Sepsis has been regarded as one of the cardinal causes of death across the globe. Its significance and time-critical nature accounted for 20% of worldwide deaths, according to a 2024 WHO study. As for the Hong Kong condition, Ling et al. have documented a 21% surge in incidence and 1-in-4 deaths from 2009 – 2018 in the Intensive Care Unit of Hong Kong, leading to a major health burden to society. Emergency Department (ED) Nurses as the ‘gatekeeper’ for various life-threatening diseases, while it appears not to be the case in the ‘Hour-1-Sepsis Bundle', judging by its low compliance rate. Nevertheless, various studies focused on Sepsis management instead of reviewing knowledge, attitude, and self-reported competencies of ED Nurses towards Sepsis screening, or implementing educational programs prompting early identification of Sepsis in the ED  This is a single-center interventional study conducted in the ED of Kwong Wah Hospital. 70 eligible ED... Continue Reading

Methemoglobinemia is a rare but life-threatening hematologic condition where hemoglobin is oxidized from the ferrous (Fe2+) to the ferric (Fe3+) state, impairing oxygen delivery to tissues. While congenital forms exist, acquired methemoglobinemia often triggered by medications or chemical exposures is more common. Prevalence in pediatric populations is estimated at approximately 0.0015%. ​ Case Presentation: A 6-year-old male presented to the Apollo Hospitals Navi Mumbai Emergency Department with fever, abdominal pain, vomiting, epistaxis, and acute breathlessness. Physical examination revealed central and peripheral cyanosis with an SpO2 of 88% on room air, which only improved to 92% despite high-flow oxygen (10L). Notably, the patient had a history of exposure to a watch repair solution and prior consumption of "outside food." ​ Diagnostic Workup: Venous Blood Gas (VBG) analysis confirmed methemoglobinemia with a level (FMetHb) of 31.0% and respiratory alkalosis. Laboratory results showed mild thrombocytopenia (Platelets: 89,000) and a normal hemoglobin (15.5 g/dL).... Continue Reading

Abstract: Background: shock is a complex condition where similar vital signs at the bedside can actually reflect very different underlying physiology. While protocol-driven management helps stabilize early, it can sometimes mismatch treatment to the patient’s actual physiology, especially in undifferentiated shock. This can lead to avoidable harm, such as fluid overload or using the wrong vasoactive medications.   Objective: To introduce a practical, physiology-based framework that uses bedside ultrasound to help tailor early assessment and treatment for patients in shock.   Methods/Framework: After reviewing the subject, we introduce the Physiology–Profile–Plan (3Ps) framework, a quick, repeatable clinical process that complements ABC resuscitation. The first step, Physiology, is to identify the main cause of shock, such as pump failure, vasodilation (pipe failure), volume loss, obstruction, or a combination of these. Profile creates a real-time picture of the patient’s hemodynamics by combining clinical exams with various types of monitoring, with a focus on... Continue Reading

  TITLE A Novel Trajectory-Based, Anticipatory Model for the Management of Emergency, Intensive Care, and Chronic Conditions, Exemplified by Hypertension   AUTHOR Abdulatif Aljaili Mohammed   ABSTRACT Background:Conventional hypertension management relies on fixed diagnostic thresholds, most commonly 140/90 mmHg. This threshold-based approach is inherently reactive and often permits silent vascular injury to progress for years before intervention is initiated. Such delays may contribute to irreversible cardiovascular, cerebrovascular, and renal complications that ultimately present as emergencies, increasing emergency department (ED) visits and intensive care unit (ICU) admissions. Objective:To introduce the Progressive Serial Incremental Change (PSIC) Model, a novel trajectory-based framework that reconceptualizes hypertension as a dynamic process rather than a static threshold, enabling earlier identification of pathological blood pressure evolution and anticipatory intervention. Methods / Conceptual Framework:Serial blood pressure measurements can demonstrate gradual, progressive increases over time—such as readings evolving from 110 mmHg to 114 mmHg, 117 mmHg, and 119 mmHg... Continue Reading

Sepsis has been regarded as one of the cardinal causes of death across the globe. Its significance and time-critical nature accounted for 20% of worldwide deaths, according to a 2024 WHO study. As for the Hong Kong condition, Ling et al. have documented a 21% surge in incidence and 1-in-4 deaths from 2009 – 2018 in the Intensive Care Unit of Hong Kong, leading to a major health burden to society. Emergency Department (ED) nurses are the ‘gatekeepers’ for various life-threatening diseases, while it appears not to be the case in the ‘Hour-1-Sepsis Bundle', judging by its low compliance rate. Nevertheless, various studies focused on Sepsis management instead of reviewing knowledge, attitude, and self-reported competencies of ED Nurses towards Sepsis screening, or implementing educational programs prompting early identification of Sepsis in the ED  This is a single-center interventional study conducted in the ED of Kwong Wah Hospital. 70 eligible ED... Continue Reading

Background: Metformin-associated lactic acidosis (MALA) is a well-recognized adverse effect of metformin, which can rapidly progress to severe clinical features including altered mental status, respiratory failure, circulatory failure, and multiple organ dysfunction syndrome. While MALA is known, fatal cases resulting from intentional metformin overdose for suicide are comparatively rare, posing unique management challenges. Case Presentation: A 56-year-old male with a history of hypertension and diabetes mellitus was found unconscious in a bathtub with multiple wrist lacerations. A suicide note and empty blister packs of prescription medication were discovered nearby, including a total of 162 hypoglycemic tablets containing 10,500 mg of metformin. He was initially transported to a local hospital, where he received fluid resuscitation and bicarbonate therapy for severe lactic acidosis (pH 7.186, lactate 16.0 mmol). However, the acidosis remained uncorrected, and transfer to our facility was arranged due to the lack of continuous hemodiafiltration (CHDF) capabilities at the referring... Continue Reading

Introduction: Calcium channel blocker (CCB) overdose typically presents with early hypotension and bradycardia. This case highlights an unusual delayed complication in a 21-year-old female with iron deficiency anemia, depression, and connective tissue disease who intentionally ingested 100 mg of amlodipine.   Case Presentation: The patient presented 2 hours post-ingestion with dizziness, hypotension (98/57 mmHg), tachycardia (HR 103 bpm), and mild fever (37.7°C). Initial management included IV calcium gluconate and hydration. Unexpectedly, 20 hours later, she developed acute hypoxemia and dyspnea. Imaging revealed bilateral pulmonary infiltrates, pleural effusions, atelectasis, and B-lines on ultrasound, with preserved ejection fraction. NT-proBNP escalated sharply (46 → 1701 → 2002 pg/mL). She was managed with diuretics, steroids, and high-flow nasal cannula (HFNC) oxygen, with suspected non-cardiogenic pulmonary edema.   Key Learning Points: Atypical Delayed Complication: CCB overdose may precipitate late-onset non-cardiogenic pulmonary edema despite initial hemodynamic stabilization. Role of Biomarkers & Imaging: Rising NT-proBNP with preserved... Continue Reading

Abstract: Background: shock is a complex condition where similar vital signs at the bedside can actually reflect very different underlying physiology. While protocol-driven management helps stabilize early, it can sometimes mismatch treatment to the patient’s actual physiology, especially in undifferentiated shock. This can lead to avoidable harm, such as fluid overload or using the wrong vasoactive medications.   Objective: To introduce a practical, physiology-based framework that uses bedside ultrasound to help tailor early assessment and treatment for patients in shock.   Methods/Framework: After reviewing the subject, we introduce the Physiology–Profile–Plan (3Ps) framework, a quick, repeatable clinical process that complements ABC resuscitation. The first step, Physiology, is to identify the main cause of shock, such as pump failure, vasodilation (pipe failure), volume loss, obstruction, or a combination of these. Profile creates a real-time picture of the patient’s hemodynamics by combining clinical exams with various types of monitoring, with a focus on point-of-care ultrasound (POCUS). Important ultrasound checks include evaluating... Continue Reading

Background: Timely access to care is a key pillar of health system quality. Reducing delays before admission to definitive care improves outcomes for patients with time-sensitive conditions, including trauma. Despite growing interest in reducing time to definitive care in many low- and middle-income countries (LMICs) and the disproportionately high burden of injuries in these countries, empirical evidence from these settings remains limited. In this study, we present the associated factors of delays experienced by injured patients admitted to hospitals, as part of the Equi-Injury study, which aims to understand access to quality injury care in LMICs. Methods: We recruited moderately to severely injured patients who were admitted for at least twelve hours to nineteen healthcare facilities across Ghana, Pakistan, Rwanda, and South Africa. Data were collected on demographics, socioeconomics, injury characteristics, the patient journey from injury to definitive care (including transport taken and number of prior facilities visited), and time... Continue Reading

BACKGROUND:   There is a growing burden or pesticide poisoning in the Philippines due to easy availability and inadequate regulatory oversight. The varying toxicities of different pesticides can complicate management, especially due to the limited understanding of the synergistic effects or increased toxicity that may result from combinations of these chemicals.   CASE REPORT   This case presents a 63-year-old male who ingested 3 bottles of pesticides with the active ingredients of Chlorpyrifos, Cypermethrin, Butachlor, Pretilachlor and Xylene. The patient was referred by EMS following a poisoning incident, with medical directives to ventilate using a BVM, provide immediate transport, and bring the pesticide bottles for identification. At the ED, the patient is unresponsive, hypotensive 80/60 mmHg, tachycardic at 116 beats per minute (bpm), tachypneic 31 breaths per minute, and desaturation of 89%. He had pinpoint pupils and milky-white, petroleum-like oral secretions. On further history, he had been drinking alcohol with... Continue Reading

Venom induced coagulopathy is a well-recognized and common complication of viper snakes. Few cases are reported from the Middle East region, where the Echis species is a particularly problematic genus of the Viperidae family, with untreated envenomations carrying an estimated 20% mortality rate. Presence of destructive enzymes in the snake venom enables them to produce their local tissue damage effects, which manifest as localized edema that can in rare cases progress into limb threatening compartment syndrome. Here we present the case of a 34 years old man who experienced a saw-scaled viper snake bite to his right index finger. In the matter of a few hours, the patient developed rapidly progressive pain and swelling that extended to his forearm despite receiving Saudi polyvalent anti-venom at a rural facility. Shortly after the patient attended a tertiary center where not only his swelling was increasing to involve the arm, but his coagulation profile... Continue Reading

Background:Injuries are a leading global health concern, accounting for 4.4 million deaths annually and contributing significantly to disability and healthcare demands. Up to 40% of injured individuals experience long-term disability, and injuries contribute to approximately 10% of the global burden of disease. Outcomes vary significantly across countries and settings, with a disproportionately high share of adverse outcomes happening in low- and middle-income countries (LMICs). Despite this, data on injury outcomes in LMICs remain limited. This study presents post-injury mortality and morbidity from the Equi-Injury project, which aimed to explore facilitators and barriers to equitable access to quality care after injury in LMICs. Methods:We recruited patients with moderate to severe injuries from 19 hospitals across Ghana, Pakistan, Rwanda, and South Africa. Data were collected on demographics, socioeconomics, injury characteristics, the patient journey from injury to definitive care (including transport taken and number of prior facilities visited), and outcomes of death or... Continue Reading

Objective: This study aimed to evaluate the pain management practices for oncology patients in the emergency department (ED), focusing on pain assessment, analgesic use, and treatment effectiveness.Methods: This retrospective cohort study was conducted at King Abdulaziz Medical City in Jeddah, Saudi Arabia, from January 2020 to December 2023. A total of 341 oncology patients who presented to the ED with pain were included. As pain scores for most patients were missing, observed values were retained, and a transparent, conservative approach was used to estimate missing scores to enable inferential analyses. The primary outcome was effective pain relief (≥2-point reduction, 0–10 scale).Results: The mean age was 54 years, and 47% of participants were male. Pre-treatment pain scores were documented in 18% of patients; reassessment after analgesia was recorded in 28%. The mean pain score decreased from 7.4 pre-treatment to 1.6 post-treatment (p < 0.001). Opioid use was associated with greater odds... Continue Reading