakniyat
,
Sabrina Berdouk
,
Shahryar Lahouti
,
Rasha Buhumaid
Year:
2026
Abstract: Background: shock is a complex condition where similar vital signs at the bedside can actually reflect very different underlying physiology. While protocol-driven management helps stabilize early, it can sometimes mismatch treatment to the patient’s actual physiology, especially in undifferentiated shock. This can lead to avoidable harm, such as fluid overload or using the wrong vasoactive medications. Objective: To introduce a practical, physiology-based framework that uses bedside ultrasound to help tailor early assessment and treatment for patients in shock. Methods/Framework: After reviewing the subject, we introduce the Physiology–Profile–Plan (3Ps) framework, a quick, repeatable clinical process that complements ABC resuscitation. The first step, Physiology, is to identify the main cause of shock, such as pump failure, vasodilation (pipe failure), volume loss, obstruction, or a combination of these. Profile creates a real-time picture of the patient’s hemodynamics by combining clinical exams with various types of monitoring, with a focus on point-of-care ultrasound (POCUS). Important ultrasound checks include evaluating...
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Understanding Delays in Injury Care: Determinants Across Four Low- and Middle-Income Countries
Leila Ghalichi
,
Kathryn Chu
,
Justine Davies
Year:
2026
Background: Timely access to care is a key pillar of health system quality. Reducing delays before admission to definitive care improves outcomes for patients with time-sensitive conditions, including trauma. Despite growing interest in reducing time to definitive care in many low- and middle-income countries (LMICs) and the disproportionately high burden of injuries in these countries, empirical evidence from these settings remains limited. In this study, we present the associated factors of delays experienced by injured patients admitted to hospitals, as part of the Equi-Injury study, which aims to understand access to quality injury care in LMICs. Methods: We recruited moderately to severely injured patients who were admitted for at least twelve hours to nineteen healthcare facilities across Ghana, Pakistan, Rwanda, and South Africa. Data were collected on demographics, socioeconomics, injury characteristics, the patient journey from injury to definitive care (including transport taken and number of prior facilities visited), and time...
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MILKSHAKE OF TOXINS: A Case Report on Mixed Pesticide ingestion (Chlorpyrifos, Cypermethrin, Herbicide and Xylene)
Kristine Marie Santos
,
Sheina Singlao-Vargas
,
Bryan Ben Cagayao
,
Deogracias Espiritu
Year:
2026
BACKGROUND: There is a growing burden or pesticide poisoning in the Philippines due to easy availability and inadequate regulatory oversight. The varying toxicities of different pesticides can complicate management, especially due to the limited understanding of the synergistic effects or increased toxicity that may result from combinations of these chemicals. CASE REPORT This case presents a 63-year-old male who ingested 3 bottles of pesticides with the active ingredients of Chlorpyrifos, Cypermethrin, Butachlor, Pretilachlor and Xylene. The patient was referred by EMS following a poisoning incident, with medical directives to ventilate using a BVM, provide immediate transport, and bring the pesticide bottles for identification. At the ED, the patient is unresponsive, hypotensive 80/60 mmHg, tachycardic at 116 beats per minute (bpm), tachypneic 31 breaths per minute, and desaturation of 89%. He had pinpoint pupils and milky-white, petroleum-like oral secretions. On further history, he had been drinking alcohol with...
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Severe Venom-Induced-Consumption-Coagulopathy and Compartment Syndrome Following Saw-Scaled Viper envenomization: a case report
Fatimetou Ba
,
Yusuf Mohamed Ali Saleh Abbas
,
Maryam Alrazooqi
,
Reem Khalid
,
Nandakumar Vadivelu
Year:
2026
Venom induced coagulopathy is a well-recognized and common complication of viper snakes. Few cases are reported from the Middle East region, where the Echis species is a particularly problematic genus of the Viperidae family, with untreated envenomations carrying an estimated 20% mortality rate. Presence of destructive enzymes in the snake venom enables them to produce their local tissue damage effects, which manifest as localized edema that can in rare cases progress into limb threatening compartment syndrome. Here we present the case of a 34 years old man who experienced a saw-scaled viper snake bite to his right index finger. In the matter of a few hours, the patient developed rapidly progressive pain and swelling that extended to his forearm despite receiving Saudi polyvalent anti-venom at a rural facility. Shortly after the patient attended a tertiary center where not only his swelling was increasing to involve the arm, but his coagulation profile...
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Causes of and Mortality and Morbidity after injuries in Four low- and middle-income countries
Leila Ghalichi
,
Justine Davies
,
Kathryn Chu
Year:
2026
Background:Injuries are a leading global health concern, accounting for 4.4 million deaths annually and contributing significantly to disability and healthcare demands. Up to 40% of injured individuals experience long-term disability, and injuries contribute to approximately 10% of the global burden of disease. Outcomes vary significantly across countries and settings, with a disproportionately high share of adverse outcomes happening in low- and middle-income countries (LMICs). Despite this, data on injury outcomes in LMICs remain limited. This study presents post-injury mortality and morbidity from the Equi-Injury project, which aimed to explore facilitators and barriers to equitable access to quality care after injury in LMICs. Methods:We recruited patients with moderate to severe injuries from 19 hospitals across Ghana, Pakistan, Rwanda, and South Africa. Data were collected on demographics, socioeconomics, injury characteristics, the patient journey from injury to definitive care (including transport taken and number of prior facilities visited), and outcomes of death or...
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Narrative Review: Trauma Care and Massive Transfusion Protocols in the Emergency Department
Jassica Jeniffer Adaikalanathan
Year:
1970
Background: Despite advances in trauma care, haemorrhagic shock continues to be one of the leading causes of preventable deaths after injury. Often, the difference between life and death comes down to how quickly the bleeding is recognized and treated especially in the emergency department. To address this, hospitals have developed Massive Transfusion Protocols (MTPs), which provide a structured, team-based approach to rapidly deliver the right balance of blood products. These protocols are designed to give critically bleeding patients the best possible chance of survival when every second counts. Objective: This narrative review synthesizes contemporary literature and international guidelines on the implementation and impact of MTPs in trauma care, highlighting evolving strategies, current challenges, and future directions. Methods: A narrative review was conducted using a systematic search of PubMed, Scopus, and Google Scholar databases. Boolean operators and relevant keywords were used to identify peer-reviewed articles, clinical guidelines, and consensus statements published...
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Gender-Based Job Satisfaction in Emergency Department: An Audit at Colombo South Teaching Hospital, Sri Lanka.
Nilanka Mudithakumara
,
Senitha Asanka Liyanage
Year:
1970
Introduction: Emergency Department(ED) job satisfaction is a critical determinant of ED healthcare workers' well-being, staff retention especially in the Low and Middle middle-income country(LMIC) excessive overcrowded and limited resources setting, where both “job satisfaction” and “gender-based issues” are less discussed. This comprehensive audit was initiated at Accident and Emergency Department( A&E) of Colombo South Teaching Hospital(CSTH), Sri Lanka to identify specific domains of “gender disparity in job satisfaction” for an evidence-based, targeted departmental intervention for quality improvement. Methods: A single-centre, cross-sectional audit was conducted in early 2025 within CSTH A&E (average 400-500 patients per day). This audit included the permanent ED HCW, including physicians and nursing officers. Data was collected via an anonymous, voluntary, self-administered online/ printed questionnaire specified to LMIC ED context issues. Domains assessed included overall job satisfaction, gender bias, environment and work-life balance, burnout and compensation, workplace equity, unconscious bias, threats, expectations and support available. Results: A robust...
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Drowning Incidents Among Foreign Nationals in Okinawa: A Retrospective Study Using Helicopter Emergency Medical Service Data
Yosuke Tanaka
,
Michitaka Nasu
,
Terutake Yonemori
Year:
1970
Background:Drowning remains a major cause of accidental death worldwide, particularly in coastal and tourist regions. Previous studies have suggested that foreign nationals may be disproportionately affected by drowning incidents; however, analyses based on systematic prehospital emergency medical data are limited, and no such studies have been conducted in Japan. Methods:We retrospectively reviewed drowning-related helicopter emergency medical service (HEMS) dispatches in Okinawa Prefecture, Japan, between April 2016 and March 2025. Only completed dispatches were included. Patient characteristics included age, sex, nationality (Japanese or foreign national), and cardiopulmonary arrest (CPA) status. To evaluate the impact of international travel restrictions, cases were categorized into three periods: pre-COVID (April 2016–January 2020), COVID period (February 2020–May 2023), and post-COVID (June 2023–March 2025). Results:During the study period, 226 drowning-related HEMS dispatches were recorded, of which 170 were accepted and analyzed. The median patient age was 43 years (interquartile range 25–59), and 65.3% of patients presented with...
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FROM FATAL TO FUNCTIONAL: A TRAUMA CASE WITH EXTREME ACIDOSIS AND FULL RECOVERY
Aanchal Bhandari
,
Kishalay Datta
,
Anita Rawat
,
Priya Govil
,
Arun Kaushik
,
Surjeet Acharya
Year:
1970
Introduction Arterial pH levels below 6.8 are traditionally considered incompatible with life due to irreversible cellular dysfunction and poor survival. Severe acidosis with concurrent hyperkalemia and critical anemia presents an exceptional resuscitation challenge. This case describes full recovery in a patient with a pH of 6.75 after traumatic hemorrhagic shock, highlighting how aggressive, multidisciplinary management can reverse physiology once deemed fatal. Aims / Objectives To report a trauma patient’s survival and full recovery from extreme acidosis, hyperkalemia, and anemia, underscoring the value of rapid correction and coordinated resuscitation in restoring physiological stability. Materials / Methods A multidisciplinary trauma, surgical, and critical care approach was employed using institutional massive transfusion and resuscitation protocols. Serial clinical, hemodynamic, and metabolic assessments guided real-time management, including fluid and blood replacement, electrolyte correction, and definitive surgical intervention. Case Description A 42-year-old male with no comorbidities presented 15 minutes after a high-speed motor vehicle collision with...
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ACUTE GASTRIC VOLVULUS IN A PATIENT WITH HIATUS HERNIA: A RARE CASE REPORT
Maryam Khan
,
Janath Wijesinghe
Year:
1970
Background:Acute gastric volvulus is a rare but potentially life-threatening condition that requires promptrecognition and management. Its non-specific clinical presentation often poses diagnosticchallenges, particularly in patients with predisposing anatomical anomalies such as a hiatushernia. Case Presentation:We report the case of a 48-year-old female who presented with a 24-hour history of sudden-onset, continuous upper abdominal pain and vomiting. Her medical history included asthmaand gastritis secondary to a known hiatus hernia. Examination revealed upper abdominaltenderness and bi-basal crepitations, predominantly on the right side. Laboratoryinvestigations showed elevated inflammatory markers, including a white cell count of 19.5(neutrophils 16.9) and a CRP of 320.A contrast-enhanced CT scan confirmed a large hiatus hernia complicated by gastricvolvulus, along with a right lower lobe pneumonia suggestive of aspiration. The patient wasmanaged conservatively with nasogastric decompression, intravenous fluids, and antibiotics,and was referred for surgical evaluation. Conclusion:This case highlights the importance of maintaining a high index of suspicion for gastricvolvulus in...
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A rare case of global aphasia without hemiparesis (GAWH): An atypical stroke presentation
DR HIMANSHU GUL MIRANI
Year:
1970
Background: Aphasia without accompanying motor deficit is an uncommon neurological presentation that may lead to diagnostic delay in emergency settings. Global aphasia without hemiparesis presents a particular challenge, as it may mimic seizure, metabolic encephalopathy, or postictal states, especially when early neuroimaging is unrevealing. Case Presentation: An 84-year-old man with a background of asthma was brought to the emergency department following a witnessed episode of vacant staring with possible brief limb movements lasting approximately one minute. There was no loss of continence, tongue biting, prodromal symptoms, or aura. He had been well earlier that day, with no history of alcohol misuse, recent trauma, infection, or anticoagulant use. Following the episode, the patient demonstrated complete absence of meaningful speech despite preserved limb strength. This deficit was observed by paramedics and persisted on arrival to hospital one hour after symptom onset. He was hemodynamically stable with a regular cardiac rhythm. Neurological examination...
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Rare Case of Sternal Insufficiency Fracture Unveiled by POCUS: Crack in an Osteoporotic Chest
DR HIMANSHU GUL MIRANI
Year:
1970
Background: Sternal fractures are most commonly associated with high-energy blunt thoracic trauma and are readily identified on computed tomography. In contrast, sternal insufficiency fractures are rare and may present insidiously, particularly in older adults with severe osteoporosis. Delayed symptom evolution and initially negative imaging can obscure diagnosis and delay appropriate management. Case: An 84-year-old woman with hypertrophic cardiomyopathy and severe osteoporosis treated with teriparatide presented to the Emergency Department after a low-impact forward fall while gardening. Initial examination revealed facial bruising and bilateral anterior chest wall tenderness. High-resolution CT of the chest, abdomen, and pelvis demonstrated no acute traumatic injury, showing only known vertebral insufficiency fractures. She was discharged with conservative advice. Three days later, she re-presented with new-onset focal sternal pain and visible anterior chest wall swelling. She denied any further trauma. Examination now demonstrated a clear sternal deformity with marked point tenderness, findings absent during the initial assessment....
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Using POCUS to Identify Vascular Structures in Soft-Tissue Presentations in the ED:Tale of 2 cases
DR HIMANSHU GUL MIRANI
,
Rena Darbar
Year:
1970
Background: Soft tissue swellings are a frequent presentation in the emergency department and are commonly attributed to abscesses or cellulitis. In patients with vascular risk factors or prior arterial interventions, however, vascular pathology such as pseudoaneurysm must be considered. Failure to recognize pseudoaneurysms may result in inappropriate intervention and life-threatening hemorrhage. Point-of-care ultrasound offers rapid bedside assessment to distinguish vascular from non-vascular soft tissue pathology. Case Series: We present two emergency department cases highlighting the diagnostic value of POCUS in evaluating undifferentiated soft tissue swellings.The first case involved a man in his early 30s with a history of intravenous drug use who presented with a painful, firm left groin swelling following femoral injections. Clinical assessment raised concern for a groin abscess. Given the high risk of vascular injury in this anatomical region, POCUS was performed prior to intervention. Ultrasound demonstrated a complex, loculated fluid collection clearly separate from the femoral...
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Enhancing Medical Education through Gamified Microteaching and Digital Reinforcement in a new University Hospital Setting
Dr Himanshu Gul Mirani
,
Dr Chinnu Prince
Year:
1970
Background:The establishment of Midland Metropolitan University Hospital (MMUH) in October 2024, following the merger of Sandwell and City Hospitals, created the newest acute care university hospital in the UK. This transition was associated with a marked rise in patient acuity and emergency department (ED) attendances, including the highest ambulance conveyance rate in the West Midlands. Junior doctors, including non-training grade clinicians, faced increased clinical complexity alongside reduced access to structured education. A rapid, sustainable educational intervention was therefore required. Methods:An ongoing Quality Improvement Project was implemented using a three-cycle Plan–Do–Study–Act (PDSA) framework over four months. Brief, 10-minute microteaching sessions were delivered Monday to Friday during ED handovers. Sessions were interactive, case-based, gamified, and mapped to the RCEM curriculum to ensure relevance while minimising disruption to clinical workflow. Content selection was guided by curriculum mapping, local incidents, and trainee feedback. Evaluation was conducted using post-session electronic surveys assessing engagement, relevance, confidence,...
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Effect of Nebulized Epinephrine versus Standard Treatment on PRAM Score Improvement in Pediatric Asthma Exacerbations: A Double-Blind Randomized Controlled Trial
Adnan Alrawahi
,
Alya Al Kindi
,
Basma Al Jabri
,
Hana Al Ghussaini
,
Sufyan AL Rahbi
,
Lubna AL Lawati
Year:
1970
Importance Asthma exacerbations are a leading cause of emergency department (ED) visits and hospitalizations in children. Optimizing acute management is essential to improve outcomes and reduce healthcare utilization. ObjectiveTo determine whether nebulized epinephrine, when added to standard salbutamol therapy, improves PRAM (Pediatric Respiratory Assessment Measure) scores in pediatric patients with moderate to severe asthma exacerbations. Design, Setting, and ParticipantsDouble-blind, randomized controlled trial at tertiary care centers. Children aged 3 to 12 years with moderate to severe asthma exacerbations were randomized to receive either nebulized epinephrine plus standard salbutamol therapy or standard salbutamol therapy alone. InterventionsNebulized epinephrine in addition to standard salbutamol therapy versus standard salbutamol therapy alone. Main Outcomes and Measures Primary outcome: Change in PRAM score at 60, 80, and 100 minutes post-intervention. Secondary outcomes: ED length of stay, hospital admission rates, ED revisit within 72 hours, and adverse events. ResultsThirty children were randomized (15 per group). The mean...
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Reducing Door-to-Analgesia and Door-to-50% Pain Reduction Time in the Emergency Room A Prospective Quality Improvement Study Balancing Urgency, Empathy, and Safety
Ankur Masani
Year:
1970
Background Pain is a subjective but critical clinical symptom and should be managed with the same urgency as other vital signs in the emergency department (ED). Delayed analgesia, particularly among patients triaged to lower-acuity areas, contributes to prolonged suffering and reduced patient satisfaction. This study evaluated the impact of a structured Quality Improvement (QI) initiative aimed at improving timeliness and effectiveness of pain management in the ED. Objective To reduce door-to-analgesia time by at least 25% from baseline and improve time to 50% reduction of initial pain score among adult ED patients with moderate to minor injuries. Methods A prospective QI study using Plan–Do–Study–Act (PDSA) cycles was conducted over 8 weeks in a tertiary care emergency department with a 3-tier triage system. Adults aged ≥18 years presenting with pain scores ≥1/10 were included. Baseline data were collected for 50 consecutive patients over 2 weeks. Interventions included staff education...
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ABCDE and F in the First Five Minutes: POCUS for Improving Diagnostic Accuracy in Time Critical Emergency Presentations.
Ankur Masani
Year:
1970
Background - The first hour of emergency care—the Golden Hour—is critical for patient survival, with the initial five minutes (“Golden Window”) playing a decisive role in identifying life-threatening conditions. Point-of-Care Ultrasound (POCUS) provides rapid, real-time physiological information and has become an essential adjunct to clinical examination. Despite its proven utility in shock, trauma, and acute dyspnea, POCUS is often underutilised or delayed beyond the initial assessment, potentially limiting its impact on early decision-making. Objective - To evaluate the effect of performing structured POCUS within the first five minutes of emergency assessment on diagnostic accuracy, time to life-saving intervention, and early clinical decision-making in patients with undifferentiated hypotension, trauma, or acute dyspnea. Methods - A prospective observational study was conducted over three months in a high-volume tertiary emergency department. A total of 150 consecutive adult patients presenting with undifferentiated hypotension, trauma, or acute dyspnea were included. Patients were divided into two...
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Military Innovations in Trauma Care Translated into Civilian Practice
Colonel Elwood Conaway
Year:
1970
Introduction: The history of traumatic injury treatment is a progression from crude ancient practices to modern trauma systems, marked by significant developments in military medicine, surgery, and understanding of physiology. Key milestones include early documentation in ancient Egypt, the extensive but primitive record-keeping of the American Civil War, the introduction of antisepsis, the development of trauma centers, and advancements in casualty evacuation and the treatment of shock. There is a direct link between military and civilian trauma care that starts during the Civil War and continues until the current conflict in Ukraine. The wars of the last two decades have changed the nature of injuries seen on the battlefield, leading to further trauma management innovation. Trauma is a global burden of disease that is responsible for 5 million deaths around the world annually. Lessons learned in these hostile environments have guided many developments in trauma care in high-income countries, resulting...
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Multi drug-Resistant Organisms (MDROs) in Combat-Related Injuries: Comparative Insights from Iraq, Afghanistan, and Ukraine
Rena Patierno
,
Elwood Conaway
Year:
1970
Introduction Armed conflicts have been implicated in the development of antimicrobial resistance. Cases of antimicrobial-resistant microorganisms among people with war injuries were first documented during World War II and have been increasingly reported in more recent conflicts (Mende et al., 2022). As the survival of military personnel wounded in previous wars increased due to advancements in personal protective equipment and combat casualty care, there was a corresponding rise in trauma-related infections (Tribble et al, 2011). Combat trauma across the modern battlefields has revealed an alarming increase in multidrug–resistant organisms (MRDO). During these wars, the most common combat trauma–related infections were skin and soft–tissue (41%), pneumonia (13%), bloodstream infections (13%), osteomyelitis (6%), and sepsis (4%) (Tribble et al, 2016). Infection has been a complication of war wounds throughout history. Extremity wounds are the most prevalent injury pattern among combat casualties (Petfield et al, 2022). Wounds from blasts, gunfire, and shrapnel are...
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A SQUARE PEG IN A ROUND HOLE: A CASE OF PAINLESS AORTIC DISSECTION
MUHAMMAD HYDEER BIN HAMZAH
,
HARYANTI BINTI RAMLI
Year:
1970
Aortic dissection (AD), with a prevalence of 5–30 cases per million people, is a rare but life-threatening condition that often relies on pattern recognition for diagnosis. Classical presentation involves acute presentation of severe chest pain; however, atypical symptoms can obscure timely recognition. A 49-year-old man with a history of hypertension, ischemic heart disease, and previous lung empyema presented with chronic symptoms of reduced effort tolerance and left lower limb numbness during ambulation. On examination, absent pulses were noted in the left femoral artery and distal pulses. Point-of-care ultrasound (POCUS) revealed a dilated aortic root with intimal flaps in both the thoracic and abdominal aorta. CT angiography confirmed the diagnosis of a Stanford A thoracoabdominal AD. Unfortunately, due to the complexity of the tear, the patient was managed conservatively. This case underscores the critical role of clinical acumen paired with POCUS in identifying atypical presentations of AD. In emergency settings, where rapid diagnosis can be life-saving, POCUS serves as a...
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“Break it to them gently, you might be breaking their hearts too…💔” Breaking the Bad News !
Deepali Dhawan
,
Abbas Ali Khatai
Year:
1970
Breaking the Bad News ! Any news that drastically and negatively alters the patients view of their future.( Buckmann,1992) Despite the commitment to openness and right to information, the decision to whether to withhold or disclose that difficult information continues to trouble the healthcare professionals. Conveying bad news to the patient themselves or to their attendants is rather a process than an event, resulting in cognitive, behavioural or emotional deficit, and this lasts beyond the bad news encounter. These deficits have implications on how the person will think, behave and feel in their response to changes, resulting from the news in shorter and the longer term. For this reason, it is vital for a structured framework to deliver the bad news to be employed that not only dispense the required information, but also enables them to engage in decision making about their care when the choices become limited by allowing...
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Silent Threats: Pediatric Sepsis Burden and Outcome in Emergency Care Across Low-and Middle-Income Country
Sana Ur Rahman
Year:
1970
In 2017, over 80% of the 6.64 million annual deaths in children and adolescents worldwide occurred in low- and middle-income countries (LMICs) (1). Acute pediatric illnesses such as sepsis, pneumonia, diarrheal disease, and trauma are the leading causes of death and disability beyond the neonatal period in these regions, where critical care resources are often limited. Objective The primary objective of this study is to determine the incidence of sepsis in pediatric patients. The secondary objective is to assess the outcomes of sepsis patients in the emergency department (ED), including mortality rates and length of stay, to identify the need for critical care or high dependency units Method This retrospective study analyzed data from the pediatric emergency room at a tertiary care hospital PIMS Hospital Children ER and Ghulam Muhammad Mahar hospital Sukkar Children ER supported by the Child Life Foundation throughout the year 2024. The facility, which does not...
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A Novel Trajectory-Based, Anticipatory Model for the Management of Emergency, Intensive Care, and Chronic Conditions, Exemplified by Hypertension
Abdulatif Aljaili Aljaili Mohamed
Year:
1970
TITLE A Novel Trajectory-Based, Anticipatory Model for the Management of Emergency, Intensive Care, and Chronic Conditions, Exemplified by Hypertension AUTHOR Abdulatif Aljaili Mohammed ABSTRACT Background:Conventional hypertension management relies on fixed diagnostic thresholds, most commonly 140/90 mmHg. This threshold-based approach is inherently reactive and often permits silent vascular injury to progress for years before intervention is initiated. Such delays may contribute to irreversible cardiovascular, cerebrovascular, and renal complications that ultimately present as emergencies, increasing emergency department (ED) visits and intensive care unit (ICU) admissions. Objective:To introduce the Progressive Serial Incremental Change (PSIC) Model, a novel trajectory-based framework that reconceptualizes hypertension as a dynamic process rather than a static threshold, enabling earlier identification of pathological blood pressure evolution and anticipatory intervention. Methods / Conceptual Framework:Serial blood pressure measurements can demonstrate gradual, progressive increases over time—such as readings evolving from 110 mmHg to 114 mmHg, 117 mmHg, and 119 mmHg at...
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Ketamine versus Morphine for Musculoskeletal Trauma Pain: A Meta-analysis of Randomized Controlled Trials
Mansoureh Fatahi
,
Saba Aghajani
,
Alireza Ebrahimi
Year:
1970
Background: Pain is a primary reason for emergency department (ED) visits and hospitalizations following injuries, and its inadequate management can lead to complications. Effective and safe pain control is crucial in traumatic patient management. While opioids like morphine are commonly used for acute pain due to their effectiveness and rapid action, ketamine, has recently been explored for pain management in various settings. This meta-analysis aimed to compare the efficacy and safety of morphine sulfate and ketamine in trauma patients experiencing musculoskeletal pain. Methods and materials: This meta-analysis was registered in PROSPERO (CRD420251001307) and followed PRISMA guidelines. An extensive search was conducted across PubMed, Web of Science, Scopus, and Embase databases in March 2025 to identify randomized controlled trials (RCTs) comparing ketamine and morphine for pain in trauma patients. Two independent reviewers screened and evaluated articles, resolving conflicts with a third reviewer. Inclusion criteria focused on English-language RCTs comparing intravenous (IV)...
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Impaired and recovered vasorelaxation mediated by endothelium-derived hyperpolarizing factor (EDHF) under septic conditions
Tomonori Hattori
Year:
1970
Background: Endothelium-derived hyperpolarizing factor (EDHF) is a major mediator of endothelium-dependent vasorelaxation in small resistance arteries and is crucial for microcirculatory regulation. Sepsis causes endothelial injury and profound microcirculatory dysfunction, yet the time course of EDHF function during sepsis remains unclear. Methods: Male Wistar rats received intraperitoneal lipopolysaccharide (LPS) 5 mg/kg. Mesenteric and right gastroepiploic arteries were harvested at baseline (Control), 24 h (Day 1), and 72 h (Day 3). Vasorelaxation was assessed by acetylcholine (ACh)–induced relaxation in small arteries and by recording smooth muscle membrane potential (hyperpolarization). To examine nitric oxide (NO) contribution, experiments were repeated with the NO synthase inhibitor nitro-L-arginine (L-NNA). Results: ACh-induced vasorelaxation was markedly suppressed on Day 1 versus Control, accompanied by reduced endothelial hyperpolarization, indicating early impairment of EDHF-associated responses. By Day 3, vasorelaxation and hyperpolarization recovered toward baseline. However, under NO inhibition with L-NNA, the Day 3 recovery was abolished, suggesting compensatory NO-dependent...
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Gas-forming Liver Abscess Caused by Clostridium perfringens after ERCP: A Rapidly Fatal Case
Yuko Okui
,
Yuka Saeki
,
Yuka Nakajima
,
Masahiko Kambe
Year:
1970
Background: Gas-forming liver abscess caused by Clostridium perfringens is extremely rare but carries a high mortality rate. Early recognition of hemolysis and hepatic gas formation is critical for timely management. Case Presentation: An 80-year-old man with type 2 diabetes mellitus and a history of gastrectomy for gastric ulcer presented with fever, headache, abdominal discomfort, and nausea. He had undergone endoscopic retrograde cholangiopancreatography (ERCP) four times over the previous ten months, most recently three weeks before admission. On arrival, he was alert but appeared ill, with fever, tachypnea, jaundice, and an oxygen requirement of 2 L/min via nasal cannula. His abdomen was distended and tender. Laboratory tests showed leukocytosis, anemia, elevated liver enzymes, and severe hemolysis. A plain CT scan obtained at presentation revealed a 2.3-cm gas-forming lesion in hepatic segment 6. Two hours later, contrast-enhanced CT demonstrated enlargement to 4.6 cm. Empiric broad-spectrum antibiotics (sulbactam/ampicillin) were started, and percutaneous drainage...
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Barriers and Facilitators to Accessing Stroke Care Services in Tanzania: An Explorative Qualitative Study
Nyagwaswa Athanas Michael
,
Lilian Teddy Mselle
,
Costansia Anselim Bureta
,
Dickson Ally Mkoka
,
Cao Yingjuan
Year:
1970
Introduction Stroke is a leading cause of death and disability globally, posing a significant burden in low- and middle-income countries (LMICs). The government of Tanzania has initiated public health campaigns to raise stroke awareness on non-communicable diseases and established acute stroke units in tertiary hospitals to bridge the stroke care gaps. However, lack of universal health coverage and underdeveloped primary healthcare infrastructures remain significant obstacles to delivering high-quality acute care services. Objective To explore barriers and facilitators to accessing acute stroke care services in Tanzania. Materials and Methods The study adopted a descriptive phenomenology design and included 45 purposively recruited healthcare providers, stroke survivors and care givers at Muhimbili National Hospital-Mloganzila (MNH-Mloganzila) in Tanzania. In-depth interviews were conducted from June to September, 2024. Inductive thematic analysis was performed using Dedoose software. The study was approved by the Institutional Review Board of Muhimbili University of Health and Allied Sciences (Ref. No....
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Pre-hospital care given to road traffic injury patients in Tanzania: A cross-sectional study
Nyagwaswa Athanas Michael
,
Dickson Ally Mkoka
,
Anne Outwater
Year:
1970
Background Injury remains among of the leading causes of morbidity and mortality worldwide, with predominance in low-income and middle-income countries. It has been, an increasingly significant public health issue worldwide, with road traffic injuries in the rise, accounting for 16% of the global burden of disease. Despite of the observed increase in number of road traffic injuries, provision of initial care to patients sustaining such injuries is one of the big challenges. Objective The objective of this study was to describe the initial care given to road traffic injury patients, who were admitted at Muhimbili National Hospital in Tanzania from January to February, 2016. Methodology The study employed a cross-sectional study design to obtain information on the post-crash trauma experiences among road traffic injury patients admitted at trauma units of the Muhimbili National Hospital in Dar es Salaam-Tanzania from January to February, 2016. The consecutive convenient sample of 132 road...
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Early Insights from the National Stroke Surveillance Initiative in Tanzania: A Prospective Multi-Centre Study
Nyagwaswa Athanas Michael
,
Sarah Shali Matuja
,
On Behalf of Tanzania Stroke Task Force Collaborators
Year:
1970
Background: Stroke is a leading cause of death and disability worldwide, with low- and middle-income countries, particularly sub-Saharan Africa, bearing the greatest burden. Tanzania has only one active stroke registry at one hospital health facility, limiting efforts to guide stroke care and policy. To address this, we expanded the registry to a multi-centre study across eight large tertiary hospitals to generate baseline data supporting the development of a national stroke registry. Methods: Between January and August 2024, we analysed de-identified data from eight largest tertiary teaching hospitals in Tanzania, which included adults ≥18 years admitted with a World Health Organization clinical definition of stroke. We collected the following information: demographics, risk factors, brain imaging findings, and in-hospital mortality. Logistic regression was used to examine factors associated with mortality. Results: A total of 1,000 patients were registered with a mean age 60.2±15 years. The prevalence of all types of strokes was...
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Unprecedented mass casualty profile due to pager explosions in Lebanon: A report from a university hospital.
Helou Mariana
,
Tanios Alain
,
Chaaban Toufic
,
Yammine Kayssar
Year:
1970
On September 17, 2024, an unforeseen attack due to the Pagers Explosion targeting a military party in Lebanon left more than 2750 casualties. Almost two-thirds of the injuries were in the face, eyes or hands. The Lebanese American University Medical Center received 38 injured and admitted 36 patients, 13 of them to the Intensive care unit. A total of 33 patients needed surgeries. Most injuries were amputated fingers and eye injuries. Thirty-two (71%) patients had a form of finger amputation. The most prevalent amputated fingers were the 3 most radial ones. Thirty-one (69%) patients had at least one eviscerated eye. Seventeen patients (38%) presented with combined eye and hand injuries. The healthcare workers faced major challenges on that night: the severity of the injured, the unprecedent type of injuries with the same pattern and the urgent need for ophthalmology and orthopedics within the hospital and across the country. This report...
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Discharge Against Medical Advice From the Emergency Department: Results From a Private Hospital in Beirut
Danielle Abou Khater
,
Joelle Kalaji
,
Alain Tanios
,
Mariana Helou
Year:
1970
Background: Discharge against medical advice (DAMA) is a common problem worldwide, associated with increased mortality rates and higher emergency department (ED) revisit rates. This study examines the characteristics, reasons and clinical outcomes of the patients leaving from the Emergency against medical advice. Materials and Methods: This is a cross-sectional study conducted at the Lebanese American University Medical Center's ED between 2019 and 2022. Data on patient demographics, reasons for DAMA, and trends over time were analyzed. Results: Over the 4 years duration, 42,672 patients visited the ED, of whom 2,767 (6.4%) left against medical advice. DAMA rates varied across the years: 3.6% in 2019, rising to 7% in 2020, peaking at 10% in 2021, and declining to 5.8% in 2022. The increase in 2020 and 2021 coincided with Lebanon’s economic collapse that hit the country end of 2019. The most frequently cited reason for DAMA was financial constraints which accounted...
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Hypertensive Crisis Leading to Multisystem Complications: A Case Report
Aung Myo Myint
,
Zoe Shipley
,
Buddhike Mendis
Year:
1970
Background:Hypertensive crisis is characterized by a severe elevation in blood pressure associated with end-organ dysfunction. This case highlights a 65-year-old male presenting with ophthalmologic, neurological, and cardiovascular manifestations of malignant hypertension. Case Presentation:A 65-year-old male with a past medical history of type 2 diabetes mellitus with retinopathy, hypertension, hypercholesterolemia, prior superior dentate nucleus infarction, asymptomatic right carotid stenosis attended eye casualty due to double vision. Examination revealed disc swelling, splinter hemorrhages, and bilateral microvascular cranial nerve VI palsy indicative of grade 4 hypertensive retinopathy. His blood pressure was critically elevated (BP 203/77, later peaking at 232/95). Investigations included CT head (no acute findings), HbA1c 118, normal creatinine and eGFR, and a borderline blood glucose level. Neurological review and MRI confirmed microvascular cranial nerve damage secondary to hypertension and diabetes. Shortly thereafter, the patient deteriorated with acute pulmonary edema due to hypertensive crisis (NEWS 9: RR 27, SpO₂ 90% on...
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Comparison of Machine Learning Methods and Scoring Systems in Predicting MACE Risk
Murat Ersel
,
Oktay Yildiz
,
Sumeyra Kus Ordu
,
Mehmet Ragip Aktemur
Year:
1970
Introduction Machine learning (ML) models analyze various risk predictors to accurately estimate patients' risk by understanding nonlinear relationships and interactions among multiple variables. By many trials ML models tested for prediction of mortality and MACE risk for chest pain patients within 30 days. Aims & Objectives In this study, we aimed to compare the prediction accuracies of HEART and TMACS scores and various ML methods for estimating the risk of mortality and MACE in patients presenting to the ED with chest pain. Material & Methods The total number was 888, of consecutive patients aged 18 and older, presented to the ED of Ege University Hospital, Izmir, Türkiye, with chest pain or symptoms indicative of ischemia, applying the exclusion criteria, 328 patients were excluded, resulting in a final sample size of 560 patients. The data of 560 patients were used for both training and testing through K-Fold Cross Validation. For evaluation...
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Examining a Stabilization Center for Patients with Alcohol or Opioid Intoxication Transported by Paramedics
Ryan P Strum
,
John McPhee
,
Jamie Burnett
,
Russell D MacDonald
Year:
1970
Objectives: Emergency departments (EDs) face growing strain from increased health-seeking behavior. To preserve finite ED resources, a non-medical stabilization center (SC) was implemented in Toronto, Canada as an alternative destination to receive paramedic-transported patients with suspected acute alcohol or opioid intoxication who would otherwise have been taken to an ED. These patients typically require observation and recovery rather than emergency medical intervention. We described the diversion care model, clinical guideline, patient cohort, and its safety. Methods: We conducted a retrospective study of paramedic-transported patients to a SC in Toronto, Canada between December 8, 2022, and December 31, 2024. Eligible patients originated from 9-1-1 calls and were transported either directly (from the community to SC) or indirectly (from the community to an ED, then to SC). Descriptive statistics summarized the patient cohort stratified by transport method, and those later transferred from the SC to an ED. Results: A total of 3,744...
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KID THAT DO METH CASE REPORT ON PEDIATRIC METHHEMOGLOBINEMIA
SIFRAH ISAAC COTTADIYEL
,
NITIN JAGASIA
Year:
1970
Methemoglobinemia is a rare but life-threatening hematologic condition where hemoglobin is oxidized from the ferrous (Fe2+) to the ferric (Fe3+) state, impairing oxygen delivery to tissues. While congenital forms exist, acquired methemoglobinemia often triggered by medications or chemical exposures is more common. Prevalence in pediatric populations is estimated at approximately 0.0015%. Case Presentation: A 6-year-old male presented to the Apollo Hospitals Emergency Department with fever, abdominal pain, vomiting, epistaxis, and acute breathlessness. Physical examination revealed central and peripheral cyanosis with an SpO2 of 88% on room air, which only improved to 92% despite high-flow oxygen (10L). Notably, the patient had a history of exposure to a watch repair solution and prior consumption of "outside food." Diagnostic Workup: Venous Blood Gas (VBG) analysis confirmed methemoglobinemia with a level (FMetHb) of 31.0% and respiratory alkalosis. Laboratory results showed mild thrombocytopenia (Platelets: 89,000) and a normal hemoglobin (15.5 g/dL). G6PD deficiency...
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Rhabdomyolysis following Influenza A Infection: A Rare Complication of Infectious Myositis
Ma. Bianca Isabelle Olalia
,
Roemer Tanghal
Year:
1970
Infectious myositis is a rare condition caused by various pathogens, including influenza, and may lead to rhabdomyolysis with a risk of acute kidney injury. This case report details a middle-aged Filipino woman who developed life-threatening rhabdomyolysis after getting Influenza A infection. The patient with a recent travel history in Australia, presented with bilateral leg cramps, fasciculations, and severe muscle pain causing difficulty to ambulate. Workup showed elevated creatinine kinases, creatinine, as well as a positive Influenza A Antigen test. Treatment involved aggressive hydration, pain management, and antiviral therapy. This case highlights the importance of recognizing influenza-associated myositis in patients presenting with unexplained muscle symptoms and elevated creatine kinase, emphasizing early diagnosis and intervention to prevent severe complications.
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Walking on a warning sign: A hidden infection behind a unilateral leg swelling
SANJENA KUMAR AMUDDHU
,
Vinodkumar Raj Thurai Raja
Year:
1970
Introduction Lower limb swelling is a common Emergency Department (ED) presentation. Bilateral limb swelling is frequently due to venous insufficiency. However, unilateral limb edema poses a diagnostic challenge in the ED, often overshadowed by common causes such as cellulitis, deep vein thrombosis (DVT) or a ruptured Baker’s cyst. This case report describes a middle-aged lady who presented with progressive left calf swelling and pain. She was initially misdiagnosed as a ruptured baker’s cyst. Subsequent follow up and admission revealed a septic arthritis with a large calf abscess. Case presentation A healthy 63-year-old Chinese lady, presented to the ED with a two-week history of progressive left calf pain and swelling. An initial ultrasound from a private clinic, performed 9 days prior to her visit, reported a ruptured baker’s cyst and no DVT was detected. She denied any fever, trauma or insect bites to the lower limb. On examination, patient...
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FLIP THE BEAT: REVERSE VALSALVA IN SVT
Sahitya Niranjali Manikumar
Year:
1970
Background: Supraventricular tachycardia (SVT) is a common emergency department presentation. Vagal manoeuvres are recommended as first-line, non-pharmacological management in hemodynamically stable patients. Although the Modified Valsalva manoeuvre has demonstrated superior efficacy, it requires assistance, patient repositioning, and equipment, which may limit its universal applicability. Objective: To evaluate the effectiveness of the Reverse Valsalva Manoeuvre (RVM), a simple, equipment-free technique, in terminating SVT. Methods: A case-series study was conducted at a tertiary care centre in Tamil Nadu, India. Ten adult patients presenting with SVT were included. Demographic data, comorbidities, prior interventions, and outcomes were recorded. The RVM involved inhalation against resistance by sealing the mouth and pinching the nose. The primary outcome was successful reversion to sinus rhythm. Results: Of the 10 patients, 6 were male and 4 female; 8 had underlying cardiac disease or previous SVT, 6 were diabetic, and 4 hypertensive. Prior to RVM, 7 patients...
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BREATH BY BYTE: AI IN PULMONARY IMAGING
Sahitya Niranjali Manikumar
Year:
1970
Background: Chest radiography is one of the most commonly performed imaging investigations worldwide due to its affordability, portability, and widespread availability. It plays a critical role in the early detection and management of thoracic diseases, particularly in emergency and resource-limited settings. However, delays in reporting and interpretation persist globally, largely due to a shortage of trained radiologists, which may impact timely clinical decision-making. Objective: This study aimed to evaluate the role of artificial intelligence (AI) in assisting physicians with the interpretation of chest radiographs for the detection and diagnosis of thoracic pathologies. Methods: An AI-based chest radiograph interpretation system, developed using deep learning algorithms and trained on 10.7 million chest X-ray images, was assessed. The system is currently deployed in over 90 countries, provides results within 20 seconds, and integrates seamlessly into existing hospital workflows. A pilot study was conducted in the Emergency Department, wherein 100 consecutively acquired...
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Visited Gynaecology; ended up in Cardiology: A Case of Misoprostol-Induced Coronary Vasospasm
Abdullah Rana
,
Iqy Haziq Mohamad
Year:
1970
Case Presentation 53-year-old woman with a history of hypertension, hypercholesterolaemia, and a strong family history of cardiovascular disease attended a gynaecology clinic for management of menorrhagia. She received 400 micrograms of misoprostol. Within 15 minutes, she developed sudden-onset severe central chest pain radiating to both arms and her back, associated with shortness of breath. She was transferred urgently to the emergency department. On arrival, she was haemodynamically stable with normal vital signs. Physical examination was unremarkable. An initial electrocardiogram demonstrated sinus rhythm with approximately 1 mm ST-segment elevation in leads III and aVF. Given the clinical presentation and ECG findings, she was managed according to acute coronary syndrome protocols. Serial electrocardiograms demonstrated resolution of the ST-segment changes, and cardiac biomarkers were not significantly elevated. Coronary angiography was performed and demonstrated unobstructed coronary arteries with no evidence of atherosclerotic disease. Given the close temporal relationship between misoprostol administration and symptom onset,...
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One Diagnosis, Four Very Different Stories: Thoracic Aortic Dissection Presenting with Diagnostic Mimicry
Abdullah Rana
Year:
1970
Case Series Case 1:A 54-year-old man with known ischaemic heart disease presented with central chest pain identical to his previous myocardial infarction. He was hypertensive with elevated troponin and managed as non-ST elevation myocardial infarction. Transthoracic echocardiography performed the following day demonstrated a dilated aortic root. CT aortography confirmed a Type A dissection extending into the left carotid artery. He underwent urgent surgical repair and made a full recovery. Case 2:A 54-year-old man presented with agitation, hypotension, and diffuse ECG changes. He was unable to provide history and initially appeared toxic or metabolically unwell. Bedside echocardiography revealed pericardial tamponade. CT confirmed extensive dissection from the aortic root to the bifurcation. Despite emergency surgical intervention, he died intraoperatively. Case 3:A 69-year-old woman presented with sharp central chest pain. D-dimer and serial troponins were negative. She declined admission and self-discharged. She re-presented later the same day following collapse at home, with shock...
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TRAPPED: ACUTE ISCHEMIC STROKE PRESENTING AS LOCKED-IN SYNDROME IN THE EMERGENCY DEPARTMENT
Dawn Mae Ecol Raño
,
Geoffrey J. Corpuz
Year:
1970
Locked-in syndrome (LIS) is an extremely rare condition presenting as quadriplegia, bulbar palsy, and anesthesia while cognition, vertical eye movement, blinking, and hearing are preserved. Early recognition is critical but frequently missed, with studies reporting average delays of up to 16 hours. This is a case of 41/M, right-handed, security guard coming in for paralysis. Initial vital signs at the triage were 150/80mmHg 71bpm 20cpm 36.6C 99% at RA. Patient is a known hypertensive with poor medication compliance. Ten hours prior to consult, patient had sudden onset left sided body weakness consequently affecting the right side. Patient became anarthric and quadriplegic. No history of loss of consciousness, seizures, and head trauma. On physical exam, patient was noted to be consistently blinking. Further assessment revealed the ability to respond to binary questions through eye blinking. The patient is GCS 11 (E4V1M6), with affectations of all cranial nerves except CN Ill and...
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DEEP SEA FISHES DEADLY EVEN WHEN DEAD, A CASE REPORT ON ACUTE ISCHEMIC STROKE ASSOCIATED WITH SCOMBROID POISONING
Jhon Drexler Arellano Legaspi
,
Karlo Marciano Orencio Venida Hermo
Year:
1970
Seafood forms a major part of the Filipino diet. In the absence of an adequate cold chain, histamine toxicity may occur causing scombroid poisoning. Conversely, cerebrovascular accidents remain among the top five causes of mortality in the Philippines. Recognizing distinct clinical presentations—and the rare instance in which both conditions coexist—requires careful history-taking and high clinical suspicion. This is a case of a 72/M, coming in for angioedema presenting with initial vital signs of 160/80mmHg, 90bpm, 20cpm, 36.8℃, 99% O2. Patient has no known comorbidities and allergies. The night prior to consult, after eating “tulingan” (Katsuwonus pelamis), a deep-sea fish, the patient developed periorbital edema but slept through it. Upon waking up, still with angioedema now with generalized pruritic rash. Patient then noticed right sided body weakness. On physical exam, generalized rash with noted angioedema. The patient is GCS 15 but with noted right facial asymmetry and right tongue deviation, 4/5...
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Implementation of Menorrhagia Protocol in an ED Short Stay Unit
Francesca Thng
,
Michael Lisondra Ebuna
,
Shobhit Swarup
Year:
1970
Menorrhagia with associated anaemia presenting to the Emergency Department (ED) commonly leads to hospital admission for further monitoring and intervention. During their Inpatient stay, patients had to wait for a new medical team to assess them and be reviewed to establish a definitive management plan. For such a process, it resulted in disjointed care and prolonged wait times for patients. To address the issue, the Extended Diagnostics and Treatment Unit (EDTU)—a 24‑hour ED short‑stay facility—implemented a standardized Menorrhagia Protocol to streamline care delivery, reduce inpatient admissions, and optimize resource utilization. The protocol applied to haemodynamically stable patients aged over 16 years presenting with heavy menstrual bleeding and anaemia (Hb <7 g/dL, or <8 g/dL for those with ischaemic heart disease). Exclusion criteria included pregnancy, haemodynamic instability, haemoglobin levels below 5 g/dL, significant comorbidities, and non‑gynaecological causes of anaemia. Intervention included blood transfusion or intravenous iron infusion for symptomatic anaemia, accompanied...
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Transforming Acute Dyspnea Management: The Role of Point-of-Care Echocardiography in Cardiac Emergencies: Case series
Mohamed Abdou
Year:
1970
Background: Acute dyspnea and shock are among the most common and time-sensitive presentations in emergency and critical care settings. Rapid identification of underlying cardiac etiologies is essential to guide appropriate management. Conventional diagnostic tools such as electrocardiography, chest radiography, and cardiac biomarkers often provide indirect or delayed information. Point-of-care echocardiography (POCUS) enables immediate bedside assessment of cardiac structure, function, and hemodynamics, with emerging quantitative Doppler techniques offering enhanced diagnostic precision. Case Series: We present a case series of three patients presenting with acute dyspnea due to distinct cardiac pathologies, highlighting the diagnostic and therapeutic value of focused echocardiography. The first case involved a patient with ischemic cardiomyopathy complicated by left ventricular thrombus and cardiogenic shock, where POCUS identified severe biventricular dysfunction and guided early initiation of inotropes and anticoagulation. The second case demonstrated heart failure with preserved ejection fraction (HFpEF) and pulmonary edema due to a mitral valve fibroelastoma, where...
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Establishing the Emirati Field Hospital in Gaza: A Model for Rapid Deployment in Conflict Zones
Abdalla Eisa Hazeem Eisa Alzaabi
Year:
1970
Background:Armed conflicts place extraordinary strain on fragile healthcare systems, requiring rapid, scalable, and coordinated medical responses. In late 2023, the United Arab Emirates launched Operation Chivalrous Knight 3 in response to the escalating humanitarian crisis in Gaza. A fully equipped field hospital was constructed and became operational within weeks, providing advanced emergency and trauma care in an active conflict environment.Objective:To describe the planning, structure, and operational framework of the Emirati Field Hospital in Gaza and present a scalable model for rapid deployment of tertiary-level care in conflict zones.Methods:The hospital was designed and executed using the 4S disaster management framework: Space, Stuff, Staff, and System. A modular tertiary-level facility was established within a stadium complex near the Egyptian border to ensure security, accessibility, and scalability. Functional zoning included emergency resuscitation, observation, outpatient services, operating theatres, intensive care units, diagnostic imaging, laboratory services, and rehabilitation facilities. Operational data and workflow adaptations were...
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RSV-Associated Methemoglobinemia and Hemolytic Anemia: First Reported Case
Fathima Murthuza
,
Pooja Binuraj
Year:
1970
IntroductionViral infections are increasingly recognized as triggers of oxidative stress–mediated hematologic complications, including methemoglobinemia and non-immune hemolytic anemia, most commonly in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Such associations have been reported with cytomegalovirus (CMV) and COVID-19 infection. Respiratory syncytial virus (RSV) is a well-established cause of respiratory illness in older adults; however, RSV-associated methemoglobinemia with intravascular hemolysis has not been reported. We describe a case of concurrent methemoglobinemia and intravascular hemolysis precipitated by RSV infection in an immunocompetent adult. Case PresentationA 68-year-old man presented with worsening hypoxia, central cyanosis, and dark urine following a viral prodrome. He was febrile, pale, and icteric, with severe hypoxemia. Arterial blood gas analysis demonstrated methemoglobinemia with type I respiratory failure. Laboratory evaluation revealed anemia, elevated lactate dehydrogenase, reticulocytosis, indirect hyperbilirubinemia, and a negative direct antiglobulin test, consistent with non-immune intravascular hemolysis. RSV was detected on multiplex polymerase chain reaction testing, and inflammatory markers...
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Implementation of GINA Guidelines in Asthma Management: A Single-Center Pre- and Post-Intervention Study
Omar Ghazanfar
Year:
1970
This study evaluates the implementation of the Global Initiative for Asthma (GINA) guidelines in asthma management within an emergency department (ED) setting. A pre- and post-intervention design was employed to assess key asthma management metrics. Results demonstrated significant improvements in peak expiratory flow (PEF) measurement, discharge practices, follow-up adherence, and reductions in hospital admissions. The findings underscore the potential benefits of evidence-based guidelines in optimizing asthma care (Global Initiative for Asthma, 2021).
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Diagnostic Accuracy of Modalities For Acute Heart Failure In Emergency Settings. A Systematic Review and Diagnostic Accuracy Meta-Analysis
Munirah Fahaid Alhemaidani
,
Ahmed Y. Azzam
,
Saga Khalid Alwabel
,
Yara Ali Alqazlan
,
Lamya Fahad alsheheil
,
Reem Fuad Alayash
,
Dhiyaa Abdullah Almusaylim
,
Rilan Asad Alimani
,
Hussain Hussam Almusa
,
Sadeem Khalid Alquraini
,
Asayil Abdulmuttalib
Year:
1970
Background: Acute heart failure diagnosis in emergency departments remains challenging despite multiple available diagnostic modalities. Current emergency evaluations rely variably on clinical assessment, biomarkers, and ultrasound techniques; however, their comparative diagnostic accuracy remains inadequately compared in previous studies. This systematic review and meta-analysis aim to evaluate the diagnostic accuracy of four categories of diagnostic approaches: Clinical Assessment, Biomarker Assessment, Basic Ultrasound Assessment, and Advanced Ultrasound Assessment for diagnosing acute heart failure in emergency settings. Methods: We conducted a literature review across PubMed/MEDLINE, Scopus, Google Scholar, Cochrane Library, Google Scholar, and Web of Science up to December 2024. Studies investigating the diagnostic modalities for acute heart failure in emergency settings with sufficient data to construct 2×2 contingency tables were included. Two independent reviewers performed screening, data extraction, and quality assessment using QUADAS-2. Diagnostic accuracy was synthesized using a bivariate random-effects model. Summary receiver operating characteristic (SROC) curves, pooled sensitivity, specificity, and...
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UNSCHEDULED RETURN VISITS WITHIN 72 HOURS IN PEDIATRIC EMERGENCY CARE: CLINICAL BURDEN, RISK INDICATORS, AND OUTCOME TRENDS
Shagufta Kanwal
,
Zareen Qasmi
,
Irfan Habib
Year:
1970
INTRODUCTION Unscheduled return visits (RVs) to Pediatric Emergency Departments within 72 hours of discharge remain a critical quality metric in Pediatric Emergency care.Numerous studies have highlighted a trend among caregivers to return to ED rather than consult primary care providers when a child’s symptoms persist or worsen, contributing to ED overcrowding, clinician fatigue, and diagnostic delays. Children returning within a short interval are typically assigned higher triage categories due to concerns about disease progression or missed diagnoses,necessitating specialist evaluation or inpatient admission. These return visits are also associated with increased clinical risks, including a higher chance of complications or mortality. OBJECTIVE This study aims to investigate the clinical characteristics,revisit patterns,and outcomes of pediatric patients who return to the emergency department within 72 hours of discharge METHODOLOGYA retrospective chart review was conducted across five emergency departments operated by the ChildLife Foundation over a six-month period, from December1,2024, to May31, 2025.Data...
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A STUDY TO FORECAST THE FATE: CORRELATING EARLY DEATH IN EMERGENCY DEPARTMENT WITH THE HEMODYNAMIC AND BLOOD GAS PARAMETERS ON ARRIVAL – A RETROSPECTIVE STUDY
Divendu Bhushan
,
Md AN Iqbal
Year:
1970
Introduction: The emergency department is a high-pressure environment where rapid assessment and intervention can mean the difference between life and death. Vital signs, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation, serve as primary indicators of a patient’s physiological status. ABG analysis, on the other hand, provides crucial insights into respiratory function, acid-base balance, and metabolic status. This study tried to analyze deaths over a year in an emergency department in a tertiary care centre and identify hemodynamic and blood gas parameters that could predict early death in ER. Aims and objectives; Analyze mortality patterns and their association with vital signs and arterial blood gas (ABG) parameters on arrival to the ER. Methodology: This was a retrospective study conducted in the emergency department (ED) of AIIMS Patna over a one-year period ( Jan 1 , 2024 to 2025 ). Patients were categorized into two groups based on...
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Risk Stratification of Chest Pain in the Emergency Department: Comparing HEART, TIMI, and EDCAS Scores.
Sarah Salman Siddiqui
Year:
1970
Background Chest pain is one of the most common reasons for emergency department (ED) visits globally , yet only a small portion of cases are ultimately diagnosed as acute coronary syndrome (ACS). Timely and accurate risk stratification is critical to identify patients at high risk for major adverse cardiac events (MACE) while minimizing unnecessary admissions for low risk individuals. In the United Arab Emirates (UAE) , cardiovascular diseases (CVD) are the leading cause of mortality , and coronary heart disease (CHD) tends to occur 10-15 years earlier than in Western populations. This epidemiological pattern highlights the importance of implementing effective chest pain triage tools in Eds within the UAE and similar high-risk regions. Objective To critically evaluate and compare the diagnostic accuracy and clinical utility of three widely used risk stratification tools – HEART , TIMI and EDCAS – in predicting short term cardiac outcomes in patients presenting with...
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EMERGENCY PHYSICIANS IN WAR ZONES: ROLES, RISKS, AND RESILIENCE
Abdalla Eisa Hazeem Eisa Alzaabi
Year:
1970
Background:Emergency physicians deployed to conflict zones operate under extreme conditions that fundamentally expand their traditional clinical role. In active war settings, physicians must deliver high-acuity emergency care while simultaneously providing leadership, coordination, and operational stability.Objective:To describe the evolving roles, risks, and resilience requirements of emergency physicians working in war zones, drawing on operational experience from the Emirati Field Hospital in Gaza.Methods:This descriptive experience-based analysis examines the clinical, operational, and leadership responsibilities of emergency physicians deployed to a modern conflict environment. Observations were drawn from frontline emergency care, departmental leadership roles, resource management, and system-based practice within a deployed field hospital.Results:Emergency physicians were required to manage complex trauma across all age groups, including blunt and penetrating injuries, blast trauma, burns, crush syndromes, and infectious disease presentations. Beyond clinical care, physicians frequently assumed leadership positions such as Emergency Department Officer, Chief Medical Officer, and, at times, overall hospital command. Operational challenges included...
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Increased number of dispatches in emergency medical services correlates to response time extension
Natsuko Ishikawa
,
Keisuke Tomita
,
Takashi Shimazui
,
Yoko Tochigi
,
Taka-aki Nakada
Year:
1970
Aim: This study investigated the correlation between the number of emergency medical service (EMS) dispatches and response time extension. In addition, we conducted a simulation to assess the potential for reducing response times by relocating the ambulance based on the number of dispatches. Methods: This retrospective observational study analyzed data on patients treated with EMS between May 1st and June 25th, 2021, in an urban area (Chiba City, Japan). Spearman’s rank correlation tests were used to analyze the correlations among the number of dispatches, response time extension, and ambulance distance. We created a heat map to visualize the number of dispatches and distribution of emergency case occurrences, and simulated the relocation of the EMS team with the lowest number of dispatches to the closest EMS team with the highest number of dispatches. Results: In total, 7,915 emergency cases were included. The median response time across all dispatches was 9 min,...
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Triage Competence Among Emergency Nurses in Jouf, Saudi Arabia: A Cross-Sectional Study.
WAFA abdein BASHIR
,
Shahenda A Salih
,
Mohammed Abdelmalik
,
Mohamed Abdallah
,
Mohammead O. Mohammead
,
Asma Nafea Hawas Al-Ruwaili
,
Ghady Mohamed Aldhwihi
,
Shumukh Murdhi Alanazi
,
Renad Mohammed Alruwaili
,
Ariam Sayer Alruwaili
,
Farah Saud Alanazi
,
Aisha Abdullah Alyahya
,
Joud Mohaimeed Altaymani
,
Elwaleed Idris Ali Sagiron
,
Adil Abdalla
,
SALWA ALI MOUSA
,
Asia Suliman Mohamed Ahmed
,
Almoez Mohammed Edress Mohammed
,
Sitelbanat Osman Mohamed Ahmed
Year:
1970
Background Triage is a critical process in emergency departments that involves the evaluation and prioritization of patients based on the severity of their condition. Effective triage can save lives, reduce morbidity and mortality rates, and optimize healthcare resource utilization. Objectives This study aimed to assess triage knowledge, practice, and related factors among emergency department nurses. Methods This was a cross-sectional study. A total of 150 nurses from three governmental hospitals in the Jouf region of Saudi Arabia were recruited using convenience sampling techniques and self-administered questionnaires, and data collection occurred from September to December 2024. Data were analyzed using SPSS (version 26) with descriptive and inferential statistics, independent t-test, one-way ANOVA, and Pearson correlation test. Results The results indicated that 78% of the participants were female, 80.7% were aged between 25 and 30 years, and 62% had 1–5 years of work experience. More than half...
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Acute Pyrethroid Toxicity Mimicking Cholinergic Crisis Following Intentional Ingestion
Fathima Murthuza
,
Wasim Ahmad
,
Mohamed Abdou Saad
,
Maitha Almatrooshi
Year:
1970
Introduction: Pyrethroids are synthetic analogs of natural pyrethrins and are used as insecticides because of their perceived low mammalian toxicity and high insecticidal efficacy. Despite this reputation, large volume ingestion can result in systemic toxicity which may closely mimic cholinergic toxidromes, leading to diagnostic uncertainty. Case Presentation: A 21 year old male presented with vomiting, drowsiness, hypersalivation, miosis, bronchorrhea, and respiratory distress after ingesting 500 mL of a beverage mixed with Katmal, a cockroach killing powder. On examination, he was lethargic with pinpoint pupils, cold extremities, excessive oral secretions, and bilateral lung crackles. Blood gas analysis revealed primary metabolic acidosis with an elevated lactate. Organophosphate poisoning was assumed and atropine was administered, which led to improvement in secretions and respiratory distress. The ingested compound was later identified as lambda cyhalothrin, a type II pyrethroid. Discussion: This case highlights the diagnostic challenge posed by atypical toxidromes following insecticide ingestion. The initial...
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A Rare Cause of Anisocoria in the Emergency Department: A Case of Adie Pupil
Özge Can
,
Pinar Baran
,
Sadiye Midik
,
Murat Ersel
Year:
1970
Introduction: Anisocoria is a significant clinical sign that may indicate serious neurological conditions such as third cranial nerve palsy, intracranial hemorrhage, or uncal herniation. However, it can also be caused by benign disorders like Adie-Holmes syndrome. Adie pupil is characterized by a tonically dilated pupil with poor or absent light reaction and preserved, though often slow, near response. It is caused by postganglionic parasympathetic denervation at the level of the ciliary ganglion. The condition typically affects young women and is unilateral in 80% of cases. When accompanied by diminished or absent deep tendon reflexes, the condition is referred to as Adie-Holmes syndrome. We report a case of a man diagnosed with Adie pupil after comprehensive emergency evaluation. Case:A 39-year-old man presented to the emergency department with the complaint of blurred vision and a dilated right pupil noticed on awakening. He denied any history of trauma, headache, diplopia, nausea, or systemic...
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From fang to fight: A case series on clinical outcomes and management of snakebite envenomation
Nehemiah Rodney Hidalgo
,
Sheina Singlao-Vargas
,
Bryan Ben Cagayao
,
Elisha Grace Labuguen-Liwanag
,
Tysha Kae Liquit
,
Raff Emil Primero
Year:
1970
Background: Snakebite envenomation remains a life-threatening emergency in rural and resource-limited settings, where delayed presentation, limited access to antivenom, and fragmented referral systems contribute to morbidity and mortality. In the Philippines, cobra envenomation commonly results in neurotoxic manifestations requiring urgent intervention.Methods: We present a case series of four patients with neurotoxic snakebite envenomation treated with purified cobra antivenom (PCAV) at the emergency department of a tertiary referral hospital in Northern Luzon in 2024. Data were retrospectively reviewed, including demographics, clinical presentation, timing of referral, antivenom administration, supportive management, and outcomes.Results: Among 193 emergency department consultations for snakebite, 28 patients required admission, and four received antivenom. Patients included one pediatric case, two adult males, and one elderly patient with multiple comorbidities. All patients presented with neurotoxic features such as ptosis, dysarthria, dysphagia, or altered sensorium. Two patients required endotracheal intubation and mechanical ventilation, including one who suffered cardiac arrest during interfacility...
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Is major Trauma CT reported within 60 minutes?
Jitendra Siyani
,
Lamay Rahman
,
Adeep Menon
,
Saad Abdulla
,
Edward Lamuren
Year:
1970
Introduction: The National Institute for Health and Care Excellence (NICE) recommends provisional radiology reports within 60 minutes for urgent trauma CTs. Aim/Objective: To initially assess Basildon’s compliance with this 60 minute recommendation and then to formulate plus implement changes if falling below this guidance Method: We initially recorded the number of Trauma CT requests in one month and the time taken for the CT to be reported. We highlighted the issue at the local governance and education meeting. A decision was made to introduce a trauma assessment form to streamline and triage scanning requirements. Additional changes were made that scan request authorization would now only be limited to senior clinicians on duty. Results: Between May and August 2024, trauma CT reporting times averaged 72 minutes. A trauma assessment form was introduced to streamline scanning. Post-intervention, reporting times improved to 52 minutes. The number of Trauma CT requests in May 2024...
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When the Airway Fights Back: A Case of Tracheal Stenosis Masquerading as Asthma
Alia Farhana Mohammed Pisal
,
Mohammad Fathullah Rossman
,
Dayang Suratun Syafizah Dermawan
Year:
1970
Introduction: Tracheal stenosis is an uncommon yet clinically significant condition that may remain unrecognized until airway instrumentation is attempted, at which point it can precipitate acute airway compromise and life-threatening hypoxia, with presentations frequently mimicking more common respiratory pathologies and resulting in delayed diagnosis, particularly in patients with predisposing risk factors. Case: A 33-year-old patient with multiple comorbidities, including hypertension, diabetes mellitus, dyslipidemia, dilated cardiomyopathy with reduced ejection fraction, and a recent left middle cerebral artery infarct complicated by hemorrhagic transformation following thrombolysis, presented with acute respiratory distress following a two-week history of productive cough and sudden worsening dyspnea with chest tightness, in the context of active vaping. On presentation, the patient was markedly tachypneic, assumed a tripod position, and demonstrated reduced air entry with generalized rhonchi. Point-of-care lung ultrasound revealed an A-profile without pleural effusion, while bedside echocardiography showed hyperdynamic cardiac function. Initial management with bi-level positive airway pressure...
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Brainstem Stroke Presenting as Cardiac Arrest: A Reversible Diagnosis Not to Miss
Yuhei Urakami
Year:
1970
Background Cardiac arrest is a common emergency department (ED) presentation, but brainstem infarction as the underlying cause is exceptionally rare and often overlooked. Basilar artery occlusion (BAO) can result in sudden dizziness, nausea, dysarthria, diplopia, cranial nerve palsies, respiratory failure, and coma. These signs are frequently missed, as patients typically present unresponsive, making clinical assessment challenging before imaging. Although rare, BAO is potentially reversible if recognized and treated promptly. We report a case of cardiac arrest due to BAO where early suspicion and rapid imaging led to successful reperfusion and survival. Case Presentation A 63-year-old man—previously independent, with a history of hypertension, diabetes, dyslipidemia, and prior lacunar infarction—collapsed suddenly at work, moments after complaining of nausea. Paramedics found him deeply comatose (GCS 3). During transport, he developed bradypnea, hypotension, and bradycardia, progressing to pulseless electrical activity shortly after arrival to the ED. The patient was intubated immediately, and return of...
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Not Just Another Wheeze: Vocal Cord Malignancy Masquerading as Refractory Asthma
Heshila Shajanie Udumullage
Year:
1970
A 60-year-old male with a recent two-month history of bronchial asthma presented to the Emergency Department (ED) in severe respiratory distress, just nine hours after being discharged for an asthma exacerbation. At discharge, the only residual symptom was persistent hoarseness, which was under outpatient ENT clinic review. On re-admission, he was breathless with SpO₂ of 79% on room air, respiratory rate 30/min, heart rate 114/min, and BP 146/92 mmHg. He could speak only in single words and had bilateral wheeze on auscultation. Arterial blood gas showed type 2 respiratory failure. Lung ultrasound was unremarkable except for a localized B-profile in the left lower zone. No pneumothorax or effusion was detected. He received full escalation for status asthmaticus—oxygen, back-to-back bronchodilator nebulization, IV magnesium, IV steroids, salbutamol infusion, and BiPAP. Despite appropriate treatment, the patient did not improve as expected. A persistent, audible wheeze over the neck raised concern for a possible...
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Mum, Why Can’t I See? : Pediatric PRES with Atypical Presentation
Dayang suratun syafizah binti Dermawan
,
Mohammad Fathullah bin Rossman
,
Alia Farhana binti Mohammed Pisal
Year:
1970
Posterior reversible encephalopathy syndrome (PRES) is a rare but treatable condition characterized by seizures, headache, altered mental status, and visual disturbances, often associated with hypertension. While increasingly recognized in adults, pediatric cases remain uncommon and diagnostically challenging. We report an 11-year-7-month-old, previously healthy, rugby-playing boy (60 kg) who presented with sudden onset of acute vision loss after waking up from afternoon nap. Early at school, he had a presyncopal episode, followed by persistent headache. He later vomited but did not have a fever . He experienced two generalized tonic-clonic seizures, the second with facial twitching which requiring IV diazepam. Notably, he had a year-long history of orthopnea, apnea, morning somnolence, and sneezing. On arrival he was confused with GCS E3V4M4 not oriented to time, place and person with BP 188/98 HR 115 and SpO2 92% under room air. On examination, there is reduced air entry bibasally with left-sided crepitations. Neurological...
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Pyrexia of unknown origin presenting as Aortic Root Dissection
Nilanka Mudithakumara
,
Srijith Dahanayake
Year:
1970
Introduction Pyrexia of unknown origin (PUO) is a rare Emergency presentation, and the origin of pyrexia is rarely found in the Emergency Department(ED) because it requires extensive blood, imaging and other investigations to come to a diagnosis. Aortic root dissection is a rare presentation of PUO, that could present as an unstable cardiac tamponade. Aortitis is a rare aetiology of PUO as well. This case is a rare triple combination of PUO, present as an aortic root dissertation, with an aetiology of aortitis. Case Report A 50-year-old previously healthy Sri Lankan male with a history of on-and-off fever for one month presented to a peripheral ED with dizziness, was found to have low blood pressure of 86/52mmHg with a heart rate of around 120bpm, with audible heart sounds, no elevation of jugular venous pressure and with other stable vital parameters. He had no fever on admission. Initial stabilization and sepsis...
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Acalypha indica–Induced Hemolytic Crisis and Methemoglobinemia Complicated by Acute Kidney Injury in an Undiagnosed G6PD-Deficient adult
HMGN Senevirathna
,
PPDRP Maduchandra
Year:
1970
Background:Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a common enzymatic disorder in Asia and Africa that predisposes red blood cells to oxidative injury. Acalypha indica is a widely used traditional herbal plant in South Asia and contains oxidant compounds capable of precipitating hemolysis and methemoglobinemia in susceptible individuals. Severe complications such as acute kidney injury (AKI) are rarely reported. Case Presentation:A 24-year-old previously healthy male presented with dark urine, exertional dyspnea, malaise, and epigastric pain one day after ingesting Acalypha indica leaves as part of a meal. On examination, he was febrile, pale, and icteric, with tachycardia and tachypnea. Oxygen saturation was 86% on room air and showed poor response to high-flow oxygen. Arterial blood gas analysis demonstrated a normal partial pressure of oxygen despite persistent hypoxia on pulse oximetry, raising suspicion of methemoglobinemia, which was supported by bedside color chart estimation. Laboratory evaluation revealed severe anemia (hemoglobin 5 g/dL), markedly elevated...
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"ED Adams & Eves"- Gender-Based Job Satisfaction in Emergency Department: An Audit at Colombo South Teaching Hospital, Sri Lanka.
Nilanka Mudithakumara
,
Senitha Asanka Liyanage
Year:
1970
Introduction: Emergency Department(ED) job satisfaction is a critical determinant of ED healthcare workers' well-being, staff retention, especially in the excessively overcrowded Low and Middle-income countries (LMIC), where both “job satisfaction” and “gender-based issues” are less discussed. This comprehensive audit was initiated at the Accident and Emergency Department (A&E) of Colombo South Teaching Hospital(CSTH), Sri Lanka, to identify specific domains of “gender disparity in job satisfaction” an evidence-based, targeted departmental intervention for quality improvement. Methods: A single-centre, cross-sectional audit was conducted in early 2025 within CSTH A&E (average 400-500 patients per day). This audit included the permanent ED HCW, including physicians and nursing officers. Data collected via an anonymous, voluntary, self-administered online/ printed questionnaire specified to LMIC ED context issues. Domains assessed included overall job satisfaction, gender bias, environment and work-life balance, burnout and compensation, workplace equity, unconscious bias, threats, expectations and support available. Results: A robust response of 82% was achieved...
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Evaluating Inter-Hospital Transfers of Critically Ill Trauma Patients at a Major Sri Lankan Trauma Center
HMGN Senevirathna
,
Thushini Goonewardhana
,
AI Jagoda
,
PPDRP Maduchandra
Year:
1970
Background:Inter-hospital transfer of critically ill trauma patients is a high-risk, time-sensitive process requiring appropriate staffing, monitoring, documentation, and communication. Trauma patients have dynamic physiology and complex resuscitation needs, yet data evaluating the quality of trauma transfers in Sri Lanka are limited. This audit assessed adverse events, staffing, monitoring, documentation, delays, and preparedness during transfers to the National Hospital of Sri Lanka (NHSL), Colombo. Methods:A prospective audit was conducted involving 150 critically ill adult trauma patients transferred to the Accident Service of NHSL. Data were collected using structured questionnaires completed by receiving emergency physicians. Variables included adverse events, monitoring practices, documentation quality, staffing, delays in key interventions, and pre-transfer communication. Associations were analyzed using Chi-square and Fisher’s exact tests and compared against national and international transfer standards. Results:Adverse events occurred in 64% of transfers. Cardiovascular events were most frequent, including sinus tachycardia (65.3%), hypotension (13.3%), and cardiac arrest (2%), all in...
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Intrathecal Hemorrhage in Severe Preeclampsia Causing Spinal Cord Compression in a Concealed Pregnancy
HMGN Senevirathna
,
PPDRP Maduchandra
Year:
1970
Background:Neurological complications of severe preeclampsia are most commonly cerebral, with seizures and posterior reversible encephalopathy syndrome (PRES) being well recognized. Spinal cord involvement is exceptionally rare, and intrathecal hemorrhage causing spinal cord compression has been only sparsely reported. When occurring in the context of a concealed pregnancy, such presentations pose a significant diagnostic challenge in the emergency department. Early recognition is critical to prevent irreversible neurological injury. This case highlights a rare dual neurological complication of severe preeclampsia and emphasizes the importance of maintaining a high index of suspicion in emergency care. Clinical Case:A 38-year-old previously healthy woman presented to the emergency department with sudden-onset bilateral lower limb weakness, urinary retention, and progressive abdominal distension. She denied being pregnant. Point-of-care ultrasound performed to evaluate abdominal distension revealed a live intrauterine fetus at approximately 34 weeks of gestation. Her blood pressure was 200/110 mmHg, and urinalysis demonstrated 3+ proteinuria, consistent with...
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Inhalational Injury Secondary to Oxalic Acid and Chlorine Exposure: A Case Series
Zeus Paolo Enriquez Rapada
,
Amado A. Flores III
Year:
1970
Background: Inhalational injury secondary oxalic acid and chlorine, individually, is uncommon and combination of the two is rare. Injuries from both agents are from accidental ingestion or inhalation and attempt to self-harm. Objectives: We present patients exposed to oxalic and chlorine gasses and seen at the emergency department, the adverse reactions related to the time of exposure, abnormalities in the diagnostic exams, and management. Case Series Presentation: A total of six patients were seen in this study. Patients exposed within 2 minutes to 10 minutes experienced difficulty of breathing, non-productive cough, sore throat, shortness of breath, throat itchiness. However, there was noted vomiting for a patient who was exposed for 15 minutes. There were no noted significant changes on complete blood count, electrolytes, 12 lead electrocardiograph and chest radiograph with one exception. There was an incidental finding of pneumonia in one of the patients. Conservative treatment was given to all...
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Emphysematous Cholecystitis - The Deadly Variant
Nursyafiqah Mohd Noor
,
Mohammad Fathullah Rossman
Year:
1970
Emphysematous cholecystitis (EC) is a rare but severe form of acute cholecystitis, distinguished by the presence of gas within the gallbladder wall, lumen, or surrounding tissues. It predominantly affects elderly, diabetic, and immunocompromised individuals and carries a significantly higher risk of complications and mortality compared to typical acute cholecystitis. A case study shown a 70 years old lady with comorbid of hypertension and hyperlipidemia presented to emergency department with two days history of abdominal pain which more over the epigastric region radiated to the right side with concurrent episodes of vomiting. She was also complaining of having loose stool for the past two days . However , no fever was documented . Upon examining her, vital sign was stable ,however in the abdomen, there was tenderness over the right iliac fossa with positive Murphy sign.Bedside transabdominal ultrasound of the gallbladder revealed mixed hypoechogenicity over the liver segment II surrounding the...
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NEWS2 Escalation of deteriorating patients in ED
Bashar Elwir
,
Mei JINGHON
,
Aqsa Munir
,
Thomas Selina
Year:
1970
Background Emergency Departments (EDs) are increasingly affected by crowding, prolonged patient stays, and delayed transfer of care, increasing the risk of missed or delayed recognition of clinical deterioration. At Royal Derby Hospital ED, delays and inconsistencies in escalation following abnormal National Early Warning Score 2 (NEWS2) observations were identified as a patient safety concern. A sentinel event involving a patient with viral myocarditis, where delayed escalation and response contributed to a fatal outcome, triggered this quality improvement project (QIP). Although trust escalation guidance existed, adherence was inconsistent and did not reflect ED workflow. Aim To improve compliance with timely escalation and response for deteriorating adult patients in the ED from 56% to 80% within 6 months, by standardising escalation pathways and embedding reliable NEWS2-aligned escalation processes. Methods A multidisciplinary QI team was established including ED consultants, registrars, nursing staff, healthcare assistants (HCAs), junior doctors, and digital transformation colleagues. The project...
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THE STROKE THAT WASN’T: MILLER FISHER SYNDROME – A NEUROLOGICAL MASQUERADE UNCOVERED IN THE EMERGENCY DEPARTMENT
Gina Rami Salama Ibrahim Abdelmesih
Year:
1970
Introduction: Miller Fisher Syndrome (MFS) is a rare, immune-mediated variant of Guillain-Barré Syndrome (GBS), classically presenting with the triad of ophthalmoplegia, ataxia, and areflexia. A viral or gastrointestinal illness usually precede MFS MFS incidence is 0.09 per 100,000 annually and accounts for roughly 1–5% of GBS cases in Western populations. It predominantly affects males and typically presents in middle age. Although the initial presentation can mimic other serious neurological conditions such as brainstem stroke, MFS usually has a benign course with good recovery if treated early and appropriately. Case description : A 59-year-old previously healthy man presented to the Emergency Department (ED) with the sudden onset of tongue heaviness and difficulty speaking while at work, which began one hour prior to arrival. His symptoms were accompanied by blurry vision, unsteadiness, and dizziness. He denied any limb weakness, headache, chest pain, or vomiting. His vital signs were stable. Based on the...
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Outcomes of Patients with Septic Shock Adhering to a Standardized Protocol
Aisha Siddiqua
,
Zareen Qasmi
,
Shagufta Kanwal
Year:
1970
Background Sepsis is a life-threatening condition resulting from the body's dysregulated response to infection, leading to tissue damage, organ dysfunction, and potentially death. If not recognized and managed promptly, it may progress to septic shock and multiorgan failure. Adherence to standardized septic shock management protocols has been associated with improved patient outcomes. According to data published in 2020, there were approximately 48.9 million cases of sepsis and 11 million sepsis-related deaths worldwide, accounting for 20% of global mortality. Nearly 20 million cases occurred in children under the age of five. Furthermore, for every 1,000 hospitalized patients, around 15 are estimated to develop sepsis as a complication of healthcare delivery. Objective This study aims to evaluate the outcomes of pediatric patients with septic shock who received early protocol-driven management—including fluid resuscitation, inotropic support, and antibiotics—within the first hour of presentation to the emergency department. Methods - Design: Retrospective cross sectional study...
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Ripping abdominal pain with a tortoise heart: Descending Aortic Dissection Presentation with Backache and Sinus Bradycardia in the Emergency Department.
Nilanka Mudithakumara
,
Dushyantha Goonewardene
Year:
1970
Introduction Severe tearing-type chest pain radiating to the back is the typical presentation of Aortic Dissection, commonly manifest with tachycardia and hypertension, especially Stanford type B Aortic Dissections. We present a case of sinus bradycardia in a type B aortic dissection patient with a severe, painful aortic dissection, not involving the coronary arteries initially. This is a case of paradoxical bradycardia with severe pain. Case Report A 17-year-old, previously unscreened Sri Lankan male presented with acute onset abdominal pain radiating to the back with no hematuria, limb paralysis, fever or other urinary bowel symptoms. The clinical examination revealed no radio-radial or radio-femoral delay or blood pressure discrepancy. He had Marfanoid features and kyphoscoliosis, but the vital parameters were stable, other than severe bradycardia and sinus arrhythmia. The pain was not settling with intravenous Morphine, requiring additional analgesia. Despite being in severe pain (worst-ever 10/10), the patient was in persistent bradycardia...
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Pyrexia of unknown origin presenting as Aortic Root dissection
Nilanka Mudithakumara
,
Srijith Dahanayake
Year:
1970
Introduction Pyrexia of unknown origin (PUO) is a rare Emergency presentation, and the origin of pyrexia is rarely found in the Emergency Department(ED) because it requires extensive blood, imaging and other investigations to come to a diagnosis. Aortic root dissection is a rare presentation of PUO, that could present as an unstable cardiac tamponade. Aortitis is a rare aetiology of PUO as well. This case is a rare triple combination of PUO, present as an aortic root dissertation, with an aetiology of aortitis. Case Report A 50-year-old previously healthy Sri Lankan male with a history of on-and-off fever for one month presented to a peripheral ED with dizziness, was found to have low blood pressure of 86/52mmHg with a heart rate of around 120bpm, with audible heart sounds, no elevation of jugular venous pressure and with other stable vital parameters. He had no fever on admission. Initial stabilization and sepsis...
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Implementation of a Real-Time Integrated Emergency Department Dashboard and Its Impact in a Tertiary Indian Emergency Department
Saisaranya
,
Shameem K U
Year:
1970
Background: Emergency departments (EDs) in India frequently experience overcrowding, delayed imaging, and limited visibility into time-critical pathways. Conventional dashboards primarily track census and waiting times but do not support clinical escalation or multidisciplinary coordination. This study evaluates the impact of implementing a real-time integrated dashboard in a high-volume tertiary ED. Objectives: To implement a unified dashboard linking operational, radiological, and clinical pathways and to measure its effect on efficiency and critical care timelines. Methods: This quality improvement initiative was conducted in a tertiary care ED in Kerala, India, using a two-phase design. Phase 1 employed a conventional administrative dashboard. Phase 2 introduced a clinical-operational integrated system with automated investigation tracking, color-coded delay alerts, radiology waiting clocks, multispecialty consultation tracking, and full integration of time-sensitive pathways. Pre and post-intervention metrics were compared. Results: Implementation of the integrated dashboard produced measurable improvements across radiology, operational flow, and critical care timelines. Mean CT...
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"Compassion First": An audit on Bystander Feedback and Communication Standards in a High-Volume Tertiary Care Emergency Department
Nilanka Mudithakumara
,
Senitha Asanka Liyanage
Year:
1970
Background: Effective communication is a cornerstone of patient-centered care and a critical indicator of healthcare quality. In overcrowded Emergency Departments (ED) within Lower-Middle Income Countries (LMIC), balancing rapid clinical intervention with clear communication owns unique challenges. This study evaluates healthcare staff (HCS) communication standards and their direct impact on bystander satisfaction at the Colombo South Teaching Hospital (CSTH). Methods: A prospective study was conducted in February 2025 at the CSTH Accident and Emergency (A&E) Department, which manages an average of 450 patients and 15 resuscitations daily. Feedback was gathered from 198 randomly selected patients’ families through direct observation and medical officer quality assessments. The study focused on doctor-family communication, the clarity of information provided, and the management of "bad news". Results: The assessment revealed high performance in several communication metrics: 97% of respondents reported clear communication, and 93.9% expressed overall satisfaction. Senior doctor involvement was strongly correlated with higher family...
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FRAILTY SCREENING AT ED TRIAGE: STUDY OF PREVALENCE AND PREDICTIVE VALUE IN OLDER ADULTS
Saisaranya
,
Shameem K U
Year:
1970
Background:The global population is aging rapidly, and emergency departments (EDs) increasingly serve as a primary point of care for older adults. Frailty, characterized by reduced physiological reserve and heightened vulnerability to stressors, is a strong predictor of morbidity, hospitalization, and mortality. Despite its clinical relevance, frailty assessment at ED triage remains underutilized, particularly in Indian settings. The Clinical Frailty Scale (CFS) is a simple, validated tool suitable for rapid triage evaluation, yet regional data on its prevalence and prognostic utility are limited. Objectives:To determine the prevalence of frailty among ED patients aged ≥65 years and evaluate the ability of CFS to predict hospital admission and 30-day mortality. Methods:We conducted a prospective observational study from October 1, 2024, to October 1, 2025, at a 30-bed tertiary-care ED at KIMSHEALTH, Trivandrum, South India, with an annual census exceeding 45,000 adult patients. Consecutive patients aged ≥65 years presenting to triage were assessed using...
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Dreaded Lazy eyelid in an innocent jammed sinus – A rare presentation of acute Sinusitis presenting with acute unilateral ptosis
Nilanka Mudithakumara
,
Viraj Jayasinghe
Year:
1970
Introduction Unilateral ptosis could be the initial presentation of a disease with dreaded complications including neurological conditions, ophthalmological and mechanical causes, tumors, etc. Acute sinusitis may present with facial pain with mild swelling and catarrhal features. Ipsilateral ptosis with sinusitis could be due to a complication of sinusitis, indicating orbital or cavernous sinus involvement. We present a case of a 13 year old Sri Lankan boy presenting with unilateral ptosis with one weekof nasal congestion, diagnosed with left frontal sinusitis complicated with right eye ptosis without other evidence of neurological orinfectious pathologies or a trauma history. Case Report A 13 -year-old boy was presented to the emergency department with leftsideddrooping eye lid and chronic ipsilateral headache and seven days history of nasal congestion. He had no fever or other features to suggest infection, trauma or toxin exposure. He was not appearing ill looking , no photophobia, no neck-stiffness. On examination,...
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OUTCOME OF PATIENTS WITH NEONATAL SURGICAL EMERGENCIES IN EMERGENCY DEPARTMENT
Aisha Siddiqua
,
Huma Waqar
Year:
1970
BACKGROUND : Neonatal surgical emergencies can have varying outcome depending upon condition , promptness of diagnosis, intervention and presence of other anomalies in neonates. Neonates born with birth defects need to addressed surgically but cultural norms hinder delayed treatment modalities in developing countries. Disease processes are often well advanced when patients received in emergency department after traditional remedies have failed at home . Immediate and appropriate surgical intervention is not available in developing countries. OBJECTIVES: The study was conducted to explore the factors influence the outcome in neonates having surgical emergencies depend upon the early recognition , timely diagnosis, stabilization , early timely referral and multidisciplinary care . By understanding these factors and providing prompt , high quality care , health care providers can improve the outcome for neonates with surgical emergencies in Emergency department and significantly reducing the morbidity and mortality in neonates....
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IMPACT OF TELEMEDICINE IN DIAGNOSIS AND MANAGEMENT OF CARDIAC ARRYTHMIAS IN CHILDREN.
Huma Waqar
,
Zareen Qasmi
,
Aisha Siddiqua
Year:
1970
OBJECTIVE: To evaluate the impact of telemedicine in diagnosis and management of cardiac arrythmias in children (0-13 years) in Pediatric emergency. INTRODUCTION: Telemedicine is defined as diagnosing and treating patients remotely using telecommunications technology. The increased burden of critically ill patients in emergency departments across the country highlights the role of telemedicine which provide remote monitoring of critical patients and assistance to emergency doctor in making accurate diagnosis and effective management of affected patients. Use of telemedicine help determine the abnormal cardiac rhythm and allows early diagnosis and management. Telemedicine is a cost effective way to bridge the gap between primary and secondary health care especially in underprivileged areas. INCLUSION CRITERIA: Patients aged 0-13 years who were diagnosed and managed for different cardiac diseases including cardiac arrhythmias after consultation with telemedicine physician. EMRs with complete data on diagnosis, treatment and outcome, from November 2023 to May 2025 were included. MATERIAL&METHODS:...
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TRENDS & CLINICAL OUTCOMES OF PEDIATRIC MEASELS CASES OVER 3 YEARS. A RETROSPECTIVE REVIEW FROM A TERTIARY CARE FACILITY IN SINDH
Wahida Latif
,
Zareen Qasmi
,
Tayyaba Ali
Year:
1970
Introduction: Measles is a contagious airborne disease which is vaccine preventable, although included in the extended programme of immunization with administration of two doses at 9 and 15 months of age. It remains a menace for children or causing short- and long-term complications and even death in infected patients. According to WHO an 11-fold rise in 2025 was reported as compared to the same period in 2024. Objective: The objective of this study is to analyse the cases of measles presenting in the paediatric emergency department of Dr Ruth K M Pfau Civil Hospital Karachi. Method: It is a retrospective analysis of three years data from May 22- Apr 25 of measles patient who visited the ED and a clinical diagnosis of measles is made. The study includes all patients from 1 month to 13 years of age triaged as P1, P2 and P3 according to the WHO ETAT system....
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Evaluating adherence to clinical guidelines for croup management and its impact on emergency department length of stay and patient outcomes.
Saleem Khoso
,
Aisha Siddiqua
Year:
1970
Objective: To evaluate adherence to clinical guidelines for croup management and its impact on emergency department length of stay and patient outcomes at pediatric emergencies of major tertiary care hospitals in Sindh. Background / Introduction Mostly affecting young children, croup is a common viral respiratory disease that frequently leads to ED visits. In an effort to maximize the use of healthcare resources and enhance patient outcomes, clinical guidelines and protocols have been established to standardize the management of croup. Following these recommendations has been demonstrated to lower hospital admission rates, duration of stay, and critical care admissions without raising adverse events or readmissions. Typically, these recommendations call for the use of systemic corticosteroids and racemic epinephrine for more severe cases. Determining how well these clinical standards are followed is therefore essential to comprehending how they affect patient outcomes and ED length of stay, as well as to find ways to...
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Moving With No Beating Heart: CPR-Induced Consciousness in Three Middle-Aged Women—A Case Series
Nilanka Mudithakumara
,
Jagath Wijayarathna
Year:
1970
Background: Cardiopulmonary resuscitation-induced consciousness (CPRIC), also known as CPR-induced awareness, is a rare but increasingly recognized phenomenon where patients exhibit signs of consciousness—such as purposeful movements or following commands—during active chest compressions despite the absence of a spontaneous heartbeat. Estimated to occur in 0.3% to 0.9% of cardiac arrests, it is thought to be a surrogate for high-quality CPR that provides sufficient cerebral perfusion to maintain brain function. However, the lack of standardized clinical guidelines for managing conscious patients during resuscitation creates significant challenges for healthcare providers. Case Series: This series describes three middle-aged Sri Lankan women (aged 52, 55, and 62) who presented to the Emergency Department in ventricular tachycardia (VT) cardiac arrest secondary to acute myocardial infarction. In all three cases, the patients gained consciousness specifically during high-quality, uninterrupted chest compressions. * Case 1: A 52-year-old patient attempted to grasp the resuscitator's gown during CPR. * Case 2:...
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"Researching the research interest" An audit of research involvement in Emergency Medicine Trainees of Sri Lanka.
Nilanka Mudithakumara
,
Bandara Ekanayake
Year:
1970
Introduction: Research involvement among Emergency Medicine (EM) trainees is a critical yet under-studied area, particularly within Low- and Middle-Income Countries (LMIC). In Sri Lanka, where Emergency Medicine is currently in its establishing phase, trainees face unique challenges. This study investigates the research involvement, knowledge, and perceived barriers among EM trainees to provide actionable recommendations for enhancing the local EM research culture in LMICs. Objectives: The study aims to evaluate research knowledge, interest, and output among Sri Lankan EM trainees. It identifies systemic barriers and resource gaps while providing actionable recommendations to bridge the "interest-application" divide and establish a sustainable research culture within this developing specialty in a LMIC. Methods: A descriptive cross-sectional study was conducted using an anonymous, voluntary, self-administered questionnaire with 63 EM trainees across four current batches in Sri Lanka. Data were collected using MS Excel and focused on previous research involvement, publication and presentation history, attendance at...
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Impact of an Emergency-Department Acute-Pancreatitis Admission Protocol on CT Use: A Retrospective Pre–Post Study
Mostafa Alhabboubi
,
Laurie Robichaud
,
Seth Davis
,
Paul Brisebois
,
Jerome Williams
,
Shannon Fraser
,
Alex Guttman
,
Xiaoqing Xue
,
Marc Afilalo
,
Eli Segal
Year:
1970
Background:Early abdominal CT is often performed for acute pancreatitis (AP) in the emergency department (ED), despite guidelines recommending delayed imaging unless diagnosis is uncertain or deterioration occurs after 48–72 h. Excess imaging may prolong ED length of stay (LOS) without improving outcomes. We evaluated whether implementing an ED admission protocol for AP reduced CT use and ED LOS. Methods:We conducted a retrospective pre–post study at a university-affiliated ED. Adults with AP were included from two periods: pre-protocol (Feb 2019–Feb 2021) and post-protocol (Apr 2021–Jan 2023). Primary outcomes were proportion receiving CT before admission and ED LOS. Secondary outcomes included CT ordering service, ultrasound use, complications, and mortality. Results:A total of 458 visits were analyzed (210 pre-, 248 post-protocol). Overall CT use was unchanged (88.5 % vs 85.5 %, p = 0.40). CTs ordered by ED clinicians decreased (97.8 % to 91.9 %; p = 0.037), while those by surgery increased...
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Case of Cardiac Toxicity from Ingestion of Pong-Pong Seeds (Cerebra odolliam)
Shobhit Swarup
Year:
1970
Cerebera odollam, commonly known as the pong‑pong or suicide tree, contains potent cardiac glycosides capable of inducing life‑threatening arrhythmias and hyperkalemia. Intentional ingestion is well‑documented in parts of South and Southeast Asia. Despite the biochemical similarity of its toxins to digoxin, evidence guiding optimal medical management remains limited. This case report highlights a severe presentation of C. odollam toxicity and describes the critical role of early recognition, management of hyperkalemia, and timely administration of anti‑digoxin immune Fab. A 56‑year‑old woman presented to the Emergency Department with vomiting, dizziness, and lethargy following intentional ingestion of pong‑pong seeds obtained from a local park. Initial vital signs were stable, and point‑of‑care ultrasound revealed normal cardiac activity. Laboratory findings demonstrated acute kidney injury (creatinine 110 µmol/L), severe hyperkalemia (6.8 mmol/L), elevated lactate (3.5 mmol/L), and a measurable digoxin level of 0.7 ng/L. Electrocardiography showed abnormalities consistent with hyperkalemia and cardiac glycoside toxicity. Hyperkalemia protocol was initiated with intravenous...
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Optimizing Dog Bite Management through Telemedicine in Resource Limited Primary Health Care centers: Insights from Sindh and Balochistan
DR AIMAN ISLAM
Year:
1970
Dog bites are a significant global public health concern, causing an estimated 55,000 deaths annually, with approximately 31,000 reported from Asia, primarily affecting children under 15. In low- and middle-income countries, like Pakistan, rabies often termed “the disease of the impoverished” remains endemic due to delayed medical care and poor access to post exposure prophylaxis (PEP) . Telemedicine has emerged as a promising tool to bridge healthcare gaps in underserved settings. By facilitating accurate case categorization, standardized treatment decisions, it supports Pakistan alignment with the One Health approach recommended by WHO to achieve rabies elimination by 2030. The study explores it roles in improving protocol adherence and clinical outcomes dog bite cases at primary health centers. Objectives: To evaluate the burden of pediatric dog bite cases and access role of telemedicine in optimizing management through protocol adherence and treatment modification in resource limited primary health care centers across Sindh and...
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