BRASH syndrome is a syndrome characterized by bradycardia, renal failure, usage of atrioventricular (AV) nodal blocker, shock, and hyperkalemia (BRASH). It is more common among patients with multiple comorbidities such as cardiac disease, kidney dysfunction, and hypertension requiring AV nodal blockers. Cardiac conduction abnormalities are frequently caused by severe hyperkalemia. However, it may also occur in mild-to-moderate hyperkalemia with concomitant use of AV nodal blockers due to the synergistic effects between these two factors in the presence of renal insufficiency. It is essential for the physician to identify BRASH syndrome as the treatment may differ from standard advanced cardiovascular life support (ACLS) protocol. We report the two cases of patient who presented with BRASH syndrome who failed to respond to standard ACLS protocol.

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BACKGROUND: The first cases of the coronavirus disease 2019 (COVID-19) were reported in Wuhan, China. No antiviral treatment options are currently available with proven clinical efficacy. However, preliminary findings from phase III trials suggest that remdesivir is an effective and safe treatment option for COVID-19 patients with both moderate and severe disease. OBJECTIVE: The aim of the present meta-analysis was to investigate whether remdesivir was effective for treating COVID-19 including reduced in-hospital adverse events, oxygen support, and mortality rates. METHODS: According to the PRISMA reporting guidelines, a review was conducted from January 1, 2020, until August 25, 2020, with MeSH terms including COVID-19, COVID, coronavirus, SARS-CoV-2, remdesivir, adenosine nucleoside triphosphate analog, and Veklury using MEDLINE, Scopus, and CINAHL Plus. A modified Delphi process was utilized to include the studies and ensure that the objectives were addressed. Using dichotomous data for select values, the unadjusted odds ratios (ORs) were calculated applying Mantel–Haenszel random-effects method in Review Manager 5.4. RESULTS: Randomized controlled trials pooled in 3013 participants with 46.3% (n = 1395) in the remdesivir group and 53.7% (n = 1618) in the placebo group. The placebo group had a higher risk of mortality as compared to the intervention group with significant OR (0.61) (95% confidence interval of 0.45–0.82; P = 0.001). There was minimal heterogeneity among the studies (I² = 0%). CONCLUSIONS: Our findings suggest that remdesivir extends clinical benefits by reducing mortality, adverse events, and oxygen support in moderate to severely ill COVID-19 patients. Concerted efforts and further randomized placebo-controlled trials are warranted to examine the potency of antiviral drugs and immunopathological host responses contributing to the severity of COVID-19.

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Administration of sub-dissociative doses of ketamine is used via intranasal (IN) and intravenous routes in the pediatric emergency department for managing acute pain. Due to difficulties in both obtaining intravenous access and compliance with IN medications in children, administration of ketamine via breath-actuated nebulizer can serve as a valuable modality for timely analgesia in children where dosing titration is patient controlled. We describe five pediatric patients who received ketamine via breath-actuated nebulizer at 0.75 mg/kg, 1 mg/kg, and 1.5 mg/kg, with all patients experiencing a decrease in pain score. This case series introduces ketamine inhalation as a modality for managing pain in children.

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OBJECTIVE: Whether the use of metronome affects the quality of cardiopulmonary resuscitation (CPR) remains unclear. In this study, we investigated the effect of metronome use on CPR quality. METHODS: This was a prospective, simulation-based CPR manikin study. There were two phases: without and with metronome use. Chest compression was performed for 2 min, and three CPR quality criteria including chest compression depth, recoil, and rate were recorded with TrueCPR Feedback Device in both phases. RESULTS: In all, 102 resident physicians were included. The achievement of optimal chest compression depth and complete recoil was better with metronome use than without (83% and 77% vs. 78% and 39%, P ≤ 0.001, respectively). Optimal chest compression rate was also reached with metronome use because the range of the compression rate was closer to the normal limits than those without metronome use (110 [interquartile range (IQR) 109–113] vs. 120 [IQR 109–129], P ≤ 0.001). Of all the participants, 70.6% stated that metronome use had a positive effect on their performance during the CPR application and 66.7% stated that they wished to use the metronome in their daily practice. CONCLUSION: Using a metronome during simulation-based CPR improved the compression depth and recoil by fixing chest compression rate. We suggested that metronome should be used in CPR trainings of health-care professionals.

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OBJECTIVES: Although studies in the field of emergency medical services (EMS) generally compare survival and hospital discharge rates, there are not many studies measuring the quality of cardiopulmonary resuscitation (CPR). In this study, we aimed to compare the mechanical chest compression device and paramedics in terms of CPR quality. METHODS: This is an experimental trial. This study was performed by the EMS of Ankara city (capital of Turkey). Twenty (ten males and ten females) paramedics participated in the study. We used LUCAS™ 2 as a mechanical chest compression device in the study. Paramedics applied chest compression in twenty rounds, whereas mechanical chest compression device applied chest compression in another set of twenty rounds. The depth, rate, and hands-off time of chest compression were measured by means of the model's recording system. RESULTS: The median chest compression rate was 120.1 compressions per minute (interquartile range [IQR]: 25%–75% = 117.9–133.5) for the paramedics, whereas it was 102.3 compressions per minute for the mechanical chest compression device (IQR: 25%–75% = 102.1–102.7) (P < 0.001). The median chest compression depth was 38.9 mm (IQR: 25%–75% = 32.9–45.5) for the paramedics, whereas it was 52.7 mm for the mechanical chest compression device (IQR: 25%–75% = 51.8–55.0) (P < 0.001). The median hands-off time during CPR was 6.9% (IQR: 25–75 = 5.0%–10.1%) for the paramedics and 9% for the mechanical chest compression device (IQR: 25%–75% = 8.2%–12.5%) (P = 0.09). CONCLUSION: During patient transport, according to the chest compression performed by the health-care professionals, it was found that those performed by the mechanical chest compression device were more suitable than that performed by the guides in terms of both speed and duration.

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OBJECTIVE: The aim of this randomized, cross-over trial is to reveal the effect of smartphone cardio-pulmonary resuscitation (CPR) feedback applications (App) on a group of lay rescuers' chest compression-only CPR quality metrics. Quality metrics is measured initially and after 3 months. METHODS: A floor-based Resusci Anne mannequin (Laerdal Medical, Stavanger, Norway) was used. Three scenarios (CPR with device App-on [scenario-a], CPR with device App-off [scenario-b], and hands-only CPR [scenario-c]) were randomly allocated to all participants. All the participants performed 2 min of hands only-CPR for each scenario. Data of mean chest compression rate, mean chest compression depth, and recoil were recorded and compared for each scenario. RESULTS: One hundred and thirty-seven first-year students from the Vocational School of Health Services in Turkey participated in this study to mimic lay rescuers. Difference in the initial mean rate of chest compressions was statistically significant when CPR was performed with device App-on (scenario-a) compared to scenarios b and c (P < 0.001, P < 0.001). Furthermore, difference in the mean chest compression rate at the 3^rd month was statistically significant among the scenarios when CPR was performed with device App-on (scenario-a) (P = 0.002, P = 0.001). The difference in initial and 3^rd month mean compression depth and the percentage of recoil was not statistically significant among the scenarios. CONCLUSION: This study shows that the mean chest compression rate and percentage of compressions with adequate rate improved with smartphone App-on, and these results were persistent up to 3 months.

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Glufosinate ammonium (GLA) is widely used as a commercial herbicide in many countries. Neurotoxicity of GLA has been associated with serious neurological complications such as loss of consciousness, convulsions, and memory impairment. Late-onset memory impairment due to GLA-induced hippocampal lesions is the most distinct clinical feature in GLA poisoning. However, the lesion of the splenium of the corpus callosum (SCC) is a rare condition in GLA poisoning, so the clinical features are not well known. We report the case of a 57-year-old male patient who developed SCC damage after GLA poisoning. The patient had various late-onset neurotoxic symptoms, including prolonged overall cognitive dysfunction and psychosis-like symptoms. Emergency physicians should be aware that GLA-induced SCC lesions may be associated with various late-onset neurotoxic symptoms.

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Arterial bleeding due to pelvic fracture can be life-threatening, and angiographic embolization is the gold standard for its control. Various materials have been described, but most of them are not widely available, mainly because of the high costs. Here, we report a case of use of autologous subcutaneous fat tissue for successfully controlling bleeding in a patient with an anterior–posterior pelvic fracture.

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OBJECTIVE: The objective was to investigate the characteristics of suicide attempters as distinguished from nonsuicidal self-injury (NSSI) among those who are admitted to the emergency department (ED) following self-harm behavior using psychological scales and biochemical markers. MATERIALS AND METHODS: The initial assessment forms and medical records of patients referred to the ED after self-harm behavior between March 2017 and December 2019 were retrospectively reviewed. Based on the patients' statements, two groups were formed: the NSSI group and the suicide attempt (SA) group. RESULTS: This study included 578 patients, 76.6% (n = 443) in the SA group and 23.4% (n = 135) in the NSSI group. A univariate analysis comparing the SA and NSSI groups revealed that the SA group was statistically significantly associated with male sex, chronic disease, history of depression, unemployment, not seeking help after the attempt, reduced consciousness, and psychiatric consultation. Further, the SA group was older and showed higher Risk-Rescue Rating Scale (RRRS) value and white blood cell value compared to the NSSI group. However, multivariate logistic analysis did not produce statistically significant results for RRRS and any of the biological markers, with one exception for the accessibility to rescue item in the RRRS, where the NSSI group showed a statistically higher “ask for help” score compared to the SA group (P < 0.01). CONCLUSIONS: Among patients who were admitted to the ED following self-harm behaviors, the risk factors for SA as opposed to NSSI were chronic disease and not seeking help after the attempt. In addition, suicide attempters tended to be more cooperative in psychiatric consultation following ED admission. In clinical practice, patients admitted due to NSSI should be administered treatment equivalent to that for suicide attempters if they exhibit the characteristics of suicide attempters.

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