COVID-19 in Singapore: Our Experience as a Country, and at Singapore General Hospital's Department of Emergency Medicine.

COVID-19 has changed our lives as we knew it. The world is not naive to infectious disease outbreaks, having experienced pandemics such as the H1N1 outbreak in 2009 with up to 400,000 deaths, and the "Spanish flu" in 1919 with up to 50 million deaths worldwide respectively (https://www.euro.who.int/en/health-topics/communicable-diseases/influenza/pandemic-influenza/past-pandemics). However, this outbreak caused by the severe acute respiratory syndrome coronavirus-2 has taken the world by storm since it was first reported in end 2019. With the numbers of confirmed cases of COVID-19 and death toll rising every day, it raises the question of when will we be fully equipped to handle a pandemic of such a mammoth scale. A multi-pronged approach has to be undertaken by not only healthcare organisations and pharmaceuticals, but also government agencies and legislation in order to overcome the repercussions and mitigate the effects of an infectious disease outbreak. In this article, we share our experience in Singapore and Singapore General Hospital against COVID-19 and our ongoing efforts to keep the virus at bay.

The effect of alternative methods of cardiopulmonary resuscitation - Cough CPR, percussion pacing or precordial thump - on outcomes following cardiac arrest. A systematic review.

BACKGROUND: Cardiopulmonary resuscitation (CPR) improves cardiac arrest survival. Cough CPR, percussion pacing and precordial thump have been reported as alternative CPR techniques. We aimed to summarise in a systematic review the effectiveness of these alternative CPR techniques. METHODS: We searched Ovid MEDLINE, EMBASE and the Cochrane Library on 24/08/2020. We included randomised controlled trials, observational studies and case series with five or more patients. Two reviewers independently reviewed title and abstracts to identify studies for full-text review, and reviewed bibliographies and 'related articles' (using PubMed) of full-texts for further eligible studies. We extracted data and performed risk-of-bias assessments on studies included in the systematic review. We summarised data in a narrative synthesis, and used GRADE to assess evidence certainty. RESULTS: We included 23 studies (cough CPR n = 4, percussion pacing n = 4, precordial thump n = 16; one study studied two interventions). Only two (both precordial thump) had a comparator group ('standard' CPR). For all techniques evidence certainty was very low. Available evidence suggests that precordial thump does not improve survival to hospital discharge in out-of-hospital cardiac arrest. The review did not find evidence that cough CPR or percussion pacing improve clinical outcomes following cardiac arrest. CONCLUSION: Cough CPR, percussion pacing and precordial thump should not be routinely used in established cardiac arrest. In specific inpatient, monitored settings cough CPR (in conscious patients) or percussion pacing may be attempted at the onset of a potential lethal arrhythmia. These must not delay standard CPR efforts in those who lose cardiac output. PROSPERO REGISTRATION NUMBER: CRD42019152925.

Chlorine and its impact on an emergency department.

INTRODUCTION: An incident involving the release of chlorine gas from the pump room at a local swimming pool resulted in 54 patients seeking treatment in the emergency departments (EDs) of two local, tertiary-level hospitals in Singapore. The hospital hazardous materials (HAZMAT) disaster plan was activated. This report describes how one of the EDs organized in response to the disaster. EVENT: Of the 54 people seeking treatment, 36 were treated in the ED at the Singapore General Hospital. The patients were decontaminated at shower facilities prior to entering the ED. The ED was reorganized to cope with existing patients, as well as the large influx of patients from the event site. A protocol was established in coordination with the local drug and poison information center to manage the patients who suffered from chlorine inhalation. Most patients were observed in the ED and subsequently discharged. Outpatient review appointments were scheduled. INJURIES: Acute respiratory symptoms were the most common symptoms., Four children and four adults were admitted to the hospital, and the other patients were discharged from the ED after observation. All of the chest x-rays were normal on the day of the chlorine inhalation. There were no mortalities or significant morbidities, even up to six months after the incident. CONCLUSIONS: Although this chlorine HAZMAT incident did not cause severe injuries, and only a limited number of persons required admission to the hospital, some valuable lessons were learned.