Advanced Journal of Emergency medicine
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Management of a Penetrating Thoracic Injury with Thoracoscopy; A Case Study
Get PDFIntroduction: Various strategies could be considered dealing with penetrating thoracic injuries. Thoracoscopy is much less invasive than routine thoracotomy approach for managing such cases in which the sharp object remains in the body. The case presented in this article was managed with thoracoscopy for a penetrating dorsolateral thoracic injury. Case Presentation: A 35-year-old man with a penetrating dorsolateral thoracic injury referred to the emergency department. Despite an elevated pulse rate, the patient has proper blood pressure and O2 saturation. Considering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy. At thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space. There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications. Conclusion: Our experience of removing a retained knife by thoracoscopy showed that it can be an appropriate alternative for patients with penetrating thoracic injury who are hemodynamically stable and have appropriate conditions for thoracoscopy
An Interventional Study on Comprehensive Emergency Care and Trauma Registry for Road Traffic Injuries in India: A Protocol
Get PDFRoad traffic injuries (RTIs) stands as one of the leading causes of mortality and morbidity across the globe. Effective injury surveillance systems and pre-hospital and in-hospital interventions set up in developing countries have shown promising results in controlling the problem. This study aimed to standardise and evaluate an evidence-based intervention for safety, efficacy and quality of post-crash pre-hospital and in-hospital trauma care services to improve the outcome in RTI victims. In addition, it establishes the android-based trauma registry for effective RTI surveillance.
This multi-centric, prospective, observational study is commissioned by the Indian Council of Medical Research (ICMR) as a National Task Force Project. This study is being conducted in five sites, viz., Anand, Bengaluru, Delhi, Lucknow and Thrissur located across India. Each centre will have a level I, two level II and three level III trauma hospitals. The study will be carried out in four phases namely: i) preparatory phase, ii) trauma registry establishment and pre-intervention data collection, iii) intervention and iv) impact evaluation. The preparatory phase, which lasts for four months includes the situational analysis pertaining to managing RTIs. Trauma registry will be initiated from the fifth month. Pre-intervention data will be collected for six months. The intervention will be conducted for six months in the form of prehospital notification, training for trauma care providers and trauma care quality improvement. Post-intervention data collection will continue for 12 months and the impact of the intervention will be assessed. The primary outcome measure will be early preventable mortality, defined as death at 24 hours after admission for patients with a calculated probability of survival >50% based on their injury severity score
Acute Thrombotic Occlusion of proximal Left Anterior Descending Artery without ST-elevation (de Winter sign) in Electrocardiogram: A Case Report
Get PDFIntroduction: ST-elevation in precordial leads is diagnostic for acute transmural myocardial infarction (MI) related to acute occlusion of left anterior descending artery (LAD). Case presentation: In this case report, a 54-year-old man was admitted to the emergency department (ED) due to chest pain. ST-depression with tall T waves in precordial leads was detected in surface electrocardiogram (ECG). Angiography showed acute total occlusion of proximal LAD and ad hoc percutaneous coronary intervention (PCI) was performed successfully. Conclusion: This case highlights that total occlusion of LAD may present without typical ST-elevation pattern in ECG
Approach to Acute Abdominal Pain: Practical Algorithms
Get PDFContext: Acute abdominal pain is one of the most common complaints of patients admitted to emergency units. This study aimed to propose a new approach to abdominal pain by designing a more structured diagnostic workup for physicians. Evidence acquisition: A comprehensive review of relevant articles and algorithms presented in books and websites was conducted. Approaches which were relevant to the study concept, were selected. Results: Seven algorithms were introduced with respect to the site of abdominal tenderness. The mainstay of these algorithms was differential diagnosis of the tenderness site. Conclusion: Based on the findings, the designed approach can prevent confusion among physicians and reduce requests for many unnecessary paraclinical tests, which delay the final diagnosis and impose unacceptable costs on patients and healthcare systems
Sample Size Calculation Guide - Part 6: How to calculate the sample size for a non-inferiority or an equivalence clinical trial
Get PDFIn the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion, for an independent cohort study, for an independent case-control study, for a diagnostic test accuracy study, and for a superiority clinical trial. In this article, we will explain how to calculate the sample size for a non-inferiority or equivalence clinical trial
ED Assembly: Introducing a Simple Method of Bringing Emergency Department Staff Together to Facilitate Improvement; A Report of a Real Experience
Get PDFIntroduction: The emergency department (ED) at Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH) is a medium size department which sees around 260-300 patients per day. As a result of sustained demand, we continue to struggle to meet the four hour waiting target and face similar challenges of those of ED’s nationally. Working in a busy ED is challenging and demanding. specific challenges around communication and risks arise directly from the unique contextual demands of the ED environment. Objective: Aim being to improve the productivity of the ED team and find a mechanism to create a more supportive and enjoyable working environment within the department. Method: Our clinical leadership started looking for answer to improve communication among team members and to create a platform where there was no hierarchy and all team members could be directly involved in problem solving. With the support of the quality improvement (QI) team, ED assembly was born. The assembly is a simple method of regularly bringing together staff to facilitate improvement and better team working. It is a platform for effective communication and innovation, in which there is no hierarchy and everyone is encouraged to contribute. Results: The assembly runs to a routine; every other Wednesday at 11am, the team come together for just half an hour. The agenda is set by the team in advance and everyone is encouraged to contribute their ideas and items they wish to contribute to others. Here are some examples of the quality improvement initiatives that have been born out of ED assembly: ED board rounds, coding information, overdose proforma, timely completion of standard investigations, access to fracture clinic appointments, nil-by-mouth communication, safety huddles, patient safety and sepsis, inclusive improvement, adoption of the ED assembly model by other teams and etc. Conclusion: ED assembly has supported many small but effective QI initiatives and regular communications support timely feedback on progress and update on plan-do-study-act (PDSA) cycles, resulting in changes in the everyday practice and improved pathways of patient care
The Accuracy of GAP and MGAP Scoring Systems in Predicting Mortality in Trauma; a Diagnostic Accuracy Study
Get PDFIntroduction: Trauma scoring systems help physicians and nurses to be informed of injuries to a patient and assist their decision making in the cases of trauma and importantly prediction of their outcome and prognosis. Objective: This study aimed to compare the accuracy of GAP and MGAP scoring systems as predictors of mortality in trauma patients. Methods: This diagnostic accuracy study was conducted amongst 1861 trauma patients admitted to Rajaee Hospital in Shiraz, Iran, during 2017. The data on demographic features were extracted from the patients’ records. Then, trauma scoring systems including injury severity score (ISS), GAP, MGAP, and Glasgow coma scale (GCS) were compared to evaluate their accuracy in predicting mortality. Area under the receiver operating characteristic (ROC) curve was used to evaluate the accuracy of different trauma scoring systems and detect the sensitivity and specificity in order to predict status of discharge after 24 hours. Results: Based on the results, the area under the ROC curve was 0.8 for GCS. Moreover, Area Under Curve (AUC) of GAP was 0.91 and amongst different values, GAP value of ≤18 was selected as the cut-off point, since it exhibited the best sensitivity and specificity (72.99 and 95.52, respectively). In addition, the area under the ROC curve was 0.9 for MGAP, and value of ≤23 was selected as the cut-off point because it showed the best sensitivity and specificity (81.04 and 87.70, respectively). Additionally, AUC of ISS was 0.88. Conclusion: Both GAP and MGAP methods were able to appropriately predict mortality and were not significantly different; hence, both can be used for the right triage of patients and to predict the severity of injuries and subsequent mortality. Moreover, GAP and ISS had the best specificity and sensitivity, respectively
Jellyfish Stings Rarely Induced Infectious Cellulitis: First Aid Remedies as Double-Edged Sword
Get PDFA 27-year-old woman was presented with a burning like lesion. The skin lesion was developed after a jellyfish stings (Rhizostomae) while she was swimming in Pattaya Sea in Thailand, five days prior to her presentation. Instantly after jellyfish stings, she was taken into the ship for rescue operations. The ship personnel applied lemon juice and baking soda to the injured area believing that this remedy is efficient in this situation. The next day, she referred to a local hospital at Pattaya because she was suffering from a horrible pain in her arm and then she was discharged on oral Dicloxacillin and topical Hydrocortisone. The edema was extended the next days which intensified her pain. At this time, she was transferred to Loghman Hakim Hospital, Tehran, Iran. At admission, erythematous edematous patch with centrally grouped vesicles on the left arm was observed (Figure 1). The patient had a high-grade fever (38.1 °C) and was agitated due to her intolerable pain. Other vital signs were normal. In the sonography imaging, soft tissue edema was seen without any collection. According to the clinical and imaging findings, the diagnosis of soft tissue cellulitis due to jellyfish stings was made. The patient admitted to infections ward and intravenous antibiotics including Cefazolin at dose of 2000 mg every eight hours and Vancomycin at dose of 1000 mg every 12 hours initiated. After five days of hospitalization, the patient was recovered from left arm edema. Also, her pain decreased gradually and no obvious erythema was seen. The patient was finally discharged with a satisfactory clinical respons
Silymarin as a Promising Potential Therapeutic Agent for Treatment of Patients with Paraquat Poisoning: An Issue that Merits Further Research
Get PDFHaving an extremely toxic compound for humans and most animals, paraquat (PQ) is known as one of the most frequently used herbicides. Accordingly, PQ poisoning has been recognized as a serious medical problem across the world, with a severe case fatality rate (CFR). In this respect; accidental or intentional ingestion of PQ, even in a small amount, can be significantly associated with poor clinical prognosis and increased mortality. Moreover; inherent toxicity of PQ, absence of specific antidotes, as well as lack of effective treatments have been principally attributed to high fatality of PQ poisoning. Once PQ is ingested, it can be absorbed through skin and the digestive and respiratory system and often progresses to multi-organ failure, particularly the lungs as the main target. In this respect, PQ accumulates predominantly in the lungs and can lead to lung fibrosis, pneumonitis, and consequently respiratory failure and death. Given the nonexistence of specific and widely accepted guidelines for treatment of PQ poisoning, a range of conservative therapeutic modalities have been proposed and administered by clinicians to moderate PQ absorption and to prevent organ failure in these patients. In spite of this, PQ-induced mortality rate is high and disappointing
Validity of Triage Performed by Nurses Educated by Train-of-Trainer Workshop Participants; a Cross-sectional Study for Assessment of Cascade Training System
Get PDFIntroduction: In 2010, a national triage train-of-trainer (TOT) workshop was held in Tehran, Iran. Objective: The present study aimed to assess the validity of the triage performed by the nurses educated by those who participated in TOT workshop. Method: This cross-sectional study was carried out in 6 teaching hospitals from 4 universities in Iran. Inter-rater and intra-rater reliability of performed triage by participations was measured. Thirteen nurses were randomly selected. Thereafter, at the end of each working shift, patient data recorded in the daily data registry forms were collected. Then, duration of hospital stay, number of cases admitted to general wards or intensive care units, number of cases discharged from the ED within 12 hours and mortality rate were compared with the triage level determined by the nurse. Results: In total, 30 nurses with a mean age of 28.4 ± 3.7 years were enrolled. In this study, 1491 triage cases (61.6% male) were evaluated, of which 4.2% were triaged as level 1, 18.3% as level 2, 37.1% as level 3, 20.4% as level 4 and 20.0% as level 5. The following outcome was observed: 3.64% were discharged, 6.29% were hospitalized, 3% died and 2.3% were discharged against medical advice without completing treatment. The correlation of determined triage level and patients’ duration of hospitalization was significant based on one-way ANOVA test (p = 0.000). The outcome of the patients significantly correlated with the level of triage determined by the study nurses (p = 0.000). Conclusion: Based on the findings, it appears that triage performed by the study nurses educated by those who participated in TOT workshop through cascade training system had perfect validity