Splenic Infarct Masquerading as Myocardial Infarction.

Splenic infarction is an uncommon cause of abdominal pain. Diabetes increases the risk of blood vessel occlusion and consequent tissue infarction due to blood vessel abnormalities such as atherosclerosis or thrombosis. Systemic thromboembolism secondary to myocardial infarction is associated with an increased risk of morbidity and mortality. We report the case of a 45-year-old woman with uncontrolled diabetes who presented to the emergency department with the sole complaint of left upper quadrant pain. Upon investigations, it was discovered that she had concomitant splenic and myocardial infarctions. This case demonstrates the significance of thrombotic complications in various organs in patients with uncontrolled diabetes mellitus. Clinicians should have a high suspicion of acute vascular infarction of several organs in poorly controlled diabetic patients with nonspecific symptoms.

Clinical Care Pathway and Management of Major Bleeding Associated with Nonvitamin K Antagonist Oral Anticoagulants: A Modified Delphi Consensus from Saudi Arabia and UAE.

Background: The nonvitamin K antagonist oral anticoagulants (NOACs) have become the mainstay anticoagulation therapy for patients requiring oral anticoagulants (OACs) in the Gulf Council Cooperation (GCC) countries. The frequency of NOAC-associated major bleeding is expected to increase in the Emergency Department (ED). Nonetheless, we still lack local guidelines and recommendations for bleeding management in the region. The present Delphi-based consensus aims to establish a standardized and evidence-based clinical care pathway for managing NOAC-associated major bleeding in the Kingdom of Saudi Arabia (KSA) and the United Arab Emirates (UAE). Methods: We adopted a three-step modified Delphi method to develop evidence-based recommendations through two voting rounds and an advisory meeting between the two rounds. A panel of 11 experts from the KSA and UAE participated in the consensus development. Results: Twenty-eight statements reached the consensus level. These statements addressed key aspects of managing major bleeding events associated with NOACs, including the increased use of NOAC in clinical practice, clinical care pathways, and treatment options. Conclusion: The present Delphi consensus provides evidence-based recommendations and protocols for the management of NOAC-associated bleeding in the region. Patients with major DOAC-induced bleeding should be referred to a well-equipped ED with standardized management protocols. A multidisciplinary approach is recommended for establishing the association between NOAC use and major bleeding. Treating physicians should have prompt access to specific reversal agents to optimize patient outcomes. Real-world evidence and national guidelines are needed to aid all stakeholders involved in NOAC-induced bleeding management.

Analysis of guideline recommendations for treatment of asthma exacerbations in children: a Pediatric Emergency Research Networks (PERN) study.

RATIONALE: There is significant practice variation in acute paediatric asthma, particularly severe exacerbations. It is unknown whether this is due to differences in clinical guidelines. OBJECTIVES: To describe and compare the content and quality of clinical guidelines for the management of acute exacerbations of asthma in children between geographic regions. METHODS: Observational study of guidelines for the management of acute paediatric asthma from institutions across a global collaboration of six regional paediatric emergency research networks. MEASUREMENTS AND MAIN RESULTS: 158 guidelines were identified. Half provided recommendations for at least two age groups, and most guidelines provided treatment recommendations according to asthma severity.There were consistent recommendations for the use of inhaled short-acting beta-agonists and systemic corticosteroids. Inhaled anticholinergic therapy was recommended in most guidelines for severe and critical asthma, but there were inconsistent recommendations for its use in mild and moderate exacerbations. Other inhaled therapies such as helium-oxygen mixture (Heliox) and nebulised magnesium were inconsistently recommended for severe and critical illness.Parenteral bronchodilator therapy and epinephrine were mostly reserved for severe and critical asthma, with intravenous magnesium most recommended. There were regional differences in the use of other parenteral bronchodilators, particularly aminophylline.Guideline quality assessment identified high ratings for clarity of presentation, scope and purpose, but low ratings for stakeholder involvement, rigour of development, applicability and editorial independence. CONCLUSIONS: Current guidelines for the management of acute paediatric asthma exacerbations have substantial deficits in important quality domains and provide limited and inconsistent guidance for severe exacerbations.

Challenges in Assessing Blood Pressure in Adults Following Intravenous Paracetamol Infusion in the Emergency Room.

Background and objective The negligible side effects of paracetamol along with its ease of availability have catapulted paracetamol to be a widely used medication in emergency room management to reduce pain and subsequent elevations in blood pressure (BP). Our study aimed to address the challenges in informed clinical decision-making in the emergency room following paracetamol intravenous infusion. Methods This was a retrospective cross-sectional study involving the extraction of data from electronic medical records of patients who received intravenous paracetamol infusion between January 2022 and May 2022. Demographic information and BP-related data were collected for analysis. Results We initially considered a total of 162 patient records, with 132 of them eventually meeting the inclusion criteria. Among patients receiving paracetamol infusion for 15 minutes or less, 34% showed a drop of 1-5 mmHg in systolic BP (SBP), while 26% experienced a drop of 6-10 mmHg. However, infusion time longer than 16 minutes did not significantly reduce SBP. Diastolic BP (DBP) was not significantly affected by the duration of the paracetamol infusion. Analysis of the drop in SBP revealed no significant associations with age, gender, or ethnicity. Mean arterial pressure (MAP) was not significantly affected by the duration of paracetamol infusion. Conclusion Our findings suggest that intravenous paracetamol infusion does not significantly lower BP in adults in the emergency room, except for infusions of shorter durations. However, various factors, including infusion rate, patient characteristics, and concomitant medications, may influence BP measurements. The study emphasizes the need for establishing standardized criteria and conducting further research to assess intravenous paracetamol's hemodynamic effects accurately.

COVID-19 Encephalopathy Presenting As New-Onset Seizure: A Case Report.

Since its outbreak, it's been well-documented that coronavirus disease 2019 (COVID-19) can present with wide variety of neurological manifestations in absence of the usual respiratory symptoms. We report one such severe neurological manifestation of SARS-CoV-2 infection. To our knowledge, this is the first reported case of COVID-19 encephalopathy with CSF and MRI findings in the United Arab Emirates. We present a case of a 52-year-old female who presented with complaints of altered mentation, anosmia, headache, dizziness, weakness, lethargy, and vomiting. While in the emergency department she developed two generalized tonic-clonic seizure episodes, a more pronounced delirium, and tachypnea which required intubation. She was then admitted to the intensive care unit (ICU). She was COVID-19 positive and subsequent MRI revealed encephalopathy. She was discharged from ICU and was under long-term care at the time of case documentation.

The COVID-19 pandemic reduced the trauma incidence and modified its pattern in Al-Ain City, United Arab Emirates.

AIM: We aimed to study the impact of the COVID-19 pandemic on the pattern of injury and outcome of hospitalized trauma patients in Al-Ain City, United Arab Emirates, to use this information in the preparedness for future pandemics. METHODS: We retrospectively compared the trauma registry data of all hospitalised trauma patients, who were treated at the two main trauma centres in Al-Ain City (Al-Ain Hospital and Tawam Hospital); those who were treated over 1 year before the pandemic (n = 2002) and those who were treated at the first year of the COVID-19 pandemic (n = 1468). RESULTS: There was a 26.7% reduction in the overall incidence of trauma admissions in the COVID-19 pandemic period. The mechanism of injury significantly differed between the two periods (p < 0.0001, Fisher's exact test). There was an absolute increase in the number of injuries, due to machinery and falling objects during the pandemic (39.7% and 54.1% respectively, p < 0.001). In contrast, road traffic collisions and falls were reduced by 33.5% and 31.3%, respectively. Location significantly differed between the two periods (p < 0.0001, Fisher's exact test). There was an absolute increase of 18.4% in workplace injuries and a reduction of 39.3% in home injuries over the study period. In addition, we observed relatively more workplace injuries and fewer home injuries during the pandemic (11.3% and 42.8% compared with 7.1% and 52.4%, respectively). Mortality was similar between the two periods (1.8% compared with 1.2%, p = 0.16, Fisher's exact test). CONCLUSIONS: The COVID-19 pandemic has modified the trauma risk exposure in our population. It reduced trauma hospital admissions by around 27%. Work-related injuries, including falling objects and machinery injuries, were relatively higher during the pandemic. Prevention of work-related injuries should be an important component of preparedness for future pandemics.

Assessing the Clinical Learning Environment in an Institution in the United Arab Emirates: The Resident Perspective.

BACKGROUND: A new accreditation model in the United States has increased focus on the clinical learning environment (CLE). There is limited research on trainee perceptions of the CLE in international settings. OBJECTIVE: We surveyed residents to obtain their perspective on the CLE at 1 sponsoring institution in the United Arab Emirates (UAE). METHODS: We surveyed residents at Tawam Hospital, UAE, a sponsoring institution with 142 trainees, on their perspectives in the 6 focal areas of the US Clinical Learning Environment Review (CLER) to gather baseline information. We administered a 26-item questionnaire to residents through an audience response system in November 2018. RESULTS: Of 100 residents in postgraduate year 2 and above, 72 (72%) responded. The perspective of the majority of respondents was favorable in the areas of reporting patient safety incidents, engaging in quality improvement activities, using a standardized form for care transition, and using professional guidelines for electronic health record documentation. In contrast, only half of the respondents perceived there is honesty in the reporting of duty hours, and only 36% felt the organization supported fatigue management. Other areas for improvement included residents' understanding of the concept of health disparities and activities to address health disparities. CONCLUSIONS: Our findings suggest that in key focal areas related to patient safety, health care quality, care transitions, and professionalism, UAE residents have similar perceptions of their CLE as US trainees. Opportunities for improvement include duty hour reporting, fatigue mitigation, and addressing health disparities.

Acute angioedema: recognition and management in the emergency department.

Angioedema is characterized by localized swelling of subcutaneous tissues or mucosa of the upper respiratory or gastrointestinal tract. Laryngeal involvement may threaten airway patency and can be fatal if not addressed promptly. There are several distinct subtypes of angioedema, caused by different pathological processes involving a range of proinflammatory mediators. In the emergency department, it is essential not only that acute angioedema is identified as quickly as possible but also that the likely working diagnosis is established so that the most effective treatment may be administered to resolve potentially life-threatening swelling. In this paper, we present an overview of the various types of angioedema, and offer a practical diagnostic and therapeutic approach to their management.

The impact of adult major trauma centre status on paediatric trauma activity.

OBJECTIVES: The London Trauma Network was launched in April 2010 in order to centralise trauma care in the capital city. The consultation and resourcing of the four new major trauma centres (MTC) was adult focused. The objective of this study was to assess the impact that adult MTC status has on paediatric trauma workload. METHODS: A retrospective review of paediatric major trauma calls was performed between 1 April 2009 to 31 January 2010, before MTC status, and the same time period in 2010/11 when St George's Healthcare Trust was a designated adult MTC. The following variables were assessed; number of trauma calls, admissions to hospital, radiological services usage, inpatient stay, mechanism of injury and injury severity score (ISS)--calculated from abbreviated injury score. RESULTS: There was a 200% increase in trauma calls between the two time periods and a 191% increase in admission to hospital. The usage of radiology increased 221% for CT and 161% for plain radiology. Mean inpatient stay decreased by 0.2 days. Mechanisms of injury were similar. Despite becoming a MTC the relative volume of major injuries (ISS>15) decreased between the two time periods by 1% with a relative increase in minor trauma (ISS<5) from 63% to 72%. These results may suggest at present paediatric trauma patients are being over triaged. CONCLUSIONS: Major adult trauma centre status has a significant effect on paediatric trauma workload and hence resources. When reconfiguration of trauma services are being considered it is essential to take into account the impact on paediatric services alongside those of the adult population.

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma.

INTRODUCTION: Penetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging. PRESENTATION OF CASE: A 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation. DISCUSSION: We review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians. CONCLUSION: A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.

Spontaneous upper limb monoplegia secondary to probable cerebral amyloid angiopathy.

Cerebral amyloid angiopathy is a clinicopathological disorder characterised by vascular amyloid deposition initially in leptomeningeal and neocortical vessels, and later affecting cortical and subcortical regions. The presence of amyloid within the walls of these vessels leads to a propensity for primary intracerebral haemorrhage. We report the unusual case of a 77-year-old female who presented to our emergency department with sudden onset isolated hypoaesthesia and right upper limb monoplegia. A CT scan demonstrated a peripheral acute haematoma involving the left perirolandic cortices. Subsequent magnetic resonance imaging demonstrated previous superficial haemorrhagic events. One week following discharge the patient re-attended with multiple short-lived episodes of aphasia and jerking of the right upper limb. Further imaging demonstrated oedematous changes around the previous haemorrhagic insult. Cerebral amyloid angiopathy is an overlooked cause of intracerebral haemorrhage; the isolated nature of the neurological deficit in this case illustrates the many guises in which it can present.

Hereditary angioedema: a survey of UK emergency departments and recommendations for management.

Patients with hereditary angioedema may present to the emergency department (ED) with subcutaneous and submucosal swellings, the most important being the development of laryngeal oedema, which can rapidly obstruct the airways and cause death. The aim of this study was to establish whether local guidelines exist for the management of such patients and to determine where the C1 inhibitor concentrate (C1 INHC) was kept in the trusts. A questionnaire survey of the availability and use of C1 INHC was sent to 35 EDs across the UK with established immunology services within their trusts. A hundred percent response was received. Thirty-three trusts had a supply of the drug C1 INHC in varying quantities. Nineteen trusts had it in their ED. Only 17 departments had any guidance with regard to their use. There is a significant lack of guidance for C1 INHC use in the EDs surveyed. A guideline was developed as a result that can be used by EDs across Europe.

Outcomes from implementing early goal-directed therapy for severe sepsis and septic shock : a 4-year observational cohort study.

OBJECTIVES: The aim of this study was to determine the outcome of patients with severe sepsis and septic shock who did and did not receive early goal-directed therapy (EGDT) in the emergency department (ED). The primary end point was the in-hospital mortality rate. The secondary end points were lengths of stay in the ICU and in hospital. METHOD: Patients with sepsis who satisfied two of the four systemic inflammatory response criteria and who either had a lactate of greater than 4 mmol/l or a systolic blood pressure of less than 90 mmHg after 20-30 ml/kg of fluid, were included. Patients who had EGDT commenced, and all patients who were admitted to ICU who met EGDT criteria over a 4-year period from 1 January 2006 to 31 December 2009, were studied. RESULTS: One hundred and seventy-four patients with sepsis met the criteria for EGDT. Ninety-seven patients had EGDT commenced in the ED. The mortality rate in the EGDT group was 22.7% compared with 42.9% in the non-EGDT group (P=0.004). The length of stay in ICU was [(median and interquartile range)] 3D(5) versus 4D(8), P value less than 0.0001. There was no difference in the length of in-hospital stay. CONCLUSION: Initiating EGDT in the ED in patients with severe sepsis and septic shock was associated with a significant reduction in in-hospital mortality and length of stay in ICU.

The attitudes and awareness of emergency department (ED) physicians towards the management of common dentofacial emergencies.

OBJECTIVE: Dentofacial emergencies are a common presentation to the emergency department (ED) but there is little recent data on physicians' knowledge, confidence and attitudes in handling these cases. METHOD: A questionnaire was administered to 103 ED physicians. The sample was primarily drawn from London hospitals as well a smaller contribution from around the UK and included physicians with a range of experience and at different grades. RESULTS: The majority of the 102 participants (76.5%) did not receive any formal training in managing dentofacial emergencies. The percentage of participants who were happy to manage common dentofacial emergencies is as follows: dental trauma (20.4%); major facial trauma (39.8%); interpreting facial X-rays (68.0%); and facial suturing (85.4%). When questioned 12.1% of the participants felt that ED physicians should be responsible for managing dental emergencies compared to 22.4% who felt that ED physicians should manage maxillofacial emergencies. Only 3.9% of the participants would opt to be treated by an ED doctor in the event of them presenting to the ED with a dental injury. The remaining 72.5% would prefer to be seen by a maxillofacial surgeon, 23.5% by a dentist and none of the participants opted to be seen by the emergency nurse practitioner. CONCLUSION: ED physicians do not feel confident in managing some dentofacial emergencies. This may be attributed to a lack of training in this area as well as exposure to these types of emergencies. There is a need for greater awareness, validated guidelines and training resources for ED physicians to treat dentofacial emergencies as well more research in this field of emergency medicine.

Pituitary apoplexy can mimic acute meningoencephalitis or subarachnoid haemorrhage.

Pituitary apoplexy is an uncommon but life-threatening condition that is often overlooked and underdiagnosed. We report a 45-year-old man who presented to our emergency department with a sudden onset headache, acute confusion, signs of meningeal irritation and ophthalmoplegia. An initial diagnosis of acute meningoencephalitis was made, which was amended to pituitary apoplexy following thorough investigation within the emergency department.A 45-year-old man was brought to our emergency department by ambulance with a history of sudden onset of frontal headache and acute confusion. His wife provided the history. There was no significant past medical history of diabetes, hypertension, recent travel abroad, exposure to sick contacts, involvement in outdoor pursuits such as hiking/cave diving, or trauma. He worked in a bank and had been well until 24 h prior to the onset of sudden headache, which was gradually worsening in nature and associated with increasing confusion. The patient's wife reported that he had neither experienced any fevers, night sweats, or coryzal symptoms nor received any recent vaccinations. He was not on any regular medications. He was a non-smoker and occasionally consumed alcohol. There was no significant family history. On examination in the ED, his temperature was 37.6°C, his pulse was 110/min, and he was normotensive and normoglycaemic. A macular blanching rash was noted over the patient's trunk. The patient was disoriented to time and place. Neurological examination revealed reduced GCS (11/15-E3, M6, V2), marked neck stiffness, a positive Kernig's sign and a right sixth nerve palsy.A provisional diagnosis of acute meningoencephalitis was made and the patient was started on a course of intravenous antibiotics with benzyl penicillin 1.2 g, cefotaxime 2 g and acyclovir 750 mg. Baseline blood investigations revealed hyponatraemia (122 mmol/l), a white-cell count of 11 × 109/l and a C-reactive protein > 250. Due to the sudden onset of the symptoms and lack of prodrome, an urgent CT head scan was performed to rule out a cerebrovascular event. The scan demonstrated an enlarged pituitary gland (3 cm in diameter) with impingement of the optic chiasm. The centre of the enlarged pituitary gland was noted to be hypodense in comparison to its periphery, which was consistent with a diagnosis of pituitary apoplexy. A subsequent MRI confirmed the diagnosis (Figure 1) of an enlarged sella containing abnormal soft tissue with increased signal intensity suggestive of haemorrhage (Figure 1A).Post-MRI a lumbar puncture was performed revealing glucose 3.4 mmol/l, protein 1.0 g/l, red cells of 53/mm3 and white cells of 174/mm3 with predominant neutrophilia. No organisms were seen, and CSF cultures and HSV DNA tests were found to be negative. Endocrinological investigations demonstrated low concentrations of thyroid hormones [TSH: 0.14 mIu/l (0.35-5.5 mlU/l), FT3: 1.1 nmol/l (1.2-3.0 nmol/l), FT4: 9.6 pmol/l (8-22 pmol/l)], gonadal hormones (LH: < 1 u/l) and prolactin: 16 u/l (<450 u/l). Serum FSH was 2.9 u/l (0.8-11.5 u/L) and cortisol 575 nmol/l (450-700 nmol/l). The patient was treated for hypopituitarism based on clinical and radiological findings with intravenous fluids, hydrocortisone (100 mg) and thyroxine (50 µg) as loading doses in the ED.Within 24 h of commencement of therapy the patient's GCS rose to 15, and within 48 h there was marked improvement in the right sixth cranial nerve palsy. Formal visual field assessment demonstrated temporal visual field loss in the left eye. The patient was discharged to his usual residence a week later and follow-up was organised with both the endocrinologists and ophthalmologists. Follow-up MRI demonstrated that there was no significant change in either size or signal characteristics of the pituitary fossa mass (Figure 1B).