Advanced Journal of Emergency medicine
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Use of Promethazine and Meperidine as Premedicants in Asthmatics before Initiation of Surgery: An Interim Report
Get PDFPatients with bronchial asthma usually land up for surgery and pose a significant challenge as far as their anesthetic management is concerned. Most of these patients either take medicines or else are in a comparatively controlled state. Different protocols have been suggested for such cases such as corticosteroids, long-term β2 agonists, leukotriene receptor antagonists and theophylline sustained-release preparations. 
Development and Implementation of Integrated Road Traffic Injuries Surveillance – India (IRIS-India): A Protocol
Get PDFRoad traffic accidents stand as one of the leading causes of mortality and morbidity across the globe. The reasons for the high burden of road traffic injuries (RTIs) in developing countries are increasing in the number of motor vehicles, poor enforcement of traffic safety regulations, inadequacy of health infrastructure and poor transport facility. However, the systematic collection of road traffic data is not well developed in many developing countries including India and under-reporting of RTIs and deaths are common. Hence, surveillance of RTIs is recommended to assess the burden, to identify high-risk groups, to establish an association with probable risk factors and to plan interventions to control the RTIs. The broad objective of this study is to establish an electronic-based comprehensive and integrated RTI surveillance system, to assess the burden of RTIs, its risk factors and outcomes across rural and urban settings in India. This study with the support of the Indian Council of Medical Research (ICMR) is progressing in three cities (Chennai, Delhi and Jaipur) and two rural areas (Chittoor and Tehri-Garhwal). At each centre, major sources of data can be categorized under two categories including health facilities and community. In urban areas, one trauma centre, one private hospital and a community of 10000-population are included in the study. In rural areas, a district hospital, a private nursing home and two sub-centres areas of different primary health centres at each site are included for the surveillance. Passive surveillance is done at the trauma centres/district hospitals, while active surveillance is done in private hospitals/nursing homes, sub-centres and communities. Before establishing the surveillance system, situational analysis has been undertaken. Surveillance-related software was developed during the preparatory stage. This electronic surveillance platform allowed to gather data electronically across multiple sites. This internet-enabled surveillance platform has several modules to capture and analyse the data. The present study provides a model of surveillance including both passive and active surveillance to cover maximum number of RTIs. This study further provides the first comprehensive epidemiology of RTIs. The results of these studies will contribute to the setting of research and investment priorities to tackle the burden of RTIs
Accuracy of Extended Focused Assessment with Sonography in Trauma (e-FAST) Performed by Emergency Medicine Residents in a Level One Tertiary Center of India
Get PDFIntroduction: It could be claimed that extended focused assessment with sonography for trauma (e-FAST) is the most important use of ultrasound in every emergency department (ED). It is a rapid, repeatable, non-invasive bedside method that was designed to answer one single question, which is, “whether free fluid is present in the peritoneal, pleural and pericardial cavity or not?” This examination may also be used to evaluate the lungs for pneumothorax. Objective: The current comparative study was conducted to assess the accuracy and reproducibility of e-FAST performed by emergency medicine residents (EMRs) and radiology consultants (RCs) in multiple trauma patients. Method: This diagnostic accuracy study was conducted prospectively in patients presenting over a period of 12 months from January 1, 2013, to December 31, 2013 to the ED of Kerala Institute of Medical Sciences (KIMS), Kerala, India. All multiple trauma patients older than 18 years of age presenting within 24 hours of their traumatic event, who underwent both e-FAST and thoracoabdominal computed tomography (CT) scan were included. The e-FAST exams were first performed by the EMRs and then by RCs. The thoracoabdominal CT scan findings were considered as the gold standard. The results were compared between both groups to assess the inter-observer variability. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated both for EMRs and RCs. Results: In the study period, 150 patients with a mean age of 42.06 ± 18.1 years were evaluated (76.7% male). Only 19 cases (12.7%) had a history of fall from a height, and the others were admitted due to RTA. Thirty-four cases (22.7%) did not require surgery; but the others underwent various interventions. Both EMRs and RCs reported positive findings in 20 cases (13.3%) and negative findings in 130 cases (86.7%). The correlation of e-FAST done by EMRs with that by RCs was 100%. E-FAST exam had a sensitivity of 90.4%, specificity 99.2%, PPV 95.0%, NPV 98.4%, and accuracy 98%, both for EMRs and RCs. Conclusion: Based on the findings, the sensitivity, specificity, and accuracy of e-FAST exams performed by EMRs were equal to those performed by RCs. It seems that e-FAST performed by EMRs were almost accurate during the initial trauma resuscitation in the ED of a level one trauma center in India
Gender-Based Violence Causing Severe Multiple Injuries; a Case Report
Get PDFIntroduction: Gender-based violence (GBV) against women has been identified as a global health and development issue. We reported a case of GBV causing sever, multiple injuries in a middle-aged female. Case report: A 47-year-old woman presented to emergency room with disturbed level of consciousness, shortness of breath and multiple patches of skin discoloration. On examination, the patient was semi-conscious, with multiple ecchymosis and bilateral decreased air entry. Computed tomography scan of the neck and chest showed six rib fractures on the left side, and eight rib fractures on the right side, sternal fracture, manubriosternal dislocation, bilateral hemothorax, fracture of body of eleventh thoracic vertebra, and fracture of cervical spine of fifth and seventh vertebrae. The patient was intubated and admitted to intensive care unit. She was discharged with good health condition after 23 days of hospital admission. Conclusion: GBV is still a cause of severe trauma that puts the patient’s life at risk
Correlation of Patients’ Baseline Characteristics with Success Rate of Cardiopulmonary Resuscitation; a Cross-Sectional Study
Get PDFIntroduction: Many advances have been made in method, applied medications and the skill of the treatment staff for performing cardiopulmonary resuscitation (CPR), yet the rate of mortality following cardiac arrest is still high, which is affected by many factors. Objective: This study was designed and performed aiming to evaluate the effective factors in the success rate of CPR. Method: This cross-sectional study was performed on patients who had undergone CPR in Dr. Shariati Hospital, Isfahan, Iran, from March 2017 to March 2018. A pre-designed checklist was used for data gathering, which included questions regarding demographic data and medical history of the patients, data related to CPR and the final outcome of resuscitation. Results: A total of 190 patients with the mean age of 69.4±17.7 years were evaluated in the present study, 115 (60.5%) of which were male. Overall, 28.9% of CPRs were initially successful and 5.3% of the cases were finally discharged from the hospital. There was no significant correlation between CPR success and age, sex, hospitalization ward, time interval between hospitalization and cardiac arrest, the number of CPR attempts, or working shift (p > 0.05). On the other hand, CPR success significantly correlated with underlying illnesses and the first cardiac rhythm recorded before the initiation of resuscitation (p < 0.05). Conclusion: Based on the findings of the present study, it seems that underlying illness and the initial cardiac rhythm recorded correlate with the probability of CPR success
Upper Gastrointestinal Bleeding as Delayed Presentation of Traumatic Diaphragmatic Hernia: a Case Report
Get PDFIntroduction: Traumatic diaphragmatic hernia (TDH) is one of the critical complications resulting from penetrating chest trauma. The rate of undiagnosed TDH equivocates 12-60%. The significant part of complications happens 1-4 years after the primary damage. Here, we report a case of delayed TDH presented with upper gastrointestinal bleeding (GIB) as an excuse to discuss this issue. Case presentation: The patient was a 35-year-old man, admitted with objection of abdominal pain. A nasogastric tube was inserted and fixed that resulted in drainage of about 500cc dark blood. He was candidate for emergent endoscopy due to upper GIB. During resuscitation measures, he suddenly developed respiratory distress that could not be justified by upper GIB alone. Therefore, bedside sonography discovered some soft tissue apart from lung tissue in the left hemithorax. After performing diagnostic measures, with diagnosis of diaphragmatic herniation and strangulation he underwent emergent surgery. Conclusion: Small diaphragmatic lesions, which usually result from stab wounds, may develop into larger injuries if left untreated and they might lead to a diaphragmatic hernia with a potential risk of early or late complications and mortality. One of the rare complications is GIB, which should be considered in a patient with past history of trauma and presentation of GIB
To Head CT Scan or Not: The Clinical Quandary in Suspected Subarachnoid Hemorrhage; a Validation Study on Ottawa Subarachnoid Hemorrhage Rule
Get PDFIntroduction: The Ottawa Subarachnoid Hemorrhage rule (OSR) is a clinical decision tool identified for ruling out subarachnoid hemorrhage (SAH) in those patient above 15 years of age who present to the emergency department (ED) with acute onset atraumatic headache. Objective: The primary objective of this study was to externally validate the OSR in a single national health service (NHS) setting in the UK and secondly, to compare it with our current practice without using a decision rule. Method: A retrospective review of computerized medical records was done for all patients registered with headaches from January to December 2016. The data were manually charted on a data sheet from individual patient records. Patients fulfilling the preset inclusion and exclusion criteria as per the OSR were enrolled in the analysis. According to the OSR, if patient had any of the 6 criteria enlisted (age > 40 years, neck stiffness/pain, witnessed loss of consciousness, onset during exertion, thunderclap headache, limited neck flexion on examination), further diagnostic decision was required. All patients were followed up for 6 months on the computer system as it gets highlighted if the patient is represented again to the ED or is deceased. Results: A total of 737 ED visits with acute headache were reviewed for potential eligibility. Out of these, 649 were estimated to be eligible. On excluding 485 patients that could not meet the predetermined inclusion criteria and 19 patients as per the exclusion criteria, 145 (19.7%) patients were included in the analysis. There were 5 cases of SAH, yielding an incidence of 3.4 % (95% CI 1.3 % – 8.3 %). The sensitivity for SAH was 100% (95% CI, 46.3 % - 100 %); specificity of 44.2 % (95% CI, 36 % - 53 %); positive predictive value of 6.02 % (95% CI 2.2 % - 14.1 %); and negative predictive value of 100% (95% CI, 92.7 % - 100%). Conclusion: Although being poorly specific, the OSR is a highly sensitive, simple tool for ruling out SAH in alert patients with a headache in ED settings
Pituitary Macroprolactinoma with Mildly Elevated Serum Prolactin: Hook Effect
Get PDFA 45-year-old man was admitted in our department with complaints of severe headache for over 6 months period. He also suffered from several problems such as visual field defect, decreased energy and libido, body hair loss, cold intolerance, decreased appetite and dry skin. On physical examination, he was afebrile: BP (blood pressure): 110/70 mm/Hg, PR (pulse rate) :65 beat/min, BMI (body mass index): 24. He had no terminal hair on face or chest and subcutaneous adipose tissue mass had been decreased substantially. Laboratory tests revealed; Hb: 12 g/dL (N: 14–17 g/dL), Total testosterone: 1.2 ng/mL (N:–-10 ng/mL), Luteinizing hormone (LH):3.3MIU/mL (N:1–8 MIU/mL), Follicle Stimulating hormone (FSH):1.3 MIU/mL (N:1–7 MIU/mL), T4:3.4 micg/dL (N:4–12 micg/dL), TSH:0.6 MIU/mL (N:0.5–5 MIU/mL), Prolactin:100 ng/mL (2–24 ng/mL), serum cortisol:6 MIU/mL (N:4–21 MIU/mL), IGF1:162 ng/mL (50–245). Pituitary MRI showed macroadenoma (29*16*14 mm) in left side of sella turcica which bulged to suprasellar cistern with pressure effect on left optic nerve (Figure 1, 2). Visual field examination revealed mild temporal hemianopia. These findings are consistent with macroadenoma and mild prolactin elevation. We also observed a discrepancy between pituitary tumor size and prolactin level. The correct estimate of serum prolactin was obtained after serial dilutional measurement. Serum prolactin after dilution was 6470 ng/mL. With these findings pituitary macroadenoma was diagnosed and treatment with cabergoline (dopamine agonist) 0.5 mg/week was started. After one month follow-up he had no symptoms, visual field defect was improved and pituitary MRI showed significant shrinkage of tumor
An Interesting Case of Isolated Pancreatic Transection Following Blunt Abdominal Trauma in Emergency Department
Get PDFIntroduction: Traumatic injury to the pancreas is not common, but if the diagnosis is delayed or misdiagnosed in the emergency department (ED), the condition is associated with high morbidity and mortality and raises a question about the quality of emergency care. Here, we describe a rare case of blunt abdominal trauma resulted in isolated pancreas injury. Case presentation: A 25-year-old young male came to our emergency room (ER) in a conscious, anxious state from a nearby town with a history of roadside trauma. Further investigations revealed an isolated pancreatic injury due to trauma with no other major injuries, which occurred due to a sudden high-speed impact of the steering wheel to the epigastrium of a driver while driving the car, severely compressing the pancreas between the backbone and steering wheel. The patient was admitted to the intensive care unit for close observation and monitoring. He was managed conservatively on intravenous fluids, antibiotics, analgesics, and vasopressors. He was discharged after five days in a hemodynamically stable and afebrile condition, on a normal diet. Conclusion: Isolated pancreatic injury following blunt abdominal trauma is rare, and the symptoms are difficult to analyze early due to its retroperitoneal anatomy. Early detection and early intervention are important in the ED, and if left unrecognized, could result in a poor outcome
Emergency Department Patient Satisfaction Assessment using Modified Servqual Model; a Cross-sectional Study
Get PDFIntroduction: The quality of medical services and attention paid to patients in medical centers have been concerning for healthcare providers. Objective: The present study was designed to identify factors affecting patient satisfaction with medical service in the emergency department (ED). Method: This was a cross-sectional study conducted in spring 2016 in Imam Khomeini Hospital, Jiroft, Iran. Patients aged more than 18 years presenting to the ED with a minimum stay of 24 hours were included. Unwillingness to take part, incomplete questionnaires, or unavailability for an interview were considered the exclusion criteria. Data were collected using a 24-item researcher-made questionnaire based on Servqual quality measuring tool with five components of tangibles, reliability, responsiveness, assurance, and empathy. Results: The present study recruited 373 patients with the mean age of 41.7±21.8 years (minimum 18 and maximum 79 years), of whom, 67.1% were men. Mean scores indicate the level of patient satisfaction with the hospital service ranging from relatively satisfied to totally satisfied. The components ranking in improving patient satisfaction were as follows: tangibles 4.59, assurance 2.77, reliability 2.74, responsiveness 2.57, and empathy 2.33. Conclusion: Of the components assessing the patient satisfaction, tangibles were the most effective component and empathy was the least effective one