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Inpatient hyperglycaemia and diabetes mellitus (DM) are common and are associated with an increased risk of complications and mortality. The severity of hyperglycaemia determines the rate of complications in patients treated in the emergency department (ED). Our aim was to examine whether determination of the capillary haemoglobin A1c (HbA1c) is a reliable method for detecting unknown diabetes and poor glycaemic control in the ED. A prospective observational study was conducted in adult (>18 years) patients treated in a single-centre ED. We compared the results of HbA1c levels measured by Bio-Rad in2it point-of-care device on a capillary blood sample and by the hospital laboratory. A total of 187 ED patients with an average age of 57.1 ± 19.2 years were studied. The mean HbA1c value was 5.78 ± 1.26 % by capillary POC testing and 6.10 ± 1.12 % by the hospital laboratory (correlation = 0.712, P < 0.001). A total of 17.1 % of cases had a prior diagnosis of DM. The diagnosis of DM (plasma glucose > 126 mg/dL and/or HbA1c > 6.5 %) was made in ten (5.4 %) additional cases (prior undiagnosed DM) for a total prior DM prevalence of 22.5 % (95 % CI 16.4–28.5 %). Capillary HbA1c detected 11 additional cases of unknown DM (5.9 %). A capillary HbA1c value greater than 6 % has a sensitivity of 85.7 % and specificity of 85.3 % for the screening of DM. Determination of the capillary HbA1c in the ED is a reliable, fast, and simple system for the screening of unknown or uncontrolled DM.

High-sensitivity C-reactive protein (hs-CRP) rises with cardiac injury/ischemia. We evaluated its efficacy in aiding in the identification of an acute coronary syndrome (ACS) in patients (pts) admitted to the chest pain unit (CPU) for possible ACS. Retrospective study of all patients admitted to the CPU with chest pain who underwent hs-CRP testing as part of their CPU evaluation from January 2004 to October 2008. Patients were low risk for ACS (compatible symptoms, nondiagnostic initial ECG, and negative cTnI). ACS was diagnosed by positive functional study, cardiac catheterization, or cardiac event during 30-day follow-up. Positive hs-CRP was defined based on local laboratory levels (>1.0 mg/l or >3.0 mg/l), and population-based and prior study values >2.0 mg/l. Chi-square analysis was performed, and odds ratios (OR) are presented. Multivariate analysis was done to determine whether hs-CRP was independently associated with the diagnosis of ACS. Cardiac risk factors, demographics, and diagnosis of ACS were included in the model. Medians with IQR are presented for continuous data. Ninety-five percent confidence intervals are presented where applicable. A total of 958 patients had hs-CRP testing as part of their CPEU evaluation. Excluded from the analysis were 39 patients lost to follow-up. The final cohort comprised 478 (52%) women and 441 (48%) men with a median age of 56 (IQR 48-64). ACS was diagnosed in 128 (13.4%). The median cohort hs-CRP value was 2.2 mg/l (IQR 0.7, 5.8) and 2.3 mg/l (IQR 0.6, 5.9) in those with and without ACS, respectively. In the multivariate analysis hs-CRP was not independently associated with the diagnosis of ACS (0.99; 95% CI 0.98 - 1.01). In large patient cohort managed in a single-center CPU, measurement of hs-CRP did not enhance the diagnostic accuracy for ACS. Routine hs-CRP as a diagnostic tool should not be recommended in the CPU setting.

The treatment of acute pain in the emergency department is not always optimal. Peripheral nerve blocks using “blind” or nerve stimulator techniques have substantial disadvantages. Ultrasound-guided regional anesthesia may provide quick, safe, and effective pain relief in patients with proximal femoral fractures with severe pain. However, no evidence exists on emergency physician-performed ultrasound-guided regional anesthesia in these patients in Dutch emergency departments. We hypothesized that emergency physicians can be effectively trained to safely perform and implement ultrasound-guided femoral nerve blocks, resulting in effective pain relief in patients with proximal femoral fractures. In this prospective observational study, emergency physicians were trained by expert anesthesiologists to perform ultrasound-guided femoral nerve blocks during a single-day course. Femoral nerve blocks were performed on patients with proximal femoral fractures. A system of direct supervision by skilled anesthesiologists and residents was put in place. A total of 64 femoral nerve blocks were performed. After 30 min, blocks were effective in 69% of patients, and after 60 min, in 83.3%. The mean reduction in pain scores after 30 and 60 min was 3.84 and 4.77, respectively (both p <  0.001). Patients reported a mean satisfaction of 8.42 (1 to 10 scale). No adverse events occurred. Ultrasound-guided femoral nerve block is an effective, safe, and easy to learn (single-day course) procedure for emergency physicians to implement and perform in the emergency department. Patient satisfaction was high.

Methanol poisoning usually occurs in a cluster and initial diagnosis can be challenging. Mortality is high without immediate interventions. This paper describes a methanol poisoning outbreak and difficulties in managing a large number of patients with limited resources. A retrospective analysis of a methanol poisoning outbreak in September 2018 was performed, describing patients who presented to a major tertiary referral centre. A total of 31 patients were received over the period of 9 days. Thirty of them were males with a mean age of 32 years old. They were mostly foreigners. From the 31 patients, 19.3% were dead on arrival, 3.2% died in the emergency department and 38.7% survived and discharged. The overall mortality rate was 61.3%. Out of the 12 patients who survived, two patients had toxic optic neuropathy, and one patient had uveitis. The rest of the survivors did not have any long-term complications. Osmolar gap and lactate had strong correlations with patient’s mortality. Serum pH, bicarbonate, lactate, potassium, anion gap, osmolar gap and measured serum osmolarity between the alive and dead patients were significant. Post-mortem findings of the brain were unremarkable. The mortality rate was higher, and the morbidity includes permanent visual impairment and severe neurological sequelae. Language barrier, severity of illness, late presentation, unavailability of intravenous ethanol and fomipezole and delayed dialysis may have been the contributing factors. Patient was managed based on clinical presentation. Laboratory parameters showed difference in median between group that survived and succumbed for pH, serum bicarbonate, lactate, potassium and osmolar and anion gap. Management of methanol toxicity outbreak in resource-limited area will benefit from a well-designed guideline that is adaptable to the locality.

Disaster medicine education is an enormous challenge, but indispensable for disaster preparedness. We aimed to develop and implement a disaster medicine curriculum for medical student education that can serve as a peer-reviewed, structured educational guide and resource. Additionally, the process of designing, approving and implementing such a curriculum is presented. The six-step approach to curriculum development for medical education was used as a formal process instrument. Recognized experts from professional and governmental bodies involved in disaster health care provided input using disaster-related physician training programs, scientific evidence if available, proposals for education by international disaster medicine organizations and their expertise as the basis for content development. The final course consisted of 14 modules composed of 2-h units. The concepts of disaster medicine, including response, medical assistance, law, command, coordination, communication, and mass casualty management, are introduced. Hospital preparedness plans and experiences from worldwide disaster assistance are reviewed. Life-saving emergency and limited individual treatment under disaster conditions are discussed. Specifics of initial management of explosive, war-related, radiological/nuclear, chemical, and biological incidents emphasizing infectious diseases and terrorist attacks are presented. An evacuation exercise is completed, and a mass casualty triage is simulated in collaboration with local disaster response agencies. Decontamination procedures are demonstrated at a nuclear power plant or the local fire department, and personal decontamination practices are exercised. Mannequin resuscitation is practiced while personal protective equipment is utilized. An interactive review of professional ethics, stress disorders, psychosocial interventions, and quality improvement efforts complete the training. The curriculum offers medical disaster education in a reasonable time frame, interdisciplinary format, and multi-experiential course. It can serve as a template for basic medical student disaster education. Because of its comprehensive but flexible structure, it should also be helpful for other health-care professional student disaster education programs.