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BACKGROUND: A high-flow nasal cannula (HFNC) is a device for non-invasive ventilation (NIV). It was utilized during the COVID-19 pandemic in patients with moderate to severe respiratory distress due to its benefit profile in delaying intubation, ease of use, and comfort of patients in comparison to NIV. OBJECTIVES: Our main objective is to calculate the intubation rate of patients with suspected or lab-confirmed COVID-19 in moderate to severe respiratory distress who failed graded oxygen therapy (GOT). Before incorporating HFNC as a treatment option, the intubation rate was 100% after GOT failure. We calculated the rate of intubation at two, six, and 12 hours of starting HFNC, where each patient is in their own control with an assumed intubation rate of 100%. Other objectives include measuring the rate of improvement of the ROX index, respiratory rate (RR), and oxygen saturation (SPO2) levels at two, six, and 12 hours. METHODS: We retrospectively screened patients with suspected or lab-confirmed COVID-19 infection in moderate to severe respiratory distress at Rashid Hospital Trauma Center, Emergency Department in Dubai, United Arab Emirates, from April 10, 2020, until December 31, 2020. The list of patients was pooled from the SALAMA electronic system. RESULTS: A total of 121 patients were included in the analysis. Assuming an intubation rate of 100% at 0 hours (end of GOT), after starting HFNC, the intubation rate (primary outcome) at two hours was 7.43% (9/121), at six hours was 7.14% (8/112), and at 12 hours was 5.77% (6/104). The total intubation rate at 12 hours was 19% (23/121). The use of HFNC was also shown to improve the ROX index, RR, and SPO2 at two, six, and 12 hours. CONCLUSION: In patients with suspected or lab-confirmed COVID-19 in moderate to severe respiratory distress who failed GOT and were started on HFNC, it was noted that the intubation rate decreased from an assumed rate of 100% to 19% at 12 hours from starting the treatment. There was also a statistically significant improvement in the ROX index, SPO2, and RR at two, six, and 12 hours from the initiation at 0 hours.
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OBJECTIVE: A systematic and straightforward triage system is crucial for the proper and timely care of patients within the emergency department (ED). This study unfolds a detailed understanding of the impact of the Canadian Triage and Acuity Scale (CTAS) on patient care and resource allocation in a private tertiary hospital. To the best of our knowledge, this is the only article studying the impact of the CTAS in one of the private hospitals in the United Arab Emirates (UAE) to achieve triage optimisation strategies. There is scope for further research in both public and private hospitals in the UAE. A triage system not only helps healthcare professionals prioritise cases conveniently but also guides patients to the most suitable area for a consultation. As a general rule, EDs follow an algorithm for the purpose of triage, and the aim of our study is to assess one such five-level triage system, CTAS, for its effectiveness and relevance during overcrowding in a UAE ED. METHOD: Within a period of approximately three weeks, a total of 351 CTAS-triaged patients were included in a prospective observational study during peak hours (17:00-22:00) of an ED in the UAE. The CTAS app was used as the triage tool to assess relevance, in terms of patient waiting times, resource allocation, and urgency level distribution, to the Canadian scale. All patients presenting to the ED were included with no exclusion criteria. The relationship between urgency level, duration of visit, and resources used was assessed, and the department's triage results were compared with those of the CTAS app. RESULTS: Our sample showed a female (187; 53.3%) and adult preponderance (215; 61.3%) with most of the adult patients aged between 30 and 40 (96; 44.65%). 41.5% (145) of the triage was mismatched between the department and the CTAS app with 115 (79.3%) cases of under-triaging and 30 (20.7%) cases of over-triaging. There was a statistically significant difference (p=0.004) between average waiting times across triage categories 4 and 5 with the former category patients waiting for a longer period of time. Cohen's kappa showed moderate inter-relatability (k=0.42). The average utilisation costs per triage category showed a positive correlation with the urgency level for CTAS (Pearson's r=0.59); however, the costs declined as the urgency level rose for the department. CONCLUSIONS: The high compliance rate demonstrates that the CTAS can be applicable to institutions outside of Canada. The categorisation of patients by the CTAS and their resource allocation were more accurate than the standard triage proving its effectiveness as a triage tool. Lack of synchronisation among the triage nurses and inadequate triage training are the most plausible reasons for this comparison. The recommended "time to be seen by a physician" was achievable in our ED, and that, along with the expected relationship between CTAS and resource utilisation, can be seen as valid indicators for a quality triage system for use in the UAE.
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Acute massive pulmonary embolism is the most critical presentation of venous thromboembolism that needs early detection and management for a better outcome. We present the case of a 42-year-old female who presented to the emergency department (ED) complaining of acute dyspnea and descended into cardiac arrest. Working through the advanced cardiac life support guidelines and appropriate resuscitative measures, having high clinical suspicion supported by bedside ultrasound findings, massive pulmonary embolism was the most likely diagnosis, and so the patient was treated with thrombolytic therapy delivered via a central venous catheter. Return of spontaneous circulation was achieved, and consequently, she made a complete recovery with no adverse neurological or hemodynamic sequelae. The aim of presenting this topic is to review the literature available on approaches to thrombolytic doses in life-threatening cases of massive pulmonary embolism and to add to an already ongoing discussion about the effects and outcomes of various dosing regimens. The above facts will lead us to conclude that any discussion seeks to remind us of the primary management principle. All physicians should bear this in mind while managing any case ("primum non-nocere," which is a Latin phrase that means "first, do no harm"); it helps to fuel ideologies to seek best practice interventions that ensure the best outcome for pulmonary embolism patients. And such experiences are worth sharing with the world.
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Due to the increase in the number of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases globally, more medical case reports are being published showing the different complications of coronavirus disease 2019 (COVID-19). One of the important complications is thrombotic events that occur as a sequela of COVID-19. Here we present a case of a previously healthy male patient in his 30s who presented to the emergency unit experiencing headaches, vomiting, and weakness in his left arm. On examination, he was vitally stable, and fully oriented, but noted to have jerky movements of the left arm; therefore, he was sent for a CT brain scan. Shortly after, he developed a generalized tonic-clonic seizure. After stabilizing the patient, CT brain with cerebral venography was done, which revealed extensive thrombosis of the superior sagittal sinus and bilateral superficial cortical veins. The patient's blood test showed a high D-dimer (4.90 ug/ml), and the COVID-19 polymerase chain reaction (PCR) swab test was positive. It is commonly known that COVID-19 infection presents with fever and respiratory symptoms; however, our case illustrates the thrombotic complication of SARS-CoV-2 infection with no pneumonia or respiratory symptoms with a high level of d-dimer.