The Jerusalem tribune collapse incident: Challenges in the management of a pediatric mass casualty incident.

OBJECTIVES: Children comprise up to 30-50 percent of all disaster victims. Pediatric disaster medicine is a poorly established field, and most protocols are designed without adequate emphasis on the special needs of the pediatric population. During the 2021 Shavuot holiday in Israel, the collapse of temporary steel bleachers in a partially constructed synagogue resulted in a mass casualty incident (MCI) with a majority of pediatric casualties. This study analyzed the differences in post-incident casualty management, treatment, and outcomes in three Jerusalem medical centers. METHODS: Multicenter retrospective data were collected from two tertiary level 1 trauma centers and one secondary hospital in Jerusalem. The data included demographics, triage scores, injury mechanisms, medical workups, and the management of the pediatric patients. RESULTS: A total of 171 children and adolescents aged 9-18 years presented to three centers. In two institutions, the triage was performed by a senior emergency medicine physician, and in the third institution, by a senior trauma physician. Different protocols were applied, resulting in significant differences in triage, identification and documentation, admission strategies, adherence, and analgesic treatment. Most patients presented with orthopedic injuries (115/171, 67 percent). A small number had head, chest, abdominal, and multisystem injuries (11, 5, 2, and 2 percent, respectively). CONCLUSION: Pediatric MCI management presents specific challenges. The lack of consistency in triage, registry, and management highlights the need for robust pediatric MCI training programs.

Carbon monoxide poisoning cases in the emergency department are increasing in the last decade in Jerusalem.

BACKGROUND AND AIMS: The aim of our study was to describe the epidemiology of Carbon monoxide poisoning in the Emergency Department. METHODS: A retrospective descriptive analysis of patients with Carbon monoxide poisoning who were presented to the Emergency Department of Hadassah hospital in Jerusalem from 2007 to 2016. All patients that were included are confirmed cases [carboxyhemoglobin level > 5%]. Sources of exposure, seasonal variation, and demographic characteristics were analyzed. RESULTS: There were 244 patients (60% males) with 37 family clusters that accounted for 135 (55.3%) patients. One hundred seventy-three (70.9%) patients presented during the winter months. The main sources of exposure were: non-gas residential heating system, mainly charcoal grills and kerosene stoves (n = 100, 41%). Other sources were fires (n = 70, 28.7%), faulty gas heater (n = 34, 13.9%) and smoking (n = 15, 6.1%). The estimated annual incidence increased from an average of 20.8 cases a year between 2007-2011 to an average of 34 cases in 2011-2016. High-risk poisoning (levels > 25%) occurred in 28 patients (11.5%). Factors associated with severe poisoning were female gender and exposure in clusters compared with individual patients. CONCLUSION: Our current study has showed an increase of Carbon Monoxide poisoning in contrary to our study performed in the previous decade. Fortunately, we did find a lower rate of cases with severe poisoning. Beside the implementation of safer standards for residential heating systems, customized public education is advised in order to lower rates of poisoning in the future. A predicted heavy snow fall should be considered a trigger for a public health warning regarding the risk of CO poisoning.

Prognosis of patients with extreme acidosis on admission to the emergency department: A retrospective cohort study.

AIM OF THE STUDY: The development of acidosis in critically ill patients is considered to be a negative prognostic factor, and when extreme, even incompatible with life. We aimed to test the prognosis of patients with a pH lower than 6.9 on emergency department admission. METHODS: A retrospective cohort study in adult patients admitted to two emergency departments with a pH < 6.9 during the first 12 h of admission. Primary outcome was mortality within 24 h from emergency department admission. We performed a regression analysis of clinical and laboratory data in order to identify factors associated with mortality in this population. RESULTS: We analyzed data of 206 admissions to the emergency departments between 2008 and 2018 with extreme acidosis. pH Values ranged from 6.898 to 6.35 (mean 6.8 and median 6.83). 60 (29%) of the patients survived the first 24 h. 35 patients (58%) of those also survived to hospital discharge, and of them 80% have returned to their previous functional status. Patient's age, type of acidosis, cardio-pulmonary resuscitation on arrival, and diagnosis on admission were correlated with survival. CONCLUSIONS: A small but significant portion of patients with extreme acidosis on emergency department admission survive at least to 24 h and until hospital discharge. The clinical decision making should be based on other prognostic factors rather than pH value by itself.

Successful Treatment of Near Fatal Cardiogenic Shock Following Toxic Mushroom Ingestion.

Myocardial injury and hemodynamic compromise following toxic mushroom ingestion is rare. Here we present a case of cardiogenic shock after Amanita proxima ingestion, presenting with severe hemodynamic collapse necessitating mechanical circulatory support. Prompt identification, multidisciplinary clinical decision making, and timely treatment resulted in an outstanding complete clinical resolution. (Level of Difficulty: Intermediate.).

Gastrointestinal manifestations of synthetic cannabinoids: a retrospective cohort study.

BACKGROUND: Synthetic cannabinoids (SC) are chemical substances which activate cannabinoid receptors similarly to tetrahydrocannabinol, but with a higher efficacy. These substances are used as illicit recreational drugs, often smoked as herbal mixtures. The continuing availability and rapid evolution of SC is an ongoing health risk. The adverse effects of SC are wide ranging, and span from mild behavioral changes to death. Knowledge regarding gastrointestinal (GI) manifestations of SC use is sparse. METHODS: Single tertiary-care referral medical center retrospective study. RESULTS: The medical records of patients presented to hospital emergency care due to SC use between January 2014 and February 2018 were retrieved from Hadassah Mount Scopus Hospital's computerized database. The records were reviewed for clinical outcomes and laboratory tests. Fifty-five (55) patients were identified with a hospital presentation due to SC use. Twenty-one (21) out of 55 patients (38%) reported gastrointestinal complaints. The most common complaints were abdominal pain and vomiting. Of those, 28% had recurrent emergency department presentations due to abdominal pain and 66% presented with leukocytosis. Serum lactate was elevated in 66% of patients with GI manifestations. One patient had an abnormal computerized tomography (CT) abdominal angiography scan, which was compatible with intestinal ischemia. CONCLUSIONS: The clinical spectrum of gastrointestinal manifestations in SC intoxication ranges from mild symptoms, such as abdominal pain and vomiting, to even more severe symptoms suggestive of intestinal ischemia. Clinicians should be aware that abdominal pain and other gastrointestinal complaints can be associated with SC use.

Assessing the Performance of a Novel Point-of-Care Qualitative Assay for Early Diagnosis of Acute Coronary Syndrome.

BACKGROUND: Early and accurate diagnosis of acute coronary syndrome (ACS) is essential for initiating lifesaving interventions. In this article, the diagnostic performance of a novel point-of-care rapid assay (SensAheart©) is analyzed. This assay qualitatively determines the presence of 2 cardiac biomarkers troponin I and heart-type fatty acid-binding protein that are present soon after onset of myocardial injury. METHODS: We conducted a prospective observational study of consecutive patients who presented to the emergency department with typical chest pain. Simultaneous high-sensitive cardiac troponin T (hs-cTnT) and SensAheart testing was performed upon hospital admission. Diagnostic accuracy was computed using SensAheart or hs-cTnT levels versus the final diagnosis defined as positive/negative. RESULTS: Of 225 patients analyzed, a final diagnosis of ACS was established in 138 patients, 87 individuals diagnosed with nonischemic chest pain. In the overall population, as compared to hs-cTnT, the sensitivity of the initial SensAheart assay was significantly higher (80.4 vs. 63.8%, p = 0.002) whereas specificity was lower (78.6 vs. 95.4%, p = 0.036). The overall diagnostic accuracy of SensAheart assay was similar to the hs-cTnT (82.7% compared to 76.0%, p = 0.08). CONCLUSIONS: Upon first medical contact, the novel point-of-care rapid SensAheart assay shows a diagnostic performance similar to hs-cTnT. The combination of 2 cardiac biomarkers in the same kit allows for very early detection of myocardial damage. The SensAheart assay is a reliable and practical tool for ruling-in the diagnosis of ACS.

Blood cultures of adult patients discharged from the emergency department-is the safety net reliable?

We investigated the clinical implications of the practice in our emergency department (ED) of discharging patients with pending blood cultures. We reviewed the medical records of adults discharged with positive blood cultures from the ED of a 330-bed university hospital during a five-year period. Clinical characteristics, laboratory data, and antibiotic treatment prescribed in the ED and at discharge were accessed. Antimicrobial susceptibility profiles were used to determine whether antibiotic treatment was adequate. The outcomes assessed for 90 days following discharge were return to the ED, hospitalization, modified diagnosis, and death. Of 220,681 visits to the ED, 1362 showed positive blood cultures; of these, 307 (22.5%) were from discharged patients. More than half the isolates (56.3%) were considered contaminants. Of 124 visits with true bacteremia, Enterobacteriaceae were the most common pathogens (67.0%). This is concordant with urinary tract infection (UTI) being the most common diagnosis (52.4%). With antibiotic treatment, 69.4% had been discharged with antibiotic treatment, which was adequate in two-thirds of them. Among the 77 who returned to the ED, 27.5% had persistent bacteremia. The diagnosis was changed in 44.2% of them, mostly with brucellosis or bone and joint infections, and 84.4% were subsequently hospitalized. Within three months, 5.6% of bacteremic patients died, all after hospitalization. Bacteremia in discharged patients occurred mainly in association with UTI. Outcomes were generally favorable, although only about half received appropriate antibiotic treatment. Diagnoses were changed in a relatively high proportion of patients following culture results.

Use of Unenhanced Abdominal Computed Tomography for Assessment of Acute Non-Traumatic Abdominal Pain in the Emergency Department.

BACKGROUND: Acute non-traumatic abdominal pain is typically evaluated by abdomino-pelvic computed tomography (CT) with oral and venous contrast. The accuracy of unenhanced CT for diagnosis in this setting has not been widely studied. OBJECTIVES: To assess the accuracy of unenhanced CT in establishing the etiology of acute non-traumatic abdominal pain. METHODS: We retrospectively reviewed the medical and imaging records of patients aged ≥ 18 years who presented to the emergency department (ED) during a 6-month period with acute non-traumatic abdominal pain of unknown etiology, and who were evaluated with non-contrast CT within 24 hours of ED admission. Clinical details were recorded. A presumptive clinical diagnosis and CT diagnosis were compared to the discharge diagnosis which was considered the reference standard. The requirement for informed consent was waived. RESULTS: Altogether, 315 patients met the inclusion criteria - 138 males (44%) and 177 females (56%); their mean age was 45 years (range 18-90). Clinical diagnosis correlated with the CT findings in 162 of the cases (51%). CT was accurate in 296/315 cases (94%). The leading diagnosis in cases of a mismatch between CT diagnosis and discharge diagnosis was infection mostly in the urinary tract (12/18). Sensitivity, specificity, positive predictive value and negative predictive value were 91%, 99%, 91% and 85% respectively. The discharge diagnosis was unchanged in the patients who returned to the ED within 1 week of the first admission. CONCLUSIONS: In this study, unenhanced CT proved to be a feasible, convenient and legitimate examination for the evaluation of patients with acute non-traumatic abdominal pain presenting to the ED.

Emergency Department Administration of Oxycodone by Nurses Treating Musculoskeletal Pain: An Observational Prospective.

BACKGROUND: Acute musculoskeletal pain is one of the most commonly reported symptoms among patients visiting the emergency department (ED). Treatment with over-the-counter pain medications, given by nurses, results in improved pain management and reduces the waiting time to drug administration without significant side effects. Opioid analgesics are extensively used for acute pain in the ED. Compared to morphine, oxycodone has a much more specific pharmacological activity, higher analgesic potential, and more tolerable side effects. OBJECTIVES: To assess the degree of pain reduction using different protocols, including dypirone and oxycodone given by nurses, in treating acute musculoskeletal pain in the emergency department (primary outcome) and to evaluate the need for rescue medications (secondary outcome). METHODS: This observational prospective clinical trial compared two groups of 50 patients, each one visiting the ED due to musculoskeletal pain. One group was treated with dipyrone syrup and the other was treated with oxycodone syrup. The primary outcome was pain reduction measured by the Numeric Rating Scale (NRS). The secondary outcome was the difference in need for rescue medications. RESULTS: The reduction in the NRS was greater in the patients treated with oxycodone. This finding was statistically and clinically significant (P < 0.001). The need for rescue medications was also significantly reduced in this group of patients (P = 0.007). CONCLUSIONS: This study showed that the administration of over-the-counter oxycodone syrup by nurses decreases the post-treatment pain reported by patients, reduces the need for rescue medications, and increases the satisfaction of the medical staff.

Streptococcal pyrogenic exotoxin G gene in blood and pharyngeal isolates of Streptococcus dysgalactiae subspecies equisimilis has a limited role in pathogenesis.

BACKGROUND: Streptococcus dysgalactiae subspecies equisimilis (SE) causes human infections that clinically resemble infections due to Streptococcus pyogenes (SP). SE expresses several virulence determinants initially identified in SP, including genes encoding streptococcal pyrogenic exotoxins. SE isolates from patients with toxic shock syndrome were found to harbor a gene designated spegg, which is similar to the SP pyrogenic exotoxin-G gene, termed speG. Other streptococcal pyrogenic exotoxins known to exist in SP were not detected. METHODS: To determine the prevalence of the superantigen gene, spegg, we examined 65 invasive SE from patients presenting from 1989 to 2008 with bacteremia secondary to a variety of illnesses including two patients who fulfilled the criteria for toxic shock syndrome, in comparison with 46 noninvasive pharyngeal isolates. All isolates were tested for the presence of spegg by polymerase chain reaction. Forty-four of the 65 blood isolates were also characterized by emm typing. RESULTS: spegg was identified in 49.2% and 69.5% of the blood and pharyngeal isolates, respectively. emm typing revealed the presence of 13 distinct types. There was no association between clinical presentation and the presence of spegg. We found an association between the presence of spegg and the emm type (p < 0.001). The emm types stG485 and stG840 were more frequent among spegg positive isolates, and stG4222, stG6, and stG166b were associated with spegg negative isolates. CONCLUSION: We found a high prevalence of spegg in invasive and noninvasive SE isolates, associated with specific emm types. Our finding suggests that this gene does not have a role in the pathogenesis of bacteremia.

Bordetella holmesii meningitis in an asplenic patient with systemic lupus erythematosus.

Bordetella holmesii is a slow-growing, Gram-negative, non-oxidizing bacillus with colonies that produce a brown soluble pigment and was originally described by Weyant et al. (1995) as CDC nonoxidizer group 2 (NO-2). It has recently been shown that B. holmesii may be isolated from nasopharyngeal specimens of up to 20% of patients with pertussis-like symptoms. However, invasive B. holmesii has rarely been reported and in the vast majority of cases the patients were immune deficient, mostly as a result of splenectomy or functional asplenia. Clinical presentations have included endocarditis, pneumonia, cellulitis, suppurative arthritis, pyelonephritis and septicaemia but no previous reports have documented meningitis secondary to this organism. Here we report what we believe to be the first clinical description of an adult with B. holmesii meningitis and bacteraemia with a brief review of published cases.

Renal infarction in the ED: 10-year experience and review of the literature.

OBJECTIVE: We aimed to describe clinical and radiologic features of acute renal infarction (RI). METHODS: Clinical, computed tomography (CT), and laboratory findings were retrospectively reviewed for patients diagnosed from 1999 to 2009 with CT proof of acute RI. Possible etiology of infarction was recorded. All available published series of RI were reviewed. RESULTS: Thirty-eight patients with acute RI met inclusion criteria; 127 cases of RI from 7 previous series were pooled for analysis. The most common symptoms were abdominal pain, flank pain, nausea, and vomiting. Leukocytosis (>10 × 10(9)/L) and elevated lactate dehydrogenase levels (>620 IU/L) were the most prominent laboratory findings. Computed tomography features included wedge-shaped hypodensities in the renal parenchyma in 35 (92%) and global renal ischemia in 3 (8%) patients; 13 patients (34%) had concomitant splenic infarction. The most common etiology was atrial fibrillation. Computed tomography determined the specific cause for RI in 5 patients (13%) and a possible etiology in 17 (45%). Exact correlation with previous series was limited by methodological diversity. CONCLUSION: Renal infarction should be considered in the differential diagnosis of a patient presented to the emergency department with abdominal or flank pain. Laboratory workup should include lactate dehydrogenase levels. After ruling out stone disease, contrast-enhanced CT examination is essential for the diagnosis.

Hypersensitivity reaction to a mosquito bite in a patient with chronic myeloid leukemia.

A twenty-one-year-old male patient with an exaggerated hypersensitivity reaction to a mosquito bite presented to the department of emergency medicine for further evaluation. He was noted on physical examination to have splenomegaly. The hematological blood tests that were performed were compatible with chronic myeloid leukemia (CML). In this case, the mosquito bite heralded the diagnosis of CML.

Need for emergency department observation after scorpion sting: prospective study and review of the literature in the Middle East.

OBJECTIVE: To question the existing practice to observe the victims of scorpion sting in the emergency department at least for 6 h. METHODS: Prospective study of all adult patients presenting to emergency department after scorpion sting during 3 years, and review of existing literature from Middle East countries. CONCLUSION: Serious toxicity after scorpion sting in Israel and some of neighboring countries is rare, and always presents within 1 h from the sting. Thus, prolonged observation can be reserved for a high-risk population and patients with serious toxicity on admission.

Splenic infarction: 10 years of experience.

OBJECTIVE: The aim of this study was to study the clinical presentation of splenic infarction. METHODS: A retrospective examination of files during a 10-year period was conducted. Only computed tomography-proven diagnoses of splenic infarction were included. Signs, symptoms, medical history, and results of investigation were recorded. RESULTS: We found 49 episodes of acute splenic infarction. Abdominal or left flank pain was the most common symptoms (80%), and left upper quadrant tenderness was the most common sign (35%). Splenic infarction was the presenting symptom of underlying disease in 16.6% of the patients. Based on the computed tomography results, ultrasound was diagnostic only in 18% of patients. There was no in-hospital mortality or serious complications. DISCUSSION: We present, to the best of our knowledge, the largest series of patients with splenic infarction diagnosed on clinical and radiological grounds. Awareness of the diagnostic possibility of splenic infarction in a patient with unexplained abdominal pain is important because it can be the presenting symptom of potentially fatal diseases.

Carbon monoxide poisoning in Jerusalem: epidemiology and risk factors.

OBJECTIVES: To describe the epidemiology of carbon monoxide (CO) poisoning in Jerusalem and identify risk factors for such poisoning. DESIGN: A retrospective descriptive analysis of patients with CO poisoning who presented to the Hadassah hospitals in Jerusalem from 1994 to 2006. PATIENTS: All patients with suspected CO poisoning were examined and those with confirmed cases [carboxyhemoglobin (COHb) level >5%] were included. Sources of exposure, seasonal variation, and demographic characteristics were analyzed. RESULTS: There were 292 patients (49% males) with 40 family clusters that accounted for 149 patients (51%); 230 patients (79%) presented during the winter months. All but one had unintentional CO intoxication. The main sources of exposure were faulty gas heaters (n = 135), fire (n = 102), and other residential heating systems (n = 40). The estimated annual incidence of CO poisoning decreased from 6.45 per 100,000 in 1994-2000 to 3.53 per 100,000 in 2001-2006. High-risk intoxication (COHb level >25%) occurred in 84 patients (29%). Factors associated with severe intoxication were male gender, individual patients (compared with those in clusters), and faulty gas heaters (compared with other sources). CONCLUSIONS: Males exposed to CO may have a more severe intoxication. The lower risk in patients presenting in clusters could be explained by the assumption that severe presentation in one patient alerts the others who are less severely affected. The implementation of safer standards for residential heating systems and CO detectors together with the public education may explain the decline in the incidence of CO poisoning.

Ethnic gap in coronary artery disease: comparison of the extent, severity, and risk factors in Arab and Jewish middle-aged women.

The authors examined risk factors and extent of coronary artery disease (CAD) among Jewish and Arab women in Jerusalem, where Arab women were found to have worse outcome. All angiographically confirmed cases of CAD among women aged 45 to 65 years who were hospitalized during 1990 to 1995 consisted of 40 Arab and 179 Jewish patients. Arab women had more atypical clinical presentations (P<.0001) and more extensive CAD (P=.0016) despite younger age (53+/-3 vs 55+/-5 years; P<.0003) and lesser smoking (P<.0006). The Arab women, however, were more likely to be obese (80% vs 46%; P=.0002), be physically inactive (100% vs 89%; P=.0285), and have diabetes mellitus (73% vs 40%; P=.0004). Moreover, they were more likely to have 3 or more risk factors (45% vs 23%; P=.036). Thus, a combination of an atypical presentation and higher risk (ie, diabetes mellitus combined with hypertension and other risk factors) and much more extensive disease readily explains their worse outcome.

Smoking cessation does not alter ST deviation pattern of recurrent myocardial infarctions.

BACKGROUND: Myocardial infarction (MI) may be classified as ST elevation MI (STEMI) or non ST elevation MI (NSTEMI). We used the term recurrent MI (RMI's) to denote repeated MI episodes, in a particular patient, in which a different coronary site is responsible for each episode. Recently we reported that most patients with recurrent MI episodes will have either STEMI's or NSTEMI's but not both. A history of smoking was associated with recurrent STEMI's. OBJECTIVE: To determine whether smoking cessation will alter the type of RMI in patients with an index MI of STE type. METHODS: The analysis included 128 patients who underwent at least 2 MI episodes. We attempted to include only MI's of native vessels, without the presence of extra cardiac conditions that intensify myocardial ischemia. All 128 patients were active smokers who presented with an index MI of the STE type. Of these patients 94 had recurrent STEMI and 34 had recurrent NSTEMI (STE/NSTE group). RESULTS: We identified all patients who were no longer active smokers at the time of the recurrent MI: there were 31 (33%) such patients in the STEMI group and 13 (38%) in the STE/NSTE group (p=NS). CONCLUSION: Smoking cessation did not influence the type of recurrent MI in these patients.