BackgroundEarly identification of a patient with infection who may develop sepsis is of utmost importance. Unfortunately, this remains elusive because no single clinical measure or test can reflect complex pathophysiological changes in patients with sepsis. However, multiple clinical and laboratory parameters indicate impending sepsis and organ dysfunction. Screening tools using these parameters can help identify the condition, such as SIRS, quick SOFA (qSOFA), National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS). We aim to externally validate qSOFA, SIRS, and NEWS/NEWS2/MEWS for in-hospital mortality among adult patients with suspected infection who presenting to the emergency department.Methods and analysisPASSEM study is an international prospective external validation cohort study. For 9 months, each participating center will recruit consecutive adult patients who visited the emergency departments with suspected infection and are planned for hospitalization. We will collect patients' demographics, vital signs measured in the triage, initial white blood cell count, and variables required to calculate Charlson Comorbidities Index; and follow patients for 90 days since their inclusion in the study. The primary outcome will be 30-days in-hospital mortality. The secondary outcome will be intensive care unit (ICU) admission, prolonged stay in the ICU (i.e., ≥72 hours), and 30- as well as 90-days all-cause mortality. The study started in December 2021 and planned to enroll 2851 patients to reach 200 in-hospital death. The sample size is adaptive and will be adjusted based on prespecified consecutive interim analyses.DiscussionPASSEM study will be the first international multicenter prospective cohort study that designated to externally validate qSOFA score, SIRS criteria, and EWSs for in-hospital mortality among adult patients with suspected infection presenting to the ED in the Middle East region.Study registrationThe study is registered at ClinicalTrials.gov (NCT05172479).

Background: Limited effective interventions exist in the emergency department (ED) for COVID-19 patients with respiratory failure. One of the promising interventions is the prone position, which has been proven to improve oxygenation in ICU settings. Here, we aimed to describe and assess the utility of the prone position in awake non-intubated adult patients in EDs during the COVID-19 pandemic. Methods: We conducted a prospective cohort study of hypoxic COVID-19 adult patients who presented to our emergency department. We collected the data from June to the end of August 2020, including vital signs and physiological and clinical parameters before and after completing the four-hour prone position protocol. The main outcomes assessed were improvement in oxygenation, respiratory rate, respiratory distress score, ICU admission, and intubation. Oxygenation was calculated based on the standard pulse oximeter saturation [SpO(2)]/fractional concentration of oxygen in inspired air (FiO(2)). Results: The study included 49 patients (81.63% men; mean age, 53.37 +/- 11 years). The mean oxygen saturation during the triage was 84.49% +/- 7.98 on room air. After completing of the four-hour prone protocol, the mean SpO(2)/FiO(2) ratio increased from 1.62 +/- 0.78-1.99 +/- 0.75 (p < 0.0001). The respiratory rate decreased from 32.45 +/- 5.24-26.29 +/- 5.40 (p < 0.0001). Respiratory distress scores decreased after changing patients' positions (p < 0.0001). Twenty-four patients (48.9%) were admitted to the ICU, 6 patients were intubated (12.2%), and 7 (14.3%) died in the hospital. Conclusion: After applying the prone position in the ED, significant and immediate improvement was observed in oxygenation, respiratory rate, respiratory distress, and carbon dioxide levels. A linear relationship between the level of improvement in oxygenation and reduction in ICU admission was observed. However, further studies recommended to assess the advantage of the procedure in terms of ICU admission, intubation, or mortality. (c) 2022 Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. CC_BY_NC_ND_4.0

Background: The COVID-19 pandemic has induced a substantial burden on healthcare organizations, with increased workload and stress for healthcare providers. Healthcare professionals working on the frontline are vulnerable to stress, putting their psychological and mental wellbeing in considerable jeopardy. Methods: This is a cross-sectional study using data collected from a self-administered questionnaire that was distributed electronically to healthcare workers. The validated Kessler Psychological Distress Scale (K10) and the General Self-Efficacy Scale (GSE) were used to measure the level of stress of the healthcare professionals and the psychological impact of the pandemic on them. Results: Two hundred and thirteen participants were included. A third of the responders (34.3%) were previously infected with COVID-19, while 72.3% had to self-isolate during the pandemic. The average score for the K10 questionnaire was 24.8 ± 9 out of 50, where almost a third of the responders (33.3%) had very high psychological stress levels. The average score for the GSE was 30.2 ± 5.3 points out of 40. Nurses and physicians (p = 0.033) showed significantly higher scores on the K10 survey. Furthermore, nurses between ages 20 and 29 (p = 0.025) and nurses of any age (p = 0.009) had significantly high levels of psychological stress. Conclusion: Healthcare professionals are at significant risk of psychological and mental adverse effects, particularly nurses on the frontline. Such findings should drive initiatives to prepare task forces that can put forward and implement strategies to minimize the risk imposed on the psychological and mental wellbeing of frontline health workers.

•There was substantial burden of severe burns in the KSA.•Burns injury mostly occurring at home, among males and sustained from flames.•Unique resuscitative strategies for inhalation injury require prioritisation.•Population-based education programs are indicated to reduce burn injuries.

Background: Traumatic brain injury (TBI) is a leading cause of mortality and morbidity in children. The aim of this study was to report the burden of isolated pediatric TBI at a major trauma center in Riyadh, Saudi Arabia and assess associations with mechanism of injury. Methods: A retrospective cohort study using chart review, including children aged ≤14 years with isolated TBI over 2 years from 01 Jan 2016 to 31 Dec 2017 was undertaken. Univariable or unadjusted associations of patients presenting after motor vehicle crashes (MVC) and physiological variables were assessed. Intensive care unit (ICU) admission and mortality at hospital discharge were the primary outcome measures. Results: There were 2,501 pediatric patients that presented to the Emergency Department with head injury and 241 (9.6%) patients were admitted to hospital with isolated TBI, with an in-hospital mortality rate of 9%. MVC was the most common mechanism of injury (n = 142; 59%) followed by falls (n = 68; 28.2%), pedestrians (n = 26; 10.8%), and non-accidental injuries (n = 5; 2.1%). Patients presenting after MVC were older (p = 0.001), had similar Glasgow Coma Scale scores (p = 0.12) and more often presented in a coagulopathic state (p [SJEMed 2020; 1(2.000): 83-88]

Purpose We assessed the National Early Warning Score (NEWS) in emergency triage for predicting sepsis-related outcomes. Methods A retrospective chart review of all cases enrolled in the sepsis management protocol for a one-year duration. The protocol utilized the NEWS as a screening tool for sepsis in the triage area. Primary outcomes of interest were hyperlactatemia, admission to ICU and intrahospital mortality. Sensitivity, specificity, and area under the curve (AUC) were calculated for a given NEWS. Results A total of 444 patients were reviewed from July 2018 to June 2019, with a mean age of 58.7 years. A NEWS ≥5 was more than 88% sensitive in predicting hyperlactatemia, ICU admission, and/or mortality. Specificity, on the other hand, was as low as 12%. The AUC for the NEWS was 0.667 for predicting hyperlactatemia and 0.602 for predicting ICU admission or mortality. Conclusion The NEWS was a sensitive screening tool for predicting sepsis-related outcomes. However, it was not specific, and further studies are recommended to assess the integration of other factors to improve specificity.

Introduction A surgical approach to airway management may be essential in situations of difficult or failed airway, where immediate airway access is needed to provide oxygenation. However, the procedure is uncommonly performed and expertise among emergency clinicians may be limited. Objectives The aim of this study was to assess the accuracy of cricothyroid membrane (CTM) identification by junior and senior emergency trainees by identification of surface anatomy landmarks. A secondary aim was to determine patient variables associated with accurate identification of CTM. Methods A prospective observational study was conducted in a tertiary emergency department in the Kingdom of Saudi Arabia. Saudi Emergency Medicine board trainees participated in the study. Data were also obtained on gender and body habitus of patients. Junior trainees attempted to locate the membrane by palpation and marked it with an ultraviolet mark (blinded) pen followed by senior trainees. A certified ultrasound physician, also blinded to the trainee attempts, marked the membrane within a 5mm circumference using a different coloured ultraviolet pen and was used as the reference gold standard. Results There were 80 patients enrolled with junior and senior doctors assessing location for emergency cricothyrotomy. Proportion of correct localisation was 30% (95% CI 20% to 41%) among junior trainees and 33% (95% CI 22% to 44%) among seniors (P=0.73). Level of training, sex, height and weight of patients were not associated with success. Conclusions Clinical localisation of CTM by emergency medicine trainees was poor even in non-stressful settings, and warrants further dedicated education and/or use of adjunct techniques.

Study Objectives: Preliminary (prelim) interpretation of imaging studies is common in Emergency Departments (ED) around the USA. There is concern this practice places patients (pts.) at risk for avoidable adverse outcomes due to disparity between the reading at the time of medical decisionmaking and the final interpretation which may occur many hours later. The objective of this study is to assess the clinical impact of prelim. readings of imaging studies in an ED setting. Methods: This descriptive study was conducted in 2 ED in a single academic medical center, combined census of 62,000/yr. During the study period, Jan 1, 2011 to July 30, 2011, final readings by specialists in various imaging disciplines occurred between the hrs. of 0800 to 2300. Image readings between the hrs. of 2300 and 0800 were performed by radiology residents with ad hoc back up by board certified radiologists at a remote setting and deemed prelim. All prelim. readings were over read the next day by radiology faculty. These readings were entered into the hospital medical record as the official interpretation. Discrepancy between prelim. and final readings were called to the ED and entered into the ED electronic medical record (EMR). Based upon the nature of the discrepancy attempts were made to contact the pt. for appropriate notification and follow-up. The outcome of the follow-up attempt was entered into the ED EMR. The study included a review of all ED EMR recorded discrepancies between prelim. and final readings. Discrepancies were rated on a (1) to (5) scale by the MD investigators. (1) no clinical significance, no action required, (2) minor clinical significance requiring pt. notification only, (3) clinically significant requiring notification and either return to ED or change in outpatient management, (4) potentially major clinical significance requiring immediate return to ED or referral for further imaging and follow-up without which adverse outcome could result, (5) major clinical significance with documented patient harm related to delayed diagnosis. Results: During the study period 37,383 imaging studies were ordered. 7787 (21%) occurred during the hours when prelim. readings were provided. There were 159 (2%) discrepancies recorded in the ED EMR. 17 were categorized as (1), 50 as (2), 50 as (3), 42 as (4) and 0 as (5). Of the category (4) discrepancies 14 patients. could not be contacted and no follow-up could be arranged. Final outcome for these patients is unknown. This group included patients with nodules or masses in the lung, liver, breast, ovary, colon and bone as well as 1 case each of mediastinal mass, cerebral aneurysm, closed loop bowel obstruction, ovarian torsion and suspected hemoperitoneum. Final outcomes in these patients could not be determined. Of the level (4) patients that were contacted for whom follow-up information was available, 1 pt was admitted for ruptured ectopic pregnancy, 1 for iliac vein clot, 1 for pulmonary embolism, 1 for possible vertebral osteomyelitis, 1 for vertebral artery aneurysm and 1 for colitis. One pt. was contacted with a CT diagnosis of appendicitis but no additional follow up information was available. Conclusion: The practice of prelim. interpretation of imaging studies in the ED results in a low frequency of preventable and potentially serious adverse events. Final readings by radiology specialist at the time medical decisions are made in the ED would likely eliminate these events.

Background: Fever from a urinary tract source remains the predominant etiology of serious bacterial infection in children ages 0-36 months. Urine culture is the gold standard for diagnosing a urinary tract infection (UTI); however, urine dipstick (UDip) and urine microanalysis (UA) are typically used real time by Emergency Physicians to diagnose and treat UTIs, as cultures can take days to grow and be available. The purpose of this article is to evaluate the literature on the accuracy and utility of the UDip and UA in this pediatric population. Methods: A structured review of the medical literature to determine the accuracy of UDip and UA for the diagnosis of UTI in children before the result of the urine culture. Results: Upon comprehensive review and after applying predefined inclusion criteria, a total of 13 articles met inclusion criteria, addressed the clinical question, and were reviewed in detail. Conclusions: The literature search did not conclusively identify any component of either the UDip or the UA, which would allow a practitioner to conclude definitively that the source of an infant's fever is a UTI. (C) 2012 Elsevier Inc.