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We aimed to compare the prognostic value of a quantitative CT severity score with several laboratory parameters, particularly C-reactive protein, Procalcitonin, Neutrophil to lymphocyte ratio, D-dimer, ferritin, lactate dehydrogenase, lactate, troponin and B-type Natriuretic Peptide in predicting in-hospital mortality.This was a retrospective chart review study of COVID-19 patients who presented to the Emergency Department of a tertiary care center between February and December 2020. All patients ≥18 years old who tested positive for the COVID-19 real-time reverse transcriptase polymerase chain reaction and underwent CT imaging at presentation were included. The primary outcome was the prognostic ability of CT severity score versus biomarkers in predicting in-hospital mortality.The AUCs were: D-dimer (AUC: 0.67 95% CI = 0.57-0.77), CT severity score (0.66, 95% CI = 0.55-0.77), LDH (0.66, 95% CI = 0.55-0.77), Pro-BNP (0.65, 95% CI = 0.55-0.76), NLR (0.64, 95% CI = 0.53-0.75) and troponin (0.64, 95% CI = 0.52-0.75). In the stepwise logistic regression, age (OR = 1.07 95% CI = 1.05-1.09), obesity (OR = 2.02 95% CI = 1.25-3.26), neutrophil/lymphocyte ratio (OR = 1.02 95% CI = 1.01-1.04), CRP (OR = 1.01 95% CI = 1.004-1.01), lactate dehydrogenase (OR = 1.003 95% CI = 1.001-1.004) and CT severity score (OR = 1.17 95% CI = 1.12-1.23) were significantly associated with in-hospital mortality.In summary, CT severity score outperformed several biomarkers as a prognostic tool for covid related mortality. In COVID-19 patients requiring lung imaging, such as patients requiring ICU admission, patients with abnormal vital signs and those requiring mechanical ventilation, the results suggest obtaining and calculating the CT severity score to use it as a prognostic tool. If a CT was not performed, the results suggest using LDH, CRP or NLR if already done as prognostic tools in COVID-19 as these biomarkers were also found to be prognostic in COVID-19 patients.

Inadequate initial antibiotic treatment of ESBL urinary tract infections (UTI) can lead to increase in the number of antibiotics used, return visits, longer hospitalizations, increased morbidity and mortality and increased costs. Given the important health implications on patients, this study aimed to examine the prevalence and predictors of ESBL UTIs among Emergency Department (ED) patients of a tertiary care center in Beirut, Lebanon.Single-center retrospective observational study involving all adult UTI patients who presented to the ED of the American University of Beirut Medical Center, a tertiary care center between August 2019 and August 2020.Out of the 886 patients that were included, 24.9% had an ESBL organism identified by urine culture. They had higher bladder catheter use within the previous 90 days, antibiotic use within last 90 days, and were more likely to have a history of an ESBL producing isolate from any body site in the last year. Antibiotic use in the last 90 days and a history of ESBL producing isolate at any site in the previous year were significantly associated with developing an ESBL UTI (OR = 1.66, p = 0.001 and OR = 2.53, p0.001 respectively). Patients diagnosed with cystitis were less likely to have an ESBL organism (OR = 0.4 95%CI [0.20-0.81], p = 0.01) CONCLUSION: The prevalence of ESBL organisms was found to be 24.9% in urinary tract infections. The predictors of an ESBL UTI infection were antibiotic use in the last 90 days, a history of ESBL producing isolate at any site in the previous year. Based on the findings of our study, we can consider modifying initial empiric antibiotic treatment for patients presenting with a UTI with the above stated risk factors.

Background Out-of-hospital cardiac arrest (OHCA) remains one of the most common causes of death. There is a scarcity of evidence concerning the prevalence of bacteraemia in cardiac arrest patients presenting to the Emergency Department (ED). We aimed to determine the prevalence of bacteraemia in OHCA patients presenting to the ED, as well as study the association between bacteraemia and in-hospital mortality in OHCA patients. In addition, the association between antibiotic use during resuscitation and in-hospital mortality was examined. Methods and results This was a study of 200 adult OHCA patients who presented to the ED between 2015 and 2019. Bacteraemia was confirmed if at least one of the blood culture bottles grew a non-skin flora pathogen or if two blood culture bottles grew a skin flora pathogen from two different sites. The prevalence of bacteraemia was 46.5%. Gram positive bacteria, specifically Staphylococcus species, were the most common pathogens isolated from the bacteremic group. 42 patients survived to hospital admission. The multivariate analysis revealed that there was no association between bacteraemia and hospital mortality in OHCA patients (OR = 1.3, 95% CI= 0.2–9.2) with a p-value of .8. There was no association between antibiotic administration during resuscitation and hospital mortality (OR = 0.6, 95% CI= 0.1 − 3.8) with a p-value of .6. Conclusion In our study, the prevalence of bacteraemia among OHCA patients presenting to the ED was found to be 46.5%. Bacteremic and non-bacteremic OHCA patients had similar initial baseline characteristics and laboratory parameters except for higher serum creatinine and BUN in the bacteremic group. In OHCA patients who survived their ED stay there was no association between hospital mortality and bacteraemia or antibiotic administration during resuscitation. There is a need for randomised controlled trials with a strong patient oriented primary outcome to better understand the association between in-hospital mortality and bacteraemia or antibiotic administration in OHCA patients.KEY MESSAGESWe aimed to determine the prevalence of bacteraemia in OHCA patients presenting to the Emergency Department. In our study, we found that 46.5% of patients presenting to our ED with OHCA were bacteremic.Bacteremic and non-bacteremic OHCA patients had similar initial baseline characteristics and laboratory parameters except for higher serum creatinine and BUN in the bacteremic group.We found no association between bacteraemia and hospital mortality. There was no association between antibiotic administration during resuscitation and hospital mortality.There is a need for randomised controlled trials with a strong patient oriented primary outcome to better understand the association between in-hospital mortality and bacteraemia or antibiotic administration in OHCA patients.

BACKGROUND The weekend effect is the increased mortality in hospitalized patients admitted on the weekend. The aim of this study was to examine the effect of weekend admissions on septic shock patients. METHODS This is a retrospective observational study of the 2014 Nationwide Emergency Department Sample Database. Septic shock patients were included in this study using ICD-9-CM codes. Descriptive analysis was done, in addition to bivariate analysis to compare variables based on admission day. Multivariate analysis was conducted to examine the association between admission day and mortality in septic shock patients after adjusting for potential confounding factors. RESULTS A total of 364,604 septic shock patients were included in this study. The average age was 67.19 years, and 51.1% were males. 73.0% of patients presented on weekdays. 32.3% of septic shock patients died during their hospital stay. After adjusting for confounders, there was no significant difference in the emergency department or in-hospital mortality of septic shock patients admitted on the weekend compared with those admitted during weekdays, (OR = 1.00 [95% CI: 0.97-1.03], P value = 0.985). CONCLUSION There was no statistically significant difference in overall mortality between septic shock patients admitted on the weekend or weekday. Our results are contradictory to previous studies showing an increased mortality with the weekend effect. The previous observations that have been made may not stand up with current treatment protocols.

Objectives Lactate/albumin (L/A) ratio is a biomarker in sepsis that has been shown to outperform lactate. This prospective study aims to validate the superior prognostic value of the L/A ratio to lactate in sepsis and septic shock. Methods Prospective cohort conducted from September 2018 till February 2021 on adult patients presenting to the Emergency Department (ED) at a tertiary care centre with sepsis or septic shock. The primary outcome was the prognostic value of the L/A ratio compared to lactate with regards to mortality. Results A total of 939 septic patients were included throughout the study period. A total of 236 patients developed septic shock. The AUC value of the L/A ratio in septic patients was 0.65 (95% CI 0.61–0.70) and was higher than that of lactate alone 0.60 (95% CI 0.55–0.64) with a p

Objectives This study aims to examine the outcome of end-stage renal disease (ESRD) patients admitted with sepsis to the intensive care unit (ICU). Design Single centre, retrospective cohort study Setting The study was conducted in the Intensive Care Department of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Participants Data were extracted from a prospectively collected ICU database from 2002 to 2017. Patients were considered to have sepsis based on the sepsis-3 definition and were stratified into 2 groups based on the presence or absence of ESRD. Primary and secondary outcomes The primary outcome of the study was in-hospital mortality. Secondary outcomes included ICU mortality, ICU and hospital lengths of stay, and mechanical ventilation duration. Results A total of 8803 patients were admitted to the ICU with sepsis during the study period. 730 (8.3%) patients had ESRD. 49.04% of ESRD patients with sepsis died within their hospital stay vs. 31.78% of non-ESRD patients. ESRD septic patients had 1.44 greater odds of dying within their hospital stay as compared to septic non-ESRD patients (OR 1.44, 95% CI 1.03–1.53). Finally, the predictors of hospital mortality in septic ESRD patients were found to be mechanical ventilation (OR 3.36; 95% CI 2.27–5.00), a history of chronic liver disease (OR 2.26; 95% CI 1.26–4.07), and use of vasopressors (OR 1.74; 95% CI 1.19–2.54). Among patients with ESRD, hospital mortality was higher in subgroups of patients with chronic cardiac (OR 1.86 (1.36–2.53) vs. 1.19 (0.96–1.47)) and chronic respiratory illnesses (OR 2.20 (1.52–3.20) vs. 1.21 (0.99–1.48)). Conclusion ESRD patients admitted to the intensive care unit with sepsis are at greater odds of mortality compared to patients with non-ESRD. This risk is particularly increased if these patients have a concomitant history of chronic cardiac and respiratory illnesses.Key MessagesSepsis and bacterial infections are very common in ESRD patients and following cardiovascular disease; sepsis is the second leading cause of death in patients with ESRD.This study aims to examine the outcome of patients with end-stage renal disease (ESRD) patients admitted with sepsis to the intensive care unit (ICU).The results of this study have shown that end-stage renal disease is associated with greater odds of ICU and hospital mortality among septic patients admitted to an intensive care unit.ESRD patients were also more likely to be started on vasopressors and mechanical ventilation.

International medical graduates (IMGs) are medical graduates who have received their degree from international medical schools. IMGs must undertake a 3-step process to apply to the National Residency Matching Program match. First, they must obtain a valid standard certificate from the Educational Commission for Foreign Medical Graduates. Following certification, they must apply for and secure a position in a residency training program. Third, they must obtain a visa that would enable them to commence their training. In this article, we delve thoroughly into these stepladders to provide IMGs with a clear roadmap of the process as well as contacts to key agencies that may provide more comprehensive assistance.

BACKGROUND: Studies looking at the effect of hospital teaching status on septic shock related in-hospital mortality are lacking. The aim of this study was to examine the effect of hospital teaching status on mortality in septic shock patients in the United States. METHODS: This was a retrospective observational study, using the Nationwide Emergency Department Sample Database (released in 2018). All patients with septic shock were included. Complex sample logistic regression was performed to assess the impact of hospital teaching status on patient mortality. RESULTS: A total of 388,552 septic shock patients were included in the study. The average age was 66.93 years and 51.7% were males. Most of the patients presented to metropolitan teaching hospitals (68.2%) and 31.8% presented to metropolitan non-teaching hospitals. Septic shock patients presenting to teaching hospitals were found to have a higher percentage of medical comorbidities, were more likely to be intubated and placed on mechanical ventilation (50.5% vs. 46.9%) and had a longer average length of hospital stay (12.47 d vs. 10.20 d). Septic shock patients presenting to teaching hospitals had greater odds of in-hospital mortality compared to those presenting to metropolitan non-teaching hospitals (adjusted odd ratio [OR]=1.295, 95% confidence interval [CI]: 1.256–1.335). CONCLUSION: Septic shock patients presenting to metropolitan teaching hospitals had significantly higher risks of mortality than those presenting to metropolitan non-teaching hospitals. They also had higher rates of intubation and mechanical ventilation as well as longer lengths of hospital stay than those in non-teaching hospitals.

Pediatric oncology patients may be at a higher risk of complications and mortality from sepsis compared with their nononcology counterpart.The aim of this study is to compare characteristics, treatment, and sepsis-related mortality between oncology and nononcology patients presenting to the emergency department (ED).This is a retrospective single-center cohort study including patients18 years old with a diagnosis of sepsis, severe sepsis, septic shock, or bacteremia presenting to an academic ED between January 2009 and January 2015. A total of 158 patients were included with 53.8% having an underlying malignancy. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED vital signs, resuscitation parameters, laboratory work, infection site, general practitioner unit, intensive care unit length of stay, and hospital length of stay.Oncology patients had a higher in-hospital mortality (5.9% vs. 2.7%), however, it did not meet statistical significance (p = 0.45). On presentation, oncology patients had a lower respiratory rate (24.33 ± 9.48 vs. 27.45 ± 7.88; p = 0.04). There was a significant increase in the white blood count in oncology patients (4.011 ± 4.965 vs. 17.092 ± 12.806; p 0.001) with this cohort receiving more intravenous fluids. In the first 6 hours (33.0 ± 27.7 mL/kg vs. 24.9 ± 16.1 mL/kg; p = 0.029) as well as having a higher percentage of vasopressor administration (15.3% vs. 1.4%; p = 0.002). Antibiotics were initiated at an earlier stage in the oncology cohort (1.25 ± 1.95 vs. 3.33 ± 1.97 hours; p 0.0001). Cancer-free patients had a significantly higher rate of lung infections compared with cancer patients (68.5% vs. 32.9%; p 0.0001). In terms of infection characteristics, cancer patients had a higher percentage of bacteremia (27.1% vs. 4.1%; p 0.001).There was no statistical significance regarding mortality between the 2 cohorts. Pediatric cancer patients were found to have a higher incidence of bacteremia and received more aggressive treatment.

We report a case of a patient presenting to the emergency department in cardiac arrest following a liposuction procedure, which was performed in a physician office using lidocaine anesthesia. During liposuction of the thighs, using the power-assisted technique, the patient was given a subcutaneous dose of lidocaine equal to 71 mg/kg without any noticeable intraoperative complication. Two hours later, the patient experienced dizziness, a rapid decline in mental status, tonic-clonic seizure, and cardiac arrest. The patient was successfully resuscitated in the emergency department with the return of spontaneous circulation after 22 minutes of continuous advanced cardiovascular life support resuscitation. The patient suffered from subsequent severe hypoxic-ischemic brain injury, and a complicated hospital stay, including brain edema, electrolytes disturbances, and nosocomial infections contributed to her death two months later due to septic shock.

Purpose: The aim of this study was to check if serum lactate was independently associated with mortality among critically ill patients. Materials and Methods: This was a single-center, retrospective cohort study. All adult patients (>18 years of age) who had at least 1 measurement of lactate within 24 hours of admission to intensive care unit (ICU) between January 2002 and December 2017 were included in the analysis. Patients were stratified into 3 groups: those with a serum lactate of 4 mmol/L (high level). The primary outcome was in-hospital mortality. Secondary outcomes included ICU and hospital lengths of stay and mechanical ventilation duration. To determine the association between lactate level and hospital mortality, bivariate and multivariate logistic regression analyses were performed. Results: Of the 16,447 patients admitted to the ICU, 8167 (49.65%) had normal levels, 4648 (28.26%) had an intermediate, and 3632 (22.09%) had high lactate levels. Hospital mortality was the highest in high lactate level, followed by the intermediate and the normal level group (47.4% vs 26.5% vs 19.6%; P < .0001). Intermediate and high lactate levels were independent predictors of hospital mortality (odds ratio [OR], 1.32; 95% confidence interval [CI]: 1.20-1.46, and 1.94; 95% CI, 1.75-2.16, respectively) as well as ICU mortality (OR, 1.47; 95% CI, 1.30-1.66 and 2.56; 95% CI, 2.27-2.88, respectively). Conclusions: Intensive care unit serum lactate is associated with increased ICU and hospital mortality, independent of comorbidities, organ dysfunction, or hemodynamic status.

Background. EGDT (Early Goal Directed Therapy) or some portion of EGDT has been shown to decrease mortality secondary to sepsis and septic shock.Objective. Our study aims to assess the effect of adopting this approach in the emergency department on in-hospital mortality secondary to sepsis/septic shock in Lebanon.Hypothesis. Implementation of the EGDT protocol of sepsis in ED will decrease in-hospital mortality.Methods. Our retrospective study included 290 adult patients presenting to the ED of a tertiary center in Lebanon with severe sepsis and/or septic shock. 145 patients between years 2013 and 2014 who received protocol care were compared to 145 patients treated by standard care between 2010 and 2012. Data from the EHR were retrieved about patients’ demographics, medical comorbidities, and periresuscitation parameters. A multivariate analysis using logistic regression for the outcome in-hospital mortality after adjusting for protocol use and other confounders was done and AOR was obtained for the protocol use. 28-day mortality, ED, and hospital length of stay were compared between the two groups.Results. The most common infection site in the protocol arm was the lower respiratory tract (42.1%), and controls suffered more from UTIs (33.8%). Patients on protocol care had lower in-hospital mortality than that receiving usual care, 31.7% versus 47.6% (p=0.006) with an AOR of 0.429 (p =0.018). Protocol patients received more fluids at 6 and 24 hours (3.8 ± 1.7 L and 6.1 ± 2.1 L) compared to the control group (2.7 ± 2.0 L and 4.9 ± 2.8 L p=Conclusion. EGDT- (Early Goal Directed Therapy-) based sepsis protocol implementation in EDs decreases in-hospital mortality in developing countries. Adopting this approach in facilities with limited resources, ICU capabilities, and prehospital systems may have a pronounced benefit.

The Neutrophil to lymphocyte ratio (NLR) was shown to be associated with disease severity, poor prognosis and increased mortality in sepsis. However, the association between NLR and sepsis prognosis remains controversial. Our study aims to prospectively examine the prognostic ability of NLR in predicting in-hospital mortality among sepsis patients and determine the optimal cutoff of NLR that can most accurately predict in-hospital mortality in sepsis patients. This study was a prospective cohort study that included adult sepsis patients that presented to the emergency department of a tertiary care center between September 2018 and February 2021. Receiver operating characteristic curve was used to determine the optimal cutoff of the neutrophil to lymphocyte ratio that predicts in-hospital mortality. Patients were divided into 2 groups: above and below the optimal cutoff. Stepwise logistic regression was performed to assess the magnitude of the association between NLR and in-hospital mortality. A total of 865 patients were included in the study. The optimal cutoff for the neutrophil to lymphocyte ratio that predicts in-hospital mortality was found to be 14.20 with a sensitivity of 44.8% and a specificity of 65.3% (with PPV = 0.27 and NPV = 0.80). The area under the curve for the ratio was 0.552 with a 95% confidence intervals = [0.504-0.599] with a P value = .03. Patients that have a NLR above the cutoff were less likely to survive with time compared to patients below the cutoff based on the Kaplan-Meier curves. In the stepwise logistic regression, the optimal neutrophil to lymphocyte ratio cutoff was not associated with in-hospital mortality (odds ratios = 1.451, 95% confidence intervals = [0.927-2.270], P = .103). In conclusion the optimal cutoff of the NLR that predicts in-hospital mortality among sepsis patients was 14.20. There was no association between the NLR and in-hospital mortality in sepsis patients after adjusting for confounders. Further studies with a larger sample size should be done to determine the optimal NLR cutoff and its prognostic role in septic patients (in-hospital mortality and other clinically significant outcomes).

ObjectivesThis study aims to examine the outcome of haematological and patients with solid cancer presenting with sepsis to the emergency department (ED).DesignSingle-centred, retrospective cohort study. Setting conducted at an academic emergency department of a tertiary hospital.ParticipantsAll patients >18 years of age admitted with sepsis were included.InterventionsPatients were stratified into two groups: haematological and solid malignancy.Primary and secondary outcomeThe primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) mortality, ICU and hospital lengths of stay and mechanical ventilation duration.Results442 sepsis cancer patients were included in the study, of which 305 patients (69%) had solid tumours and 137 patients (31%) had a haematological malignancy. The mean age at presentation was 67.92 (±13.32) and 55.37 (±20.85) (pConclusionSolid tumour patients with sepsis or septic shock are at the same risk of mortality as patients with haematological tumours. However, haematological malignancy patients admitted with sepsis or septic shock have higher rates of bacteraemia.

Objective: The clinical interpretation of lactate ≤ 2.00 mmol/L in emergency department (ED) patients is not well-characterized. This study aims to determine the optimal cutoff value for lactate within the reference range that predicts in-hospital mortality among ED patients. Methods: This was a retrospective study of adult patients presenting to a tertiary ED with an initial serum lactate level of

Background: The aim of this study is to evaluate the prognostic value of the Lactate to Albumin (L/A) ratio compared to that of lactate only in predicting morbidity and mortality in sepsis patients.Methods: This was a single-center retrospective cohort study. All adult patients above the age of 18 with a diagnosis of sepsis who presented between January 1, 2014 and June 30, 2019 were included. The primary outcome was in-hospital mortality.Results: A total of 1,381 patients were included, 44% were female. Overall in-hospital mortality was 58.4% with the mortalities of sepsis and septic shock being 45.8 and 67%, respectively. 55.5% of patients were admitted to the intensive care unit. The area under the curve value for lactate was 0.61 (95% CI 0.57–0.65, p < 0.001) and for the L/A ratio was 0.67 (95% CI 0.63–0.70, p < 0.001). The cutoff generated was 1.22 (sensitivity 59%, specificity 62%) for the L/A ratio in all septic patients and 1.47 (sensitivity 60%, specificity 67%) in patients with septic shock. The L/A ratio was a predictor of in-hospital mortality (OR 1.53, CI 1.32–1.78, p < 0.001).Conclusion: The L/A ratio has better prognostic performance than initial serum lactate for in-hospital mortality in adult septic patients.

Objective The clinical interpretation of lactate ≤ 2.00 mmol/L in emergency department (ED) patients is not well characterized. This study aims to determine the optimal cutoff value for lactate within the reference range that predicts in-hospital mortality among ED patients with initial serum lactate levels within the reference range. Methods This was a retrospective study of adult patients presenting to a tertiary ED between the dates of January 1, 2014 and June 30, 2019 with an initial serum lactate level less than 2.00 mmol/L. The primary outcome was in-hospital mortality. Youden’s index was utilized to determine the optimal threshold that predicts mortality. Patients above the threshold were labeled as having relative hyperlactatemia. A multivariate logistic regression was performed to determine the association between relative hyperlactatemia and in-hospital mortality. Subgroup analyses were done to further examine the interaction between relative hyperlactatemia and hospital mortality. Results During the study period, 1638 patients were included. The mean age was 66.9 ± 18.6 years, 47.1% of the population were female, and the most prevalent comorbidity was hypertension (56.7%). The mean lactate level at presentation was 1.5 ± 0.3 mmol/L. In-hospital mortality was 3.8% in the overall population and 16.2% were admitted to the ICU. A lactate of 1.33 mmol/L was found to be the optimal cutoff that best discriminates between survivors and non-survivors. Relative hyperlactatemia was an independent predictor of in-hospital mortality (OR 1.78 CI1.18-4.03; p 0.02). Finally, Relative hyperlactatemia was associated with increased mortality in patients without hypertension (4.7% versus 1.1%; p 0.008), as well as patients without diabetes or COPD. Conclusion The optimal cutoff of initial serum lactate that discriminates between survivors and non-survivors is in the ED 1.33 mmol/L. Relative hyperlactatemia is associated with increased mortality in emergency department patients, and this interaction seems to be more important in healthy patients.

In the setting of cardiac arrest, refractory ventricular fibrillation (VF) is difficult to manage, and mortality rates are high. Double sequential defibrillation (DSD) has been described in the literature as a successful means to terminate this malignant rhythm, after failure of traditional Advanced Cardiac Life Support (ACLS) measures. The authors herein present a case of refractory VF in a patient with cardiac arrest, on whom DSD was successful in reversion to sinus rhythm, and provide a thorough review of similar cases in the literature.

Background Emergency Department (ED) visits for suicide attempts have been described worldwide; however, the populations studied were predominantly Western European, North American, or East Asian. This study aims to describe the epidemiology of ED patients presenting post-suicide attempt to an academic medical center in Lebanon and to report on factors that affect ED disposition. Methods A retrospective cohort study was conducted between 2009 and 2015. Patients of any age group were included if they had presented to the ED after a suicide attempt. Patients with unintentional self-harm were excluded. Descriptive analysis was performed on the demographics and characteristics of suicide attempts of the study population. A bivariate analysis to compare the two groups (hospitalized or discharged) was conducted using Student’s t test and Pearson Chi-square where appropriate. A multivariate analysis was then conducted to determine the predictors of hospital admission. Results One hundred and eight patients were included in the final analysis. Most patients were females (71.4%) and between 22 and 49 years of age. A considerable number of patients were unemployed (43%), unmarried (61.1%), and living with family (86.9%). Most suicide attempts were performed at home (93.5%) and on a weekday (71.3%). The most common mechanisms of injury were overdose with prescription medications (61.3%), overdose with over-the-counter drugs (27.9%), and self-inflicted lacerations (10.1%). The classes of medication most commonly abused were benzodiazepines (39.3%) followed by acetaminophen (27.3%). A large portion of our patients were admitted (70.3%), with the majority going to the psychiatric ward (71.1%). Of note, a quarter (27.5%) of our patients left the ED against medical advice, with 23.5% of admitted patients leaving the hospital before completion of treatment. The main predictors of admission were found to be overdose on prescription medications OR 9.25 (2.12–40.42 CI95%). Conclusions The characteristics of our suicide attempters mirror those of international and regional suicide attempters. Further work is required to quantify the effect of voluntary refusal of hospital treatment, the repercussions of family, and financial barriers to healthcare and suicide as a whole in our society. Electronic supplementary material The online version of this article (10.1186/s12991-018-0191-5) contains supplementary material, which is available to authorized users.

Background Elevated lactate has been found to be associated with a higher mortality in a diverse patient population. The aim of the study is to investigate if initial serum lactate level is independently associated with hospital mortality for critically ill patients presenting to the Emergency Department. Methods Single-center, retrospective study at a tertiary care hospital looking at patients who presented to the Emergency Department (ED) between 2014 and 2016. A total of 450 patients were included in the study. Patients were stratified to lactate levels: 4 mmol/L. The primary outcome was in-hospital mortality. Secondary outcomes included 72-h hospital mortality, ED and hospital lengths of stay. Results The mean age was 64.87 ± 18.08 years in the 4 mmol/L group. All 3 groups were comparable in terms of age, gender and comorbidities except for diabetes, with the 2-4 mmol/L and >4 mmol/L groups having a higher proportion of diabetic patients. The mean lactate level was 1.42 ± 0.38 (4 mmol/L). In-hospital mortality was found to be 4 (2.7%), 18(12%) and 61(40.7%) patients in the low, intermediate and high lactate groups respectively. ED and hospital length of stay were longer for the >4 mmol/L group as compared to the other groups. While adjusting for all variables, patients with intermediate and high lactate had 7.13 (CI 95% 2.22–22.87 p = 0.001) and 29.48 (CI 95% 9.75–89.07 p =

Objectives The purpose of this meta-analysis was to determine the sensitivity, specificity, and positive and negative predictive values of contrast-enhanced ultrasound (US) for confirming the tip location and placement of central venous catheters in adult patients. Methods A systematic review was performed using electronic databases, including MEDLINE, ClinicalTrials.gov, Cochrane, Embase, PubMed, and Scopus. Inclusion criteria were studies conducted on adult patients receiving an internal jugular or a subclavian central venous catheter in the emergency department or intensive care unit. Furthermore, the catheter tip location had to be checked with the use of the agitated saline contrast-enhanced US technique. Results A total of 2245 articles were screened by title and abstract. Seventeen articles were retrieved and assessed for the predefined inclusion criteria. Four articles and 1 abstract were used in the final analysis. Contrast-enhanced US showed pooled sensitivity of 72% (95% confidence interval, 44%–91%), pooled specificity of 100% (95% confidence interval, 99%–100%), a positive predictive value of 92.1%, and a negative predictive value of 98.5% compared with chest radiography for confirming the placement of central venous catheters. Conclusions In the setting of central venous catheter placement, postprocedural contrast-enhanced US imaging is a safe, efficient, and highly specific confirmatory test for the catheter tip location compared with chest radiography.

Background Blunt abdominal trauma in the setting of polycystic kidney disease is still scantly described in the literature and management guidelines of such patients are not well-established. Case presentation The authors herein present a case of hypovolemic shock secondary to segmental renal artery bleed in a 75-year-old man with polycystic kidney disease after minimal blunt abdominal trauma, who underwent successful selective arterial embolization, and provide a thorough review of similar cases in the literature, while shedding the light on important considerations when dealing with such patients. Conclusions It is important to suspect renal injury in patients with pre-existing renal lesions irrespective of the mechanism of injury; and, vice-versa to suspect an underlying abnormality in patients with a clinical deterioration that’s out of proportion to the mechanism of injury. Electronic supplementary material The online version of this article (10.1186/s12873-018-0192-3) contains supplementary material, which is available to authorized users.

Acute mesenteric venous thrombosis (MVT) is an uncommon cause of intestinal ischemia and is associated with high morbidity and mortality. Patients with acute MVT often present with gastrointestinal (GI) bleeding and other unspecific findings making the diagnosis challenging. This condition requires emergent treatment. The high rates of misdiagnosis of these patients and subsequently the delay in proper and quick management put patients at increased risk of having a negative outcome. Physicians should suspect acute MVT in patients with GI bleed while also considering other factors such as, a past medical history of pro-thrombotic conditions, past surgical history of splenectomy, symptoms of nausea, vomiting, abdominal pain, physical exam findings of abdominal tenderness and abdominal distention and a laboratory workup indicating leukocytosis and an increased plasma lactic acid level. An increase in the yield of accurate diagnosis of acute MVT is possible if physicians in the ED accurately interpret all these findings. The authors herein present a case of acute MVT in a patient whose initial complaint was GI bleeding and provide a thorough review of the literature of cases of acute MVT presenting with GI bleed.

Background The aim of this study was to investigate the value of corrected carotid flow time (FTc) with passive leg raise (PLR) as a non-invasive marker of volume status in end stage renal disease (ESRD) patients. Methods Prospective observational study of ESRD patients presenting to the Emergency department requiring hemodialysis. The common carotid artery was evaluated in long axis. Flow time measurements pre- and post-dialysis as well as before and after PLR were recorded. Results 54 patients were enrolled, of which, 30 (55%) were male. The mean age was 47.4 years. The mean volume of fluid removed was 3.89 ± 0.91 L. In the pre-dialysis cohort, the mean FTc was 340.16 ms (95% CI, 330.36–349.95). Following PLR, the mean FTc was 341.34 ms (95% CI 331.74–350.94). In the post hemodialysis cohort, the mean FTc was 302.48 ms (95% CI, 293.63–311.32). Following the PLR maneuver, the mean FTc was 340.49 ms (95% CI 331.97–349.02). The mean decrease in corrected carotid flow time was 19.15 ms (95% CI, 22.86–41.17), 32.02 ms (95% CI 4.05–34.25) and 41.17 ms (95% CI, 36.47–54.76) for patients who had 4 L removed, respectively. In patients without CHF, the mean decrease in FTc after hemodialysis was 38.80 ms (95% CI, 30.12–47.49) whereas for CHF patients the mean decrease was 35.60 ms (95% CI, 25.05–46.15). Conclusion Corrected flow time in conjunction with passive leg raise seem to correlate with volume status in hemodialysis patients.

Gangrenous cholecystitis (GC) is a serious complication of acute cholecystitis that has been associated with increased morbidity. Patient with GC can present with a wide variety of non-specific clinical, laboratory, and imaging characteristics, making the diagnosis challenging. This disease requires emergent treatment, which is why a quick and reliable diagnosis is essential for the wellbeing of the patient. The authors herein present a case of GC in a patient whose initial complaint was intractable hiccups, and provide a thorough review of the literature of cases of GC with atypical presentations.

ObjectivesPatients with congestive heart failure (CHF) may be at a higher risk of mortality from sepsis than patients without CHF due to insufficient cardiovascular reserves during systemic infections. The aim of this study is to compare sepsis-related mortality between CHF and no CHF in patients presenting to a tertiary medical centre.DesignA single-centre, retrospective, cohort study.SettingConducted in an academic emergency department (ED) between January 2010 and January 2015. Patients’ charts were queried via the hospital’s electronic system. Patients with a diagnosis of sepsis were included. Descriptive analysis was performed on the demographics, characteristics and outcomes of patients with sepsis of the study population.ParticipantsA total of 174 patients, of which 87 (50%) were patients with CHF.Primary and secondary outcomesThe primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and differences in interventions between the two groups.ResultsPatients with CHF had a higher in-hospital mortality (57.5% vs 34.5%). Patients with sepsis and CHF had higher odds of death compared with the control population (OR 2.45; 95% CI 1.22 to 4.88). Secondary analyses showed that patients with CHF had lower instances of bacteraemia on presentation to the ED (31.8% vs 46.4%). They had less intravenous fluid requirements in first 24 hours (2.75±2.28 L vs 3.67±2.82 L, p =0.038), had a higher rate of intubation in the ED (24.2% vs 10.6%, p=0.025) and required more dobutamine in the first 24 hours (16.1% vs 1.1%, pConclusionPatients with sepsis and CHF experienced an increased hospital mortality compared with patients without CHF.

Background As the field of Emergency Medicine grows worldwide, the importance of an Emergency Department Crash Cart (EDCC) has long been recognized. Yet, there is paucity of relevant peer-reviewed literature specifically discussing EDCCs or proposing detailed features for an EDCC suitable for both adult and pediatric patients. Methods The authors performed a systematic review of EDCC-specific literature indexed in Pubmed and Embase on December 20, 2016. In addition, the authors reviewed the 2015 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, the 2015 European Resuscitation Council (ERC) guidelines for resuscitation, and the 2013 American College of Surgeons (ACS) Advanced Trauma Life Support (ATLS) 9th edition. Results There were a total of 277 results, with 192 unique results and 85 duplicates. After careful review by two independent reviewers, all but four references were excluded. None of the four included articles described comprehensive contents of equipment and medications for both the adult and pediatric populations. This article describes in detail the final four articles specific to EDCC, and proposes a set of suggested contents for the EDCC. Conclusion Our systematic review shows the striking paucity of such a high impact indispensable item in the ED. We hope that our EDCC content suggestions help enhance the level of response of EDs in the resuscitation of adult and pediatric populations, and encourage the implementation of and adherence to the latest evidence-based resuscitation guidelines.

Background The placement of a central venous catheter for the administration of vasopressors is still recommended and required by many institutions because of concern about complications associated with peripheral administration of vasopressors. Objective Our aim was to determine the incidence of complications from the administration of vasopressors through peripheral venous catheters (PVC) in patients with circulatory shock, and to identify the factors associated with these complications. Methods This was a prospective, observational study conducted in the emergency department (ED) of a tertiary care medical center. Patients presenting to the ED with circulatory shock and in whom a vasopressor was started through a PVC were included. Research fellows examined the i.v. access site for complications twice daily during the period of peripheral vasopressor administration, then daily up to 48 h after treatment discontinuation or until the patient expired. Results Of the 55 patients that were recruited, 3 (5.45% overall, 6% of patients receiving norepinephrine) developed complications; none were major. Two developed local extravasation and one developed local thrombophlebitis. All three complications occurred during the vasopressor infusion, none in the 48 h after discontinuation, and none required any medical or surgical intervention. Two of the three complications occurred in the hand, and all occurred in patients receiving norepinephrine and with 20-gauge catheters. Conclusions The incidence of complications from the administration of vasopressors through a PVC is small and did not result in significant morbidity in this study. Larger prospective studies are needed to better determine the factors that are associated with these complications, and identify patients in whom this practice is safe.

Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy with an estimated incidence of 11 cases/million population per year. Early treatment is essential and is curative in this disease where lack of treatment results in 90% mortality. We describe an atypical case of a patient with TTP who presented to the Emergency Department for headache, and was found to have thrombocytopenia but only mild anemia that was explained by another disease process. Case: A 44-year-old female presented to the Emergency Department for worsening headache and weakness over the last week. She had no fever and no focal neurological deficits but was pale and complained of severe headache. A blood test showed her to be anemic and thrombocytopenic. She explained that she had been having prolonged heavy menses over the last year. She was treated with blood and platelet transfusions, and seen by the Gynecology service who treated her for uterine fibroids after which she was discharged. She returned 1 week later with the same complaint, and was found to have a stable hemoglobin level but recurrence of thrombocytopenia. A TTP diagnosis was entertained and the workup confirmed it. The patient was treated with plasmapheresis and discharged home with no sequalae. Conclusion: Emergency physicians should keep TTP in mind when approaching cases of thrombocytopenia with mild anemia, even if an alternative diagnosis exists.

Background. There are no rigid guidelines for the management of primary spontaneous pneumothorax. Although there seems to be a consensus between several medical societies regarding the management of an asymptomatic small pneumothorax, the approach toward a moderate to large symptomatic primary spontaneous pneumothorax is unclear and is not substantiated by well-designed research studies. Objectives. Our aim is to shed some light on the role of observation alone in the setting of moderate to large primary spontaneous pneumothorax and to report the different medical societies’ views on the treatment of a primary spontaneous pneumothorax. Case report. We report a case of a 26-year-old man who presented to our emergency department with shortness of breath and was found to have a symptomatic moderate-size pneumothorax that was successfully treated with oxygen therapy and supportive care. Conclusion. We hope that this case will stimulate further research in the field of primary spontaneous pneumothorax management advocating for simple observation and oxygen therapy.

A 67-year-old man presented to the emergency department with symptoms of acute myocardial infarction. Electrocardiogram showed ST segment elevations in leads II, III, and AVF. While waiting for cardiac catheterization, he developed prolonged ventricular fibrillation lasting for 69 minutes, throughout which he was resuscitated as per the 2010 Advanced Cardiac Life Support protocol. The patient was transferred to the catheterization lab while undergoing active resuscitation, where a stent was placed in his right coronary artery. He was neurologically intact postcatheterization and discharged home on the sixth day of admission.

Macrocytosis is a relatively common finding in adult patients undergoing blood cell counting. Approximately 10% of patients will have unexplained macrocytosis after laboratory evaluation. Data on the approach to patients with unexplained macrocytosis are limited.To investigate this topic and help delineate an approach to this condition, the records of 9779 patients diagnosed in our institution between 1995 and 2005 as having macrocytosis were reviewed. Patients with evidence of liver disease, alcohol abuse, hypothyroidism, folate or vitamin B12 deficiency, hemolysis, or use of any drugs known to cause macrocytosis were excluded.Forty-three patients were found to have unexplained macrocytosis. The median follow-up was 4 years. A total of 11.6% patients developed a primary bone marrow disorder (two B-cell lymphomas, two with myelodysplastic syndrome, one plasma cell disorder), 16.3% developed worsening cytopenias, 69.7% had stable disease, and 2.3% resolved. The median time to first cytopenia was 18 months, and the mean time to diagnosis of bone marrow disorder was 31.6 months. The outcomes were not significantly different when comparing patients with or without anemia upon diagnosis. The probability of a bone marrow biopsy to establish a diagnosis of a primary disorder was 33.3% in patients with macrocytosis without anemia compared with 75% in patients with macrocytosis with anemia.Patients with unexplained macrocytosis still require close follow-up. We suggest a strategy of follow-up with blood cell counting every 6 months. Bone marrow biopsy should be performed when cytopenias are present because this approach may provide a higher yield of diagnosis and aid with therapeutic decisions.

Aortic dissection is a potentially catastrophic disease with significant mortality and morbidity. Presentations are often atypical and the physician needs to have a high index of suspicion and low threshold to work up these cases. Ultrasound use in the emergency department is becoming an important tool for physicians and can expedite care in many ways. The authors describe the case of a 55-year-old man with uncontrolled hypertension, who presented to the emergency department with acute chest pain radiating to the back and abdomen. A bedside cardiac ultrasound done by the emergency medicine resident showed a flap in the descending thoracic aorta with a preserved ejection fraction and no evidence of a pericardial effusion. Appropriate management was started with intravenous esmolol and nitroprusside and based on the seriousness of the ultrasound findings, a computed tomography scan was done immediately, which revealed a Stanford type B dissection extending from the aortic arch down to the left common and external iliac arteries with a likely area of infarction in the left kidney. The patient was admitted to the cardiovascular intensive care unit and a stent was placed in his left renal artery. He was subsequently discharged home in a stable condition with adequate blood pressure control. The case presentation is followed by a discussion on the diagnosis and management of acute aortic dissection, and the importance of point-of-care ultrasonography in the emergency department is also highlighted.

Studies of acute myocardial infarction, trauma, and stroke have resulted in improved outcomes through earlier diagnosis and application of therapy at the most proximal stage of hospital presentation. Most critical therapies for these diseases are frequently instituted prior to admission to an ICU. This systems-based approach to the sepsis patient has been lacking. To change this paradigm, a trial comparing early goal-directed therapy (EGDT) versus standard care was performed using specific criteria for the early identification of high-risk sepsis patients and a consensus-derived protocol to reverse the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression, and increased metabolic demands. One decade later, EGDT has been shown to modulate inflammation, decrease the progression of organ failure, improve microcirculatory function, and decrease health resource consumption and mortality. A standard operating procedure beginning with EGDT for severe sepsis and septic shock is a hospital-wide initiative.

Background Bacterial infections are very common in End Stage Renal Disease (ESRD) patients. The diagnosis of sepsis in such patients is often challenging and requires a high index of suspicion. The aim of this study is to report on a series of patient with ESRD on hemodialysis (HD) diagnosed with sepsis. Methods Single center retrospective study looking at ESRD on HD who presented to our tertiary hospital were retrieved. Inclusion criteria included a discharge diagnosis of sepsis, septic shock or bacteremia. Results Our sample was composed of 41 females and 49 males, with a mean age of 70 ± 15 years. Infections from the HD catheters followed by lower respiratory tract infections were the most common cause of bacteremia. IV fluid replacement for the first 6 and 24 h were 0.58 and 1.27 l respectively. Vasopressors were used in 30 patients with norepinephrine, dopamine and dobutamine used in 22, nine and one patients respectively. Out of 90 subjects, 24 (26.6 %) were dead within the same hospital visit. the 28 days out of hospital mortality was 25.6 %. There was no significant difference in mortality in patients who presented with less than two SIRS or two or more SIRS criteria. Conclusion This is the first study looking at an in depth analysis of sepsis in the specific dialysis population and examining the influence of fluid resuscitation, role of SIRS criteria and vasopressor use on their mortality.