Objective We aimed to compare the modified National Early Warning Score (mNEWS), quick Sequential Organ Failure Assessment (qSOFA) score, modified Systemic Inflammatory Response Syndrome (mSIRS) score, and modified Search Out Severity (mSOS) score in predicting mortality and sepsis among patients suspected of first observed infections in the emergency department. The modified scores were created by removing variables for simplicity.Methods This was a prospective cohort study that enrolled adult patients presenting at the emergency department with signs and symptoms suggesting infection. The mNEWS, qSOFA score, mSIRS score, and mSOS score were calculated using triage data. The SOFA score was a reference standard for sepsis diagnosis. All patients were monitored for up to 30 days after the initial visit to measure each scoring system’s ability to predict 30-day mortality and sepsis.Results There were 260 patients included in the study. The 30-day mortality prediction with mNEWS ≥5 had the highest sensitivity (91.18%). The highest area under the receiver operating characteristic curve (AUC) for the 30-day mortality prediction was mNEWS (0.607), followed by qSOFA (0.605), mSOS (0.550), and mSIRS (0.423). The sepsis prediction with mNEWS ≥5 had the highest sensitivity (96.48%). The highest AUC for the sepsis prediction was also mNEWS (0.685), followed by qSOFA (0.605), mSOS (0.480), and mSIRS (0.477).Conclusion mNEWS was an acceptable scoring system screening tool for predicting mortality and sepsis in patients with a suspected infection.

Background: Intravenous adenosine is the recommended treatment for paroxysmal supraventricular tachycardia (PSVT). There is no official recommended method of giving adenosine. We compared the success rates between a standard and alternative method of first dose intravenous adenosine in PSVT. Methods: A pilot parallel randomized controlled study was conducted in the emergency department of a tertiary care hospital. Eligible patients were stable PSVT adult patients. We used block randomization and divided them into two groups, the standard method (double syringe technique of 6 mg of adenosine), and the alternative method (similar to the standard method, then immediately followed by elevating the arm to 90° perpendicular to a horizontal plane for 10 s). The primary outcome was the success rate of electrocardiogram (ECG) response which demonstrated termination of PSVT (at least two-fold of the RR-interval widening or sinus rhythm conversion). Secondary outcomes were complications within one minute after the injection. Results: We allocated 15 patients in each group and analyzed them as intention-to-treat. The success rate was 86.7% in the alternative group and 80% in the standard group (risk difference 6.7%, 95% confidence interval − 19.9 to 33.2%, P 1.00). Complications within one minute after adenosine injection were also similar in both groups, 14 of 15 patients (93%) in each group had no complications, without significant difference. Conclusions: No evidence of the difference between alternative and standard methods occurred, in terms of the success rate of ECG response and complications within one minute after adenosine injection. The standard method of adenosine injection is a safe, easy-to-administer, and widely available treatment for PSVT. Trial Registration: TCTR20200609001.

Compressions at the left ventricle increase rate of return of spontaneous circulation. This study aimed to identify the landmark of the point of maximal left ventricular diameter on the sternum (LVmax) by using chest computed tomography (CCT) in the arms-down position, which was similar to an actual cardiac arrest patient. A retrospective study was conducted between September 2014 and November 2020. We included adult patients who underwent CCT in an arms-down position and measured the rescuer’s hand. We measured the distance from the sternal notch to LVmax (DLVmax), to the lower half of sternum (DLH), and to the point of maximal force of hand, which placed the lowest palmar margin of the rescuer’s reference hand at the xiphisternal junction. Thirty-nine patients were included. The LVmax was located below the lower half of the sternum; DLVmax and DLH were 12.6 and 10.0 cm, respectively (p < 0.001). Distance from the sternal notch to the point of maximal force of the left hand, with the ulnar border located at the xiphisternal junction, was close to DLVmax; 11.3 and 12.6 cm, respectively (p = 0.076). In conclusion, LVmax was located below the lower half of the sternum, which is recommended by current guidelines.

Background: Hyperkalemia can lead to fatal cardiac arrhythmias. Ten units of intravenous (IV) regular insulin with 25 g of glucose is the mainstay for treating hyperkalemia. However, the most important complication of this treatment is hypoglycemia. We aimed to develop a scoring model to predict hypoglycemia after the treatment of hyperkalemia. Methods: A retrospective study was conducted at a university-based hospital between January 2013 and June 2021. We included the hyperkalemic patients (> 5.3 mmol/L) who were ≥ 18 years old and treated with 10 units of IV regular insulin with 25 g of glucose. Incomplete data on posttreatment blood glucose, pregnancy, and diabetes mellitus were excluded. Endpoint was posttreatment hypoglycemia (≤ 70 mg/dL or ≤ 3.9 mmol/L). Multivariable logistic regression was used to establish a full model and a subsequently reduced model using the backward elimination method. We demonstrated the model performance using the area under the receiver operating characteristic curve (AuROC), calibration plot, and Hosmer–Lemeshow goodness-of-fit test. Internal validation was done with a bootstrap sampling procedure with 1000 replicates. Model optimism was estimated. Results: Three hundred and eighty-five patients were included, with 97 posttreatment hypoglycemia (25.2%). The predictive model comprised the following three criteria: age > 60 years old, pretreatment blood glucose ≤ 100 mg/dL (≤ 5.6 mmol/L), and pretreatment potassium > 6 mmol/L. The AuROC of this model was 0.671 (95% confidence interval [CI] 0.608 to 0.735). The calibration plot demonstrated consistency with the original data. Hosmer–Lemeshow goodness-of-fit test showed no evidence of lack-of-fit (p 0.792); therefore, the model was also fit to the original data. Internal validation via bootstrap sampling showed a consistent AuROC of 0.670 (95% CI 0.660 to 0.670) with minimal model optimism. A high risk for posttreatment hypoglycemia was indicated if the patient met at least one of those criteria. Sensitivity and specificity were 95.9% and 14.9%, respectively. Conclusion: High risk was indicated when at least one of the criteria was met: age > 60 years old, pretreatment blood glucose ≤ 100 mg/dL (≤ 5.6 mmol/L), and pretreatment potassium > 6 mmol/L. Blood glucose levels should frequently check in the high-risk group. Trial registration: TCTR20210225002 (www.thaiclinicaltrials.org).

Background: In recent decades, cannabis has been widely used around the world for medical and recreational purposes, both legally and illegally. Aside from its therapeutic benefits, cannabis exhibits many adverse effects. Psychosis is one of the potentially harmful effects of cannabis. Case presentation: A 23-year-old Thai man, who reported cannabis use for 2 years and discontinued for 3 months, restarted smoking two bongs (2 g equivalence) of cannabis. Two hours later, he had a penile erection, felt a severe persistent sharp pain in his penis, and reported that his glans looked distorted. Intending to eradicate the pain, he decided to trim the penile skin several times and completely amputated his penis himself using scissors. Cannabis-induced psychosis was diagnosed because symptoms began after cannabis use, without evidence of other substance abuse. To confirm the cannabis exposure, his urine immunoassay was positive for delta-9-tetrahydrocannabinol (Δ⁹-THC). The distal penis was deemed too dirty and fragile for reconstruction. Bleeding was controlled, penile stump irrigated and debrided, and scrotal urethrostomy was performed by a urologist. After admission and cannabis discontinuation, his delusion and hallucination subsided. Conclusions: Cannabis-induced psychosis is an adverse effect of cannabis, which may lead to impaired judgement unexpected self-harm. A multidisciplinary team approach, including a primary care physician, an emergency physician, a urologist, and a psychiatrist, is essential when dealing with a patient with cannabis-induced psychosis and a urogenital injury.

Background: Drug-drug interactions (DDIs) are common but less concerning in clinical practice of time-sensitive situations. We aimed to identify factors associated with a basic common DDI knowledge among an emergency physician (EP), an emergency medicine resident (EMR), and an emergency care nurse (ECN).Methods: This was a prospective cross-sectional study. EP, EMR, and ECN did the examination (multiple-choice questions, 40 points) about common DDI. Prespecified factors associated with examination scores were profession, longer emergency medicine experience, pharmacological training, last advanced cardiovascular life support (ACLS) training, DDI checker book, and application user experience. The outcome was an examination score to evaluate the ability of DDI knowledge. Univariable and multivariable means regressions were used.Results: A total of 244 participants were enrolled. Factors associated with high examination score were EP (unadjusted mean difference 3.3 points, 95% confidence interval [CI] 2.1 to 4.5, p < 0.001), EMR (2.1, 95% CI 0.7 to 3.5, p 0.005) compared to ECN. Last ACLS training within 2 years (3.7, 95% CI 0.7 to 6.6, p 0.015), 2–4 years (3.4, 95% CI 0.4 to 6.5, p 0.027), and ≥4 years (4.4, 95% CI 1.2 to 7.6, p 0.007) were higher score than no ACLS training. Moreover, the DDI checker application experience user (1.7, 95% CI 0.6 to 2.8, p 0.003) also had a high score compared to the non-experienced user. After adjustment for all factors, EP (adjusted mean difference 3.3 points, 95% CI 1.8 to 4.7, p < 0.001), EMR (2.5, 95% CI 0.6 to 4.3, p 0.010) were higher scores compared to ECN. Meanwhile, the last ACLS training ≥4 years (3.3, 95% CI 0.1 to 6.6, p 0.042) was a higher score than no ACLS training.Conclusion: EP, EMR, and the last ACLS training ≥4 years were associated with higher DDI knowledge than ECN and no ACLS training, respectively.