Advanced Journal of Emergency medicine
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Sample Size Calculation Guide - Part 3: How to Calculate the Sample Size for an Independent Case-control Study
Get PDFIn the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion and how to calculate the sample size for an independent cohort study. In this article, we will explain how to calculate the sample size for an independent case-control study based on the odds ratios or two proportions representing the exposure rates in the case and the control groups
A New Formula for Confirmation of Proper Endotracheal Tube Placement with Ultrasonography
Get PDFBackground Endotracheal intubation is an important procedure in critical care and emergency medicine settings. Optimal depth of the tube placement has been a serious concern because of several complications associated with its malposition. Objective: The aim of the current study was to find a new formula to estimate the proper endotracheal tube depth when using ultrasonography or lighted stylet device in order to increase the accuracy of determining Endotracheal tube (ETT) depth and decrease the side effects of ETT misplacement. Method: Patients older than 18 years of age admitted to Imam emergency department who needed tracheal intubation were included. Tube’s length at the angle of the mouth while the tube passed the suprasternal notch, ETT depth after insertion and the distance from ETT’s tip to carina were recorded. Ultrasonography and portable chest x-ray were used as tools for measuring these lengths. Results: A total number of 91 patients including 55 men and 36 women were eligible for inclusion in the study. Not placing the tube at proper depth was considered as failure of intubation. This failure rate was 9.9% in the standard method which would have been 1.1% if our proposed formula was used. Conclusion: The findings of this study suggest that the use of this new formula may help in predicting the proper intubation tube placement. Further studies are warranted to confirm these findings
Teaching Approach to Tachycardia and Bradycardia in Medical Students: A Quasi-Experimental Study to Compare Team-Based Learning and Lecture Method
Get PDFIntroduction: It is crucial to find ways to improve the durability of learning in clinical units. One of these methods is team-based learning (TBL). This learning method is active and students must study the subject before the session. Objective: This study examined TBL and compared it with conventional lecture method (LM) in an educational approach to tachycardia and bradycardia in adult patients. Method: In this quasi-experimental study, medical students (interns) were randomly divided into two groups of TBL and LM. Two faculty members of emergency medicine were responsible for teaching in both LM and TBL groups. Data collection tool was a checklist including demographic information and a researcher-made questionnaire for assessing knowledge about tachycardia and bradycardia in adult patients. Two sets of questions with the same difficulty were designed to be used for pre-test and post-test. Both groups completed pre-test and post-test, which were finally compared. Results: Totally 65 medical interns with the mean age of 28.75±2.26 years were participated of whom 37 persons (56.9%) were female. There was no significant difference in terms of the mean age of the participants in the two groups (p=0.914). The two groups were also matched in terms of male/female ratio (p=0.416). There was no significant difference between TBL and LM groups regarding pre-test score (p=0.935). However, they were significantly different in post-test (p=0.001) when TBL group scored higher than the LM group. Conclusion: Based on the research findings, it seems that TBL was more effective than LM on students' understanding of approach to tachycardia and bradycardia in adult patients
Propagating Relationship of Cerebral Oximetric Volume and the Clinical Outcome of Recombinant Tissue Plasminogen Activator (r-TPA) Therapy on Acute Cerebral Ischemic Stroke Patients
Get PDFIntroduction: Currently, the most available treatment for acute ischemic stroke (AIS) is thrombolytic therapy with recombinant tissue plasminogen activator (r-TPA). A challenge in r-TPA therapy is the prediction of recovery in each case. Objective: The aim was to find a possible relationship between the cerebral oximetry indexes and the clinical outcome of r-TPA therapy to assess the cerebral oximetry as a non-invasive monitoring agent for therapy. Methods: The inclusion criteria were all patients with AIS who received r-TPA. The neurologic status was evaluated based on the national institutes of health stroke scale (NIHSS) score at arrival, and after a period of 24 hours. In addition, the levels of brain oxygenation in both hemispheres were measured before and continuously over the first 24 hours after r-TPA injection, using an oximetric sensor in the frontal lobes. The clinical success was defined as a 4-point improvement from the baseline NIHSS. Results: Total 44 patients with the mean age of 58.2 ± 2.18 years were enrolled, of whom 68.18% were male. Twenty-eight patients remained clinically unimproved and 16 patients were improved. A significant difference was found in the mean surface area under the brain oximetric curve in the 24 hour, in the affected hemisphere in the improved group, compared to the unimproved group (P = 0.007). There was a significant difference between the mean increase in brain oxygenation within 24 hours in the improved and unimproved groups (P = 0.002). Conclusion: The cerebral oximetry could contribute to predict the likelihood of r-TPA prognosis in patients with AIS
The Current Status of Genes and Genetic Testing in Emergency Medicine: A Narrative Review
Get PDFContext: An emergency is any medical problem that could cause death or permanent injury if not treated quickly. In some occasions, the kind of urgent intervention depends on patient’s exact genetic background. Unfortunately, the importance of genes in medical emergencies has been forgotten in recent decades. Evidence acquisition: In order to find relevant articles, we searched two databases of Pubmed and Embase. The exact words of “genes”, “genetics”, “epigenetics”, “DNA”, and “emergency” were used alone and in combination. All studies like randomized clinical trials (RCT), case/controls, case series, case reports, and review articles were studied to find the related data. No time limitation was considered for the studies. Results: Several aspects of genetic testing are newly considered in emergency departments including cell-free DNA (cfDNA) for disease diagnosis, pharmacogenetics for decreasing the adverse drug effects, and personalized medicine for exact emergency interventions in diseases like Vascular Ehlers-Danlos syndrome (vEDS). Data from genetic testing and genome wide association studies have yielded promising results to make medical emergency interventions more beneficial in the near future. Conclusion: Taking everything into consideration, several advanced genetic and epigenetic alteration technologies can change emergency medicine for the better. Personalized genetic data of patients can turn emergency medicine to personalized medicine
Atypical Feature of Diabetic Ketoacidosis with Low or Normal Plasma Glucose: a Narrative Review
Get PDFContext: Diabetic Ketoacidosis (DKA) is a well-known emergency in diabetic patients. In a subgroup of patients ketoacidosis is present but is not accompanied by the marked hyperglycemia considered part of the diagnostic criteria for DKA. This is known as Euglycemic DKA (EuDKA). Evidence acquisition: We searched the PubMed for the existing literature on the topic of normoglymic ketoacidosis, including its prevalence, pathogenesis, and treatment. Results: The study showed that there are many reports of the cases in which diabetic patients developed ketoacidosis without experiencing hyperglycemia. Several predisposing factors have been proposed but the precise pathophysiologic mechanisms are still under investigation. Some pathways have been suggested. Timely diagnosis is of paramount importance. Treatment is similar to DKA. Conclusion: EuDKA is a medical emergency that should be considered when evaluating a diabetic patient with ketoacidosis. It should be diagnosed and treated promptly
The Carotid Artery Thrombosis Following Blunt Neck Trauma; a Case Report
No full textIntroduction: This case emphasizes on the importance of detecting thrombosis and carotid artery injuries and the need for rapid treatment of blunt neck traumas. Case presentation: A 43-year-old male motorcyclist rider, rode into a rope and suffered blunt neck trauma. At admission to the emergency department (ED), he was fully conscious with Glasgow coma scale of 15. The biochemical tests and X-rays were normal, but initial examination revealed paresthesia in the right-hand fingertips, which exacerbated over the first 24 hours of admission. Doppler ultrasound of the neck arteries and computed tomography (CT) angiography reports showed thrombosis of the right common carotid artery, which spread to the right subclavian and vertebral arteries. Treatment was initiated with heparin injection followed by daily administration of oral warfarin, and seven days later, symptoms were relatively improved. Conclusion: Considering possible vascular injuries following blunt neck trauma should be kept in mind when dealing with such patients, and necessary physical examination required to rise the impression. By reviewing the literature, it seems that although CT angiography is usually used in screening carotid injuries, this modality appears to have poor sensitivity in this regard, and digital subtraction angiography (DSA) is still considered the gold standard for detecting carotid artery injury
Future Direction of Emergency Medicine Research; Can We Overcome the Difficulties and Fill in Knowledge Gaps?
Get PDFPace of medical research development heralded an escalation in recent years. Groundbreaking evidences have been provided for managing dyslipidemia in 2017. Beside statins, alternatives of Anti PCSK-9 monoclonal antibodies in human and AT04A anti PCSK-9 vaccine in mice have shown to significant decrease in total cholesterol level. Wonderful! Apart from this, dual pathway inhibition by using aspirin with very low dose Rivaroxaban has been shown to be more effective in mitigating ischemic event rate than aspirin alone in patients with stable coronary artery disease or peripheral artery disease. Furthermore, patients with atrial fibrillation undergo percutaneous coronary intervention will benefit more from double antithrombotic therapy than triple one. Besides, a novel risk score of PRECISE-DAPT has determine the optimal duration of antiplatelet therapy in patients implanting coronary stents; and many other medical research advances which grabs our attention on 2018.
In order to translate recent advances in medical research into clinical practice we need to design, conduct and apply high quality research in different medical subspecialties. The emergency medicine (EM) environment defined as overburdened with inability to afford more than a few minutes per patients. Where, time for research might be considered as a potential risk of interruption in clinical practice. EM is a broad field involving multiple disciplines and crosscutting themes with the unique features in research including urgency and location of the treatment. Art of research in EM comprises hybridization of clinical research, basic science and health services research. Accordingly, research priority setting should be put forwarded based on these three areas, examining existing gaps in EM knowledge, system design issues, educational predicament and disparities between diagnostic skills and clinical decisions. Where the most appropriate research questions arise? Definitely, it comes from critical thinking in patient care setting, regular reading habit, teaching, journal clubs, collaborations and society. To alleviate the issue of immense question and limited time in EM field which tangles decision makers mind we recommend to prioritize questions in line with; patients well- being, learners need, feasibility to answer, inquiries that most likely to recur in your practice and most interesting foreground research query. A research need has been defined as a gap in existing knowledge on practice, learner‚s education, patient values and societal demands. To examine the gaps in EM research knowledge we can provide research time and facilities, training new investigators, develop multicenter research networks, improve research coordination and involving funding agencies to make practical attempts for filling pre specified gaps. In conclusion, since patient oriented outcome research will provide us with the most important endpoints for clinical policy making and patient care standard setting, I totally agree with the advocates of involving stakeholders including clinicians, society and patients in EM research process to mitigate the existence knowledge gaps for dedicating high quality EM car
Comparing the Therapeutic Effects of Dexamethasone-Metoclopramide with Ketorolac in Relieving Headache in Patients with Acute Migraine Attacks Presenting to the Emergency Department
Get PDFIntroduction: Migraine is a frequent chief complaint of patients in the emergency department. A wide range of treatments are used for acute migraine. Objective: This study aimed to compare the therapeutic effects of a combination of metoclopramide + dexamethasone with those of ketorolac for treatment of acute migraine in the emergency department. Method: This quasi-experimental study enrolled patients identified as migraine headache cases admitted to the emergency departments of Shohadaye Tajrish and Sina hospitals, Tehran, Iran. The patients were divided into two groups and treated with either 8 mg Dexamethasone + 10 mg Metoclopramide or 60 mg ketorolac, and then compared regarding the rate of pain control based on visual analogue scale (VAS) on arrival and 1 and 2 hours afterward. Results: Overall, 86 patients were recruited, of whom 50 were male (58.1%). Their mean age was 37.6 ± 10.3 years. Thirty-five (40.7%) were in the ketorolac group and 51 (59.3%) were in the dexamethasone + metoclopramide group. Treatment success was defined as a reduction of at least 3 points in pain severity in comparison to the admission time. One hour after administration of medications, the reported pain intensity was 4.7 ± 2.0 and 6.2 ± 2.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. By the second hour, pain intensity was 3.4 ± 1.2 and 2.9 ± 1.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. The two groups did not show a significant difference in terms of the reported pain at this time (p= 0.04). Conclusion: Based on our findings, the pain reduction time was relatively shorter for ketorolac in acute migraine, but the final response was identical in the two groups
Invitation to the GNS-I Study; a Global Evaluation of Traumatic Brain Injury in Low-, Middle-, and High- income Countries
Get PDFWe invite worldwide neurosurgeons, trauma surgeons, emergency medicine physicians, anaesthesiologists, and trainees to join the GNS team. Any worldwide hospital the receives and manages TBI patients is eligible for participation in the study. Collaborators can register through the official GNS website available here:
https://www.globalneurosurg.org/
There are several ways in which collaborators can participate in the GNS team, these roles can be found on the GNS website here:
https://www.globalneurosurg.org/collaborator-roles