ABSTRACT Adenosine is an antiarrhythmic drug that slows conduction through the atrioventricular node and acts as a coronary blood vessel dilator. This case report highlights two unusual life-threatening events following the use of adenosine to revert supraventricular tachycardia in a structurally normal heart: non-sustained polymorphic ventricular tachycardia and myocardial infarction. A 46-year-old woman presented to the emergency department with a two-hour history of palpitations and was diagnosed with supraventricular tachycardia. Vagal maneuvers were ineffective, and after intravenous adenosine administration, the patient presented with chest pain and hypotension. The rhythm degenerated into non-sustained polymorphic ventricular tachycardia and spontaneously reverted to sinus rhythm with ST elevation in lead aVR and ST depression in the inferior and anterolateral leads. The patient spontaneously recovered within a few minutes. Despite successful arrhythmia reversal, the patient was admitted to the intensive care unit because of an infarction without obstructive atherosclerosis. This report aims to alert emergency physicians about the potential complications associated with supraventricular tachycardia and its reversal with adenosine. dilator lifethreatening life threatening heart nonsustained non sustained 46yearold yearold 46 year old twohour hour ineffective administration hypotension leads minutes atherosclerosis 4

ABSTRACT Chest pain is a frequent, potentially life-threatening condition in the emergency department and requires immediate investigation and treatment. This case report highlights a rare differential diagnosis of pleuritic chest pain: epipericardial fat necrosis. A 29-year-old man presented with normal clinical evaluation, electrocardiography, point-of-care ultrasound, and unremarkable laboratory tests. The initial hypothesis was acute pleuritis. Chest radiography revealed peri-cardiac nonspecific findings, and computed tomography revealed epicardial fat necrosis. Despite the rarity of this condition, accurate diagnosis allows for better practices. An algorithm for a diagnostic approach is proposed. frequent lifethreatening life threatening treatment necrosis 29yearold yearold 29 year old evaluation electrocardiography pointofcare point care ultrasound tests pleuritis pericardiac peri cardiac findings practices proposed 2

ABSTRACT Objective To analyze telemedicine diagnostic accuracy in patients with respiratory infections during COVID-19 pandemic compared to face-to-face evaluation in the emergency department. Methods Randomized, unicentric study between September 2020 and November 2020 in patients with any respiratory symptom (exclusion criteria: age >65 years, chronic heart or lung diseases, immunosuppressed). Patients were randomized 1:1 for brief telemedicine followed by face-to-face consultation or direct face-to-face evaluation. The primary endpoint was the International Classification of Diseases code. The secondary analysis comprised length of stay, diagnostic test ordering, medical prescription, and proposed destination. Results Ninety-eight patients were enrolled. The mean age was 36.3±9.7 years old, 57.1% were women, and 81.6% had diagnostic test ordered. Mean grouped by International Classification of Diseases code for upper respiratory tract infection, pharyngotonsillitis, and sinusitis showed no difference between study groups or secondary endpoints. The Telemedicine Group was representative of the population usually evaluated in this center. In the Telemedicine Group (n=48), 18.7% patients would be referred for evaluation at the emergency department. The distribution of diagnoses by telemedicine was 67.4% for upper respiratory tract infection, 2.3% for pharyngotonsillitis, and 0% for sinusitis, being statistically similar to the subsequent face-to-face assessment, respectively: 72.1%, 11.6% and 7% (Kappa 0.386 [95%CI: 0.112-0.66]; p=0.536). Telemedicine ordered COVID-19 molecular (RT-PCR) tests in 76.5% versus 79.4% in face-to-face evaluation (Kappa 0.715 [95%CI: 0.413-1]; p>0.999). Conclusion Diagnostic telemedicine consultation of low-risk patients with acute respiratory symptoms is not inferior to face-to-face evaluation at emergency department. Telemedicine is to be reinforced in the health care system as a strategy for the initial assessment of acute patients. ClinicalTrials.gov Identifier: NCT04806477

RESUMO Objetivo Analisar o impacto da pandemia da COVID-19 nas métricas do pronto atendimento de um hospital terciário de referência no Brasil. Métodos Uma análise retrospectiva das visitas consecutivas ao pronto atendimento, de 1o de janeiro de 2020 a 21 de novembro de 2020, foi realizada e comparada ao mesmo intervalo nos anos de 2018 e 2019. O volume de atendimentos e as características clínicas e demográficas dos pacientes foram comparados. Todos os diagnósticos foram incluídos, exceto os casos confirmados de COVID-19. Resultados Um total de 138.138 visitas ao pronto atendimento ocorreu durante o período do estudo, com redução estatisticamente significativa (p<0,01) de 52% do volume comparado tanto a 2018 como a 2019. Essa queda foi mais pronunciada nos atendimentos de pediatria, com redução de 71% se comparada aos números de anos anteriores. Em relação ao quadro clínico, houve redução dos casos graves em 34,7% e 37,6%, enquanto os casos leves caíram 55,2% e 56,2%, quando comparado 2020 a 2018 e a 2019, respectivamente. Uma queda de 30% foi vista no volume de admissões hospitalares originadas dessas visitas, porém houve aumento percentual da taxa de admissão mensal em relação ao volume desde abril de 2020. Conclusão O impacto da pandemia da COVID-19 gerou redução de 52% no volume de atendimento do pronto atendimento por outras condições clínicas, bem como aumento proporcional na taxa de admissão hospitalar de pacientes com COVID-19. Os profissionais de saúde devem orientar seus pacientes a não atrasar a procura por atendimento médico de condições graves que precisem de cuidados no pronto atendimento.

ABSTRACT Objective To analyze the impact of COVID-19 on emergency department metrics at a large tertiary reference hospital in Brazil. Methods A retrospective analysis of consecutive emergency department visits, from January 1, 2020, to November 21, 2020, was performed and compared to the corresponding time frame in 2018 and 2019. The volume of visits and patients’ demographic and clinic characteristics were compared. All medical conditions were included, except confirmed cases of COVID-19. Results A total of 138,138 emergency department visits occurred during the study period, with a statistically significant (p<0.01) reduction by 52% compared to both 2018 and 2019. This decrease was more pronounced for pediatric visits – a drop by 71% in comparison to previous years. Regarding clinical presentation, there was a decrease of severe cases by 34.7% and 37.6%, whereas mild cases decreased by 55.2% and 56.2% when comparing 2020 to 2018 and 2019, respectively. A 30% fall in the total volume of hospital admission from emergency department patients was observed during the study period, but accompanied by a proportional increase in monthly admission rates since April 2020. Conclusion The COVID-19 pandemic led to a 52% fall in attendance at our emergency department for other conditions, along with a proportional increase in hospital admission rates of COVID-19 patients. Healthcare providers should raise patient awareness not to delay seeking medical treatment of severe conditions that require care at the emergency department.