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Africa, like the rest of the world, has been impacted by the coronavirus disease 2019 (COVID-19) pandemic. However, only a few studies covering this subject in Africa have been published.We conducted a retrospective study of critically ill adult COVID-19 patients-all of whom had a confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection- admitted to the intensive care unit (ICU) of Habib Bourguiba University Hospital (Sfax, Tunisia).A total of 96 patients were admitted into our ICU for respiratory distress due to COVID-19 infection. Mean age was 62.4±12.8 years and median age was 64 years. Mean arterial oxygen tension (PaO2)/fractional inspired oxygen (FiO2) ratio was 105±60 and ≤300 in all cases but one. Oxygen support was required for all patients (100%) and invasive mechanical ventilation for 38 (40%). Prone positioning was applied in 67 patients (70%). Within the study period, 47 of the 96 patients died (49%). Multivariate analysis showed that the factors associated with poor outcome were the development of acute renal failure (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.75-25.9), the use of mechanical ventilation (OR, 5.8; 95% CI, 1.54-22.0), and serum cholinesterase (SChE) activity lower than 5,000 UI/L (OR, 5.0; 95% CI, 1.34-19).In this retrospective cohort study of critically ill patients admitted to the ICU in Sfax, Tunisia, for acute respiratory failure following COVID-19 infection, the mortality rate was high. The development of acute renal failure, the use of mechanical ventilation, and SChE activity lower than 5,000 UI/L were associated with a poor outcome.

Objective: To identify the early predictors of severe envenomation in the southern region of Tunisia. Methods: It was a retrospective monocentric study including consecutive patients admitted to the emergency department for snakebite envenomation. Snakebite envenomation was defined by a history of snakebite. Predictors of severe envenomation were determined by univariate and multivariate analyses. Results: Our sample consisted of 109 patients aged 30 (20-44) years with a 1.1:1 sex-ratio (56 males and 53 females). During the 24-hour surveillance period, 25 patients developed severe envenomation (22.9%). The in-hospital mortality rate was 4.6% (n=5). The independent predictors of severe snakebite envenomation were leucocyte count over 11 550/mm3 (OR: 18.7, 95% CI: 3.3-107.8), creatine kinase over 155 IU/L (OR: 6.16, 95% CI: 1.1-35.6), and/or tourniquet before arrival to the ED (OR: 32.14, 95% CI: 3.5-295.9). Conclusions: This study emphasizes the importance of early evaluation of snakebite envenomation. Further studies are required to approve a severity scale proper to snakebite envenomation in Tunisia.

Introduction Frail older adults are at an increased risk for adverse outcomes after an Emergency Department (ED) visit. Several tools exist for the screening of frailty among these patients. However, no tool has been validated in Tunisia. This study aims to evaluate the usefulness of frailty screening in predicting the outcome of older adults presenting to the ED. Methods This is a prospective, monocentric study. We evaluated the eligible patients at the ED and after their discharge. Follow-up phone calls were scheduled at 1, 2, 3, and 6 months after the ED visit. All patients aged 65 years or older; and visiting the ED during the inclusion period were involved. We used the ADL index and ISAR scale for assessing frailty. Results We enrolled 184 patients; they were living alone in 25% of cases. Half of them had medical care insurance. The ADL index was maximum (6 = total dependency) in 20% of cases. The ISAR score was above 1 point in 38%. Unplanned hospitalizations have accounted for 34%. In univariate analysis, the ADL index and ISAR score were statistically higher in the group of “unplanned hospitalization”. In multivariate analysis, the ISAR score and ADL index have not been associated with unplanned hospitalization. Conclusion Our results did not demonstrate the relevance of the ISAR or ADL scales in predicting the mortality or the need for unplanned hospitalization in multivariate analysis. This study did indicate an increased mortality in the “frail” patients in the univariate analysis. Further studies with larger samples and different tools are necessary.

Introduction >1000 ricin poisoning cases secondary to intentional castor bean consumption have been reported in the literature since the late 1800s. The lethality of ricin poisoning after oral ingestion is determined by a few factors. Case report We present a case that highlights the erratic absorption of ricin after accidental oral ingestion. On admission, the physical examination found a somnolent patient, with miosis, and a generalized abdominal tenderness. Her blood tests showed metabolic acidosis. Thanks to her early management, the discharge was possible three days later. Discussion The toxicity of ricin is dependent on the dose delivered and the route of the exposure. Supportive care is the mainstay of treatment. As shown in our case, early management is crucial for a good outcome.

We aimed to assess the patients' experience of threat during management of an acute coronary syndrome (ACS) in the Emergency Department (ED) and to analyze the impact of this acute stress on day-30 outcomes.This is a prospective study.We included patients with ACS in the ED. After discharge, the perceived stress (Perceived Stress Scale (PSS); Visual Analogic Scale (VAS) in stress evaluation; Patient Health Questionnaire (PHQ); and Posttraumatic Stress Disorder Checklist Scale (PCLS) were used.35 patients have developed PTSD on day-30 (31.8%). The independent predictors of developing PTSD at day-30 were high PSS score on admission (OR = 1.4; CI = 1.1-1.8; p = 0.004) and/or elevated PHQ-9 score at day-30 (OR = 1.5; CI = 1.2-1.9; p0.001). The recurrence of the chest pain was more frequent in the PTSD group of patients. Patients with PTSD symptoms were more likely to report a non-therapeutic adherence to their cardiovascular medication.Stress management in EDs should become a systematic step in the management of patients with ACS. This study emphasizes the importance of multidisciplinary follow-up and early screening of patients at risk of PTSD to improve their outcomes after discharge.

Tranexamic acid (TXA) is one of the debated therapies in the management of traumatic brain injury (TBI). We conducted this study to evaluate the benefits of TXA in TBI on the mortality and its safety in these patients. This was a prospective randomized open-label trial including all patients, aged at 18 years or older, hospitalized in the emergency room during a 13-month period, for TBI. After the realization of the body CT scan, the patients were included if they had intracranial bleeding, and were then randomized according to their medical file number to receive or not the TXA. The eligibility criteria were based on the uncertainty principle, patients with significant extracranial bleeding were excluded since there was evidence that TXA improve their outcome. We enrolled 180 patients aged at 42 ± 20 years, with an 88% men-proportion. Subarachnoid haemorrhage was the most frequent lesion in the brain CT-scan (67.5%). After randomization, 96 patients were in the TXA group (53%). Demographic data, clinical, biological and radiological features were statistically comparable in the two groups of patients (‘TXA’ and ‘noTXA’). The needs of transfusion or neurosurgery, the mortality rate, the in-hospital length of stay and the dependency at 28-post-traumatic day were similar in the two groups of patients. However, pulmonary embolism was statistically more frequent in ‘TXA’ group (11.5 versus 2.4%, p = 0.02). TXA is an interesting treatment in haemorrhagic shock. Its efficiency in head trauma is still debated and controversial. Its impact on the mortality and the needs of transfusion or surgery were not demonstrated in this study. Nevertheless, its safety worth to be studied in larger samples as we found a higher rate of pulmonary embolism in the treated group.

Introduction Scorpion envenomation is still a frequent occurance in tropical and subtropical regions. In Tunisia, multiple studies on scorpion envenoming have contributed to an improved understanding of cardiac dysfunction and factors predictive of poor prognosis. These previous studies have contributed to the current standardized management of envenomed patients. However, the epidemiology of scorpion envenoming in Tunisia has not been updated for more than 10 years. The aim of this study was to report an update of the epidemiological features of scorpion envenomation in the southern region of Tunisia. Methods This is a retrospective monocentric study including all patients admitted in the emergency room for scorpion envenomation. Cases were collected from emergency medical files during a 3-year period (2013–2015). The diagnosis of scorpion envenomation was made by history of a scorpion sting. All files in which scorpion envenomation was not certain were excluded. Data are presented as mean±SD with range or percentages, as appropriate. Results We enrolled 282 patients aged 27.4±22.8 years with a 1:1 sex ratio. During surveillance in the emergency room, 39 patients developed cardiac dysfunction. Overall, 42 patients (14.9%) were at stage 3 of severity, and 240 patients (85.1%) had moderate scorpion envenomation (stage 2). Only 1 patient died a few hours after admission. In the remaining cases, the outcome was good. Our results show the improvement in mortality rates even in severe presentations. Conclusion This study found that the outcome of scorpion-stung patients has clearly improved. This enhancement can be explained by early medical consultation and standardized management of patients with predictive factors for cardiac dysfunction.

Minor head injury is one of the major diagnoses requiring management in emergency departments (ED) but its squeals are not well studied in our country. To describe the prevalence of post-concussive syndrome and its impacts on life activities, up to 6 months of follow-up, among patients having a minor head injury and discharged from ED. A prospective bi-centric study including adults having a minor head trauma and consenting to be followed up to 6 months after discharge. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was used at baseline, after 15 days, at 1 month, at 3 months and at 6 months post-injury to assess concussive symptoms. We also used the Rivermead Head Injury Follow-up Questionnaire (RHFUQ) to describe impacts of minor head trauma on life activities. There were 130 consenting patients at baseline interview. Proportion of patients describing post-concussive symptoms at baseline was 71/130. At 6 months of follow-up, post-concussive syndrome was diagnosed among 21.4 % of participants. Sustaining symptoms at 6 months post-injury were mainly anger and irritability (12.5 %). Correlations between high RPQ sum rates since 15 days’ post-injury call and the sum total rates of RHFUQ were significant. The major significant impact of minor head trauma at 6 months of follow-up was among domestic activities. The two most important findings of this study were the huge proportion of patients having minor head injury and discharged from ED without any explanation of possible symptoms after head trauma and the unknown impacts on life activities.

Posterior reversible encephalopathy syndrome (PRES) is a rare entity involving brainstem in very rare reported cases. We describe here the case of a boy who presented to the emergency department for headaches and strabismus. Diagnosis of PRES was retained by magnetic resonance imaging. The causes were blood pressure urgency and renal failure. Location of lesions was very rarely reported in literature and neurological troubles were persistent. Emergency physicians should evocate PRES each time there is a clinical context associated with neurological troubles by a normal brain CT scan. Early diagnosis is very important to treat its causes and improve prognosis.

Buts du travail Depister la presence de troubles anxieux et/ou depressifs chez les familles de patients hospitalises aux urgences. Etudier les attentes et besoins de ces familles au cours de leur visite a leur proche et etudier leur concordance avec la perception des soignants.

Context: Cardiac dysfunction is one of the most serious consequences of scorpion envenomation. The best tool to evaluate cardiac function is echocardiography, but it is not available at all emergency departments. Many studies aimed to describe biological predictive factors of cardiac dysfunction in scorpion envenomation. Troponin is one of these biomarkers but its correlation with myocarditis is not well established. The aim of this study was to evaluate correlation between troponin levels and cardiac dysfunction in moderate scorpion envenomation. Methods: A retrospective monocentric study including patients admitted in the emergency department for moderate scorpion envenomation with troponin measurement during their early management. On arrival, an electrocardiogram and a chest X-ray were realized for all patients. Results: We enrolled 132 patients with a mean age at 31.3 ± 24.4 years and a 1.35 sex-ratio. All patients had moderate systemic manifestations. There were 28 patients with clinical manifestations of cardiac dysfunction without life-threatening troubles (21.2%). Troponin was undetectable in 69 patients (56%). The mean value of troponin level (pg/ml) was higher in patients with clinical manifestations of left ventricular dysfunction (1.80 ± 3.8 vs. 0.11 ± 0.5; p = 0.02). Troponin levels were significantly higher in patients with positive T wave on electrocardiogram. Conclusion: In patients with moderate scorpion envenomation with positive T wave, high values of troponin suggest the presence of cardiac dysfunction.

Acute intoxication with nicotine is possible to cause nonspecific clinical signs and may be serious and lead to the death. We report a rare and severe form of acute nicotine poisoning secondary to dermal absorption of tobacco.

Background : Stress hyperglycemia among patients having an acute pathology is frequently described in recent studies.The objectives of this work were to describe epidemiologic features of elderly patients hospitalized in the emergency department and having a hyperglycemia due to stress.A retrospective chart review identified patients older than 65 years with obtained serum glucose levels. Patients with diabetes were excluded. Two levels of serum glucose were considered (6,9 mmol/l and ≤ 6,9 mmol/l). We included 165. There were 94 patients with high level of serum glucose level (56,9%). Multivariate analysis found that only cardio-vascular pathologies were more predictive of having stress hyperglycemia (p=0,014, odds-ratio=2,8, IC=1,2-6,4). There were no correlation between serum glucose levels and mortality.Stress hyperglycemia is a fairly common disorder but underestimated in emergency department. Its impact on the prognosis of elderly patients remains to be studied.

Renal injuries are commonly reported in blunt abdominal trauma and are usually associated to other abdominal injuries. Renal rupture may be misdiagnosed and its management, especially in severe lesions, is still controversial. We describe the case of renal rupture diagnosed in the Emergency Department and conservatively managed. The outcome was good thanks to the early diagnosis and the management of the renal trauma. Conservative management in renal rupture is possible in stable patients provided that the imaging is early done.