Journal of Emergency Medicine, Trauma and Acute Care - 2 - International Conference in Emergency Medicine and Public Health-Qatar Proceedings, October 2016

Background: Although the majority of sudden cardiac deaths (SCD) are due to CAD and poor LVEF, there is a considerable fraction of idiopathic ventricular fibrillation (IVF) causing SCD that is secondary to channelopathies and other inherited arrhythmias.

Objective: The present report aims to raise awareness about the prevalence of inherited arrhythmogenic disorders, besides the commonly attributed CAD causing SCD.

Case report: We report the case of a patient with a history of sudden collapse after routine duty. He had ventricular fibrillation and was successfully defibrillated to normal sinus rhythm. On examination, he was found to have a structurally normal heart, and the ECG showed early repolarisation (ERPS) with a short QT interval.

Review of the literature: SCD is defined as IVF in the absence of an identifiable cause. IVF could be the manifestation of concealed forms of arrhythmogenic disorders exacerbated by appropriate triggers. Long QT syndrome presents with structurally normal heart, QT prolongation, syncope, and SCD. Incomplete penetrance gene presents as Brugada syndrome, short QT syndrome, ERPS, sinus node dysfunction, and progressive conduction defects. Subtle ECG changes may be present, which, if identified early, can lead to further focused evaluation, leading to the prevention of a potentially life-threatening arrhythmia. ECG changes that should be looked for include: ERPS changes, especially in the inferior and lateral leads, ‘Rs’ in the inferior leads – >2 mm deep in lead II, small slurred S wave in the inferior leads, incomplete or complete RBBB with J point elevation and coved ST segment in V1 and V2 for Brugada, and long or short QT interval.

Conclusion/summary: It is important to recognise channelopathies causing SCD. This is because a majority of these channelopathies are ‘inherited’ and can cause more deaths in the family. Such potential information obtained from ECG features can help categorise patients as ‘suspected high-risk’ and provide appropriate advice.

Background: Peripheral oxygen saturation (SpO2) and heart rate (HR) are important indicators for various medical conditions such as cardiopulmonary disorders and respiratory diseases. The main objectives of this study is to design and implement a portable embedded medical system. This system wirelessly obtains SpO2 and HR data from a patient as well as his/her coordination, and sends a short messaging service (SMS) alarm to the emergency control room to contact the patient and confirm his/her health status or dispatch an ambulance in case of his/her measurements are outside the normal range based on the Qatar Early Warning Scoring (QEWS) system.

Methods: The system mainly consists of a Bluetooth finger pulse oximeter, a Bluetooth-enabled microcontroller, a global positioning system (GPS) and a General Packet Radio Service (GPRS) module. It is divided into three main stages. In the first stage, the readings of SpO2 and HR are obtained from the patient in real time. During the second stage, the readings obtained are sent over Bluetooth to the signal acquisition and processing unit. The received data is processed and a decision is made whether a SMS alarm should be sent or not. The final stage is concerned with sending the alarming SMS to the emergency control room over the GPRS network based on the QEWS system.

Results: The system was implemented and successfully tested as a stand-alone unit by avoiding the use of a PC or a smartphone for data processing. The transmitted SMS alarm includes the SpO2 and HR readings, the QEWS score and the GPS coordinates.

Conclusions: The designed system is wireless, portable, and user-friendly. This system possibly promotes quality of care for the patient living outside hospital and could improve response time from an ambulance service point of view by determining the exact location of the patient.

Background: Qatar Hamad Medical Corporation Ambulance Service (HMCAS) major incident response guide is intended to address techniques in field operations that must be utilized in the event of a major incident. This guide standardizes operations during major incidents, regardless of what caused the incident, number of patients, severity of the injuries or the complexity of the incident.

Methods: This plan was tested and implemented across the ambulance service and Hamad International Airport (HIA) in collaboration with other agencies such as police, civil defense and HIA safety department through a full-day training program. Different training methods such as workshops, lectures and simulated exercises was conducted using different scenarios.

Results: This system was implemented for five real major incidents during 2014–2015 in Qatar. The average time for all units to be on scene was 20 minutes. The total units needed by this system were 33 units, approximately according to the predetermined attendance sheet (PDA). These units include all on-scene structure of command according to the HMCAS major incident response guide. The average time to transport the victims from the scene to the hospitals was 10 minutes or less. Three communication channels were established during the whole process.

Conclusion: The designed system is suitable for up to 100 patients in pre-hospital emergency care in case of a major incident. The system would need to be tested and evaluated regularly to ensure compliancy and understanding from all staff in HMCAS to ensure that they are ready at all times in the event of a major incident.

Background:Neisseria meningitidis (NM) is a leading cause of meningitis and septicemia. NM has an overall dispersion at rate of 11%, assuming that 10%–20% of the population carries NM in their throat at any given time, and increased carriage rate may be seen during epidemics.

Objective: This study aimed to describe the incidence and epidemiological characteristics NM in Qatar.

Methods: A retrospective review of epidemiological data for cases of NM reported to the Department of Public Health, HP & CDC section in 2010–2014 form all active surveillance sites in the health region. NM types of isolates from cases were serogrouped at Microbiology Laboratory in Hamad Medical Corporation. Estimates of the incidence and number of cases in the state of Qatar were calculated by sex and age group.

Results: A total of 41 cases of NM were reported during the study period. The incidence of NM in Qatar ranged between 0.8, 0.2, 0.3 and 0.4 cases per 100,000 population in 2010, 2011, 2012, and 2013 respectively and then considerably increased by end of 2014 (0.6 per 100,000 population). The incidence of NM was highest among males (37 cases) than females (4 cases), while NM occurred mainly in young adult group of the population.

Conclusion: The incidence of NM was very low in Qatar with young adults being at the highest risk. Active surveillance and dynamic research, fast conspicuous verification, and serotyping of NM will support public health decision making in the control of rising strains in Qatar.

Keywords:Neisseria meningitidis, Qatar, active surveillance, epidemiology, Supreme Council of Healt

Introduction: Acute aortic dissection (AAD) is one of the most challenging cardiovascular emergencies presenting to the Emergency Department (ED). Prompt diagnosis and treatment is the key to patient survival. Though most AADs present with typical symptoms, it has been reported to present with a myriad of symptoms. We report a case of an AAD, which presented to our ED with predominant neurological symptoms.

Case description: A 47-year-old male was brought to our ED with acute confusion and history of seizure. He did not have any history of trauma or report any chest pain, headache or fever. He was vitally stable except for slight tachycardia and his physical examination was unremarkable. All investigations including a CT head were reported normal except leukocytosis (27 × 109/L). A few hours after admission, he started deteriorating, developed hypotension and became more agitated. Resuscitative measures were started. Ultrasound scan of the heart was performed to confirm central venous access showed a pericardial effusion and a flap in the ascending aorta. A diagnosis of AAD was made. An urgent CT was performed, which showed an extensive Type A aortic dissection extending into the branches, with rupture into pericardial cavity. During transportation for surgery, the patient had a cardiac arrest from which he could not be resuscitated.

Conclusion: AADs may present in an unusual manner with predominantly neurological manifestations such as acute confusion and seizure. In patients with unexplained acute confusional state the possibility of an AAD should be considered in the differential diagnosis. Bedside TTE has a limited sensitivity but high specificity in diagnosis of Type A AD and its early utilization may facilitate timely diagnosis improving outcome. Given the high specificity of TTE and time-dependent survival in Type A AD, institutional protocols to expedite the transfer to the operating room without waiting for CT confirmation might be considered.

Background: Injuries from air bag deployment have long been documented and studied like orbital blowout fractures, auditory injuries, etc. However, we report here a case of an alveolar process fracture associated with dental injuries and clear history of face-to-air bag impact only, which has rarely been documented and hence important to be reported.

Case report: A 25-year old female front-seat passenger was involved in a head-on collision between her large four-wheel drive vehicle and another similar-sized vehicle. She was unrestrained and suffered facial and dental pain after the air bag was deployed. She denied hitting the dashboard or losing her consciousness.

On examination, there was mild skin erythema associated with marked tenderness over her left maxilla and left upper jaw. Her upper left medial incisor was missing, while the lateral incisor and adjacent canine seemed to have been pushed upwards and embedded in their respective sockets. No other injury was elicited and she remained vitally stable.

X-ray and CT scan imaging confirmed an alveolar bone fracture with upward displacement of the alveolar margin of the maxilla. Loss of medial upper left incisor, and impaction of the adjacent lateral incisor and canine teeth in the soft tissues at the left naso-labial fold, antero-lateral to the left nasolacrimal bones were also noted.

Discussion: It is important to report these to be included in the potential range of injuries associated with air bag impact MVC. It will help widen the physicians range of possible injuries while evaluating an air bag impact MVC patient, hence aiding diagnosis and management. It will also help in the ongoing research for further modifying the techniques and types of protective devices currently used in vehicles to help prevent such injuries, as well as further highlighting the use of restraint along with use of such devices.

Background: In the past 3 years, average length of stay in the emergency department has increased by 20–30%. It was found that one of the most important factor causing this was increased number of X-rays done. At an average one x-ray adds 4–5 hours to disposition time. An observational study was done to find out reasons for the low compliance with usage of Ottawa ankle rules.

Methods: Initially observational study was done where 100 physicians were observed while they examine ankle and foot sprain cases for requesting x-ray. This was done without their knowledge. Then a questionnaire was distributed among 100 Emergency doctors to determine the factors that lead to non-compliance with use of Ottawa rules as screening tool for requesting x-ray.

Result: In the initial observational study done on 100 cases we found that, only 20 patients presenting with symptoms of ankle /foot injury had bony injury ruled out by Ottawa rules and in 11 out of these, Ottawa rule was not done appropriately. The questionnaire was completed by 100 physicians. The result showed that 64% of physicians were afraid of the liability of missing fracture. 56% were not comfortable because of difficulty in follow up. 24% expressed that increased number of patients with limited time to assess patient thoroughly put a pressure to do X-ray. 48% were not aware of Ottawa rules. 32% mentioned that lack of emergency follow-up clinics for those with persistent symptoms compel them to request x-rays than to decide clinically.

Conclusion: A proper follow-up system for patients discharged after screening will reduce the fear of liability of missing fractures. This will reduce the number of x-rays and length of stay in ED.

Introduction: We present a case of bilateral ureteric colic that causes anuric acute renal failure. Bilateral ureteric colic causing acute renal failure is not a new presentation. However, the patient had only 3 mm calculi, making our case unique.

Background: Bilateral renal calculi are an uncommon cause of acute kidney injury (AKI). Obstructing ureteroliths rarely lead to AKI without any underlying renal disease or anatomic abnormalities, such as a solitary kidney or horseshoe kidney. The literature has reported the incidence of a unilateral ureterovesicular junction obstruction secondary to a stone as 20%. However, there are a very few case reports in the literature of urology, nephrology or emergency medicine regarding the incidence of bilateral ureteric calculi. Cases of bilateral ureteric calculi are rare, and cases with AKI and anuria are very rare.

Case presentation: A 30-year-old male presented with bilateral colicky flank pain for 4 days and started to develop macroscopic haematuria. After proper pain management in the Emergency Department, the patient was found to have a raised serum creatinine level (152 μmol/L). A CT scan was performed showing two 3 mm calculi in the left and right proximal ureters. Ultrasound showed moderate left and mild right hydroureteronephrosis. Due to the relatively small size of the stones, and the clinical image of the patient, he was planned for medical expulsive therapy. Surprisingly, the patient developed complete anuria for 2 days and presented to the ED with a serum creatinine level of 843 μmol/L. Bilateral double J stents were placed and urgent ureteroscopy was done. Following treatment, the patient's condition significantly improved and his renal function returned to normal within 4 days.

Conclusion: Even small bilateral stones can result in acute kidney injury.

Background: The South West London & Surrey Trauma Network has one major trauma centre (MTC) and seven acute trauma units (TUs) over a wide geographical area. Seventy-five percent of the major trauma patients (injury severity score >15) were taken to MTC. However, many were admitted in trauma units. Available data indicates that there is a possibility that patients in TU rather than MTC may receive less than optimal care.

Aims: We would like to describe the development of a new system and process to review the management of ISS>15 cases under governance framework, assuring the delivery of safe and effective trauma care outside a MTC.

Description: The standard operating procedure and flow chart process were developed for review of major trauma cases. TARN Office identified patients were reviewed using a proforma, with key trauma measures as quality indicators. The notes were initially reviewed by clinicians, and in due course by the MDT team for the whole patient journey from arrival to discharge.

Outcomes: The commonest age group is >65 years. Head injury is most common, resulting from a fall from standing height (64%) causing subdural haemorrhage (57%). Most arrive by blue-light ambulance (86%). There is evidence of specialist team involvement in 64% of the cases and multidisciplinary team involvement in 55% of the cases. However, there are issues with the quality of record keeping, Timely CT scans and incorporating rehabilitation prescriptions into discharge letters were done.

Issues with care were formally registered with hospital incident reporting system and registered in the trauma risk register. Findings were presented in the hospital audit study day, in the Trust Governance Committee and disseminated for development. This governance system has evolved with more concrete systems now in place.

Conclusion: Initiating a robust governance system and process will minimise substandard care and help standardise care across the network.

Background: Management of serious paracetamol overdose with N-acetylcysteine (NAC) is an effective strategy. Early treatment with NAC prevents the formation of a toxic metabolite that leads to hepatic injury. However, inappropriate treatment with NAC and overtreatment with NAC can lead to potential adverse side effects and unnecessary hospital admission.

The aim of the study was to assess the administration of NAC in the setting of paracetamol overdose and determine whether the institutional use of this antidote is consistent with the international standards. We hypothesize that some patients receive antidotal NAC unnecessarily after paracetamol exposure, and that a simple quality improvement intervention in educational activity may improve the administration of this antidote.

Methods: A retrospective quality improvement chart review evaluated charts of patients who were treated with NAC for paracetamol exposure over a 2-month period in the Emergency Department of Hamad General Hospital. The quality improvement intervention consisted of establishing a paracetamol clinical practice guideline, providing access to a treatment nomogram for NAC use, enhancing educational activities to improve the clinician's understanding of appropriate NAC use, and establishing a clinical toxicology service for all paracetamol exposures.

Results: NAC administration to 67% of the cases after paracetamol exposure were found to be medically unnecessary according to the established international guidelines for management of paracetamol overdose. Post-intervention measurement showed significant improvement by decreasing unnecessary NAC administration to only 33%.

Conclusion: In our institution, NAC treatment after paracetamol exposure is usually administered unnecessarily. Inappropriate administration of this antidote results in a significant waste of resources and unnecessarily prolonged hospital stay.

Adherence to the clinical practice guidelines may lead to a significant improvement in this antidote use after paracetamol exposure. Given that this antidote is used inappropriately despite widespread knowledge that guidelines for paracetamol exposure exist, we believe that continuous education on the topic, chart audits and feedback, and use of a clinical toxicology service may improve the knowledge and appropriate use of this antidote and will improve patient care.

Background: The State of Qatar experienced a sandstorm on 1 April 2015, lasting approximately 12 hours, with winds blowing at more than 100 km/hr and average particulate matter of approximately 10 μm in diameter. The Emergency Department of the main tertiary hospital in Qatar managed 62% of the total emergency calls. The peak load of patients during the event manifested approximately 6 hours after the onset.

Methods: A retrospective review of patient mix and case load was performed for patients presenting to Emergency Department during and after the sandstorm.

Results: A total of 254 cases with respiratory illness presented to the Emergency Department within 12 hours of sandstorm onset. Of these cases, 42 had respiratory failure, of which 19 required intubation and 23 were managed conservatively. Of the remaining 212 cases, 28 with severe respiratory exacerbation of asthma, 15 with COPD exacerbation and 169 with minor asthma exacerbation were managed conservatively. In addition, a total of 26 patients presented with ophthalmological complaints. Of these, 12 had foreign body removed from the eye under slit lamp and took topical medication and antibiotics. The remaining 14 patients with anterior eye chamber emergencies were managed conservatively.

Conclusions: Patients presented mainly with exacerbations of asthma and respiratory distress, ophthalmic emergencies and vehicular trauma. Surprisingly, incidence of pedestrian injuries did not vary. With the outline of adaptations and specific areas for improvement identified in this review, we hope that future sandstorm emergencies will be better positioned to respond with optimum efficiency and effectiveness.