Advanced Journal of Emergency medicine
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Diagnostic Accuracy of Focused Assessment with Sonography for Blunt Abdominal Trauma in Pediatric Patients Performed by Emergency Medicine Residents versus Radiology Residents
Get PDFIntroduction: Focused assessment with sonography for trauma (FAST) has been shown to be useful to detect intraperitoneal free fluid in patients with blunt abdominal trauma (BAT). Objective: We compared the diagnostic accuracy of FAST performed by emergency medicine residents (EMRs) and radiology residents (RRs) in pediatric patients with BAT. Method: In this prospective study, pediatric patients with BAT and high energy trauma who were referred to the emergency department (ED) at Al-Zahra and Kashani hospitals in Isfahan, Iran, were evaluated using FAST, first by EMRs and subsequently by RRs. The reports provided by the two resident groups were compared with the final outcome based on the results of the abdominal computed tomography (CT), operative exploration, and clinical observation. Results: A total of 101 patients with a median age of 6.75 ± 3.2 years were enrolled in the study between January 2013 and May 2014. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. A good diagnostic agreement was noted between the results of the FAST scans performed by EMRs and RRs (κ = 0.865, P < 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy in evaluating the intraperitoneal free fluid were 72.2%, 85.5%, 52%, 93.3%, and 83.2%, respectively, when FAST was performed by EMRs and 72.2%, 86.7%, 54.2%, 93.5%, and 84.2%, respectively, when FAST was performed by RRs. No significant differences were seen between the EMR- and RR-performed FAST. Conclusion: In this study, FAST performed by EMRs had acceptable diagnostic value, similar to that performed by RRs, in patients with BAT
Sample Size Calculation Guide - Part 1: How to Calculate the Sample Size Based on the Prevalence Rate
Get PDFSample size calculation is an essential methodological issue in clinical research. It is crucial to ensure that the study has sufficient participants in order to detect the expected effect estimate. Moreover, it has been advocated that the underpowered clinical trials lead to wastage of time, money, and resources, and are not ethical as they do not generate expected results and expose the patients to a higher risk. Considering the importance of this methodological point, we shall commence the research methodology section of the Advanced Journal of Emergency Medicine with a series of educational letters explaining the method to calculate the sample size for various clinical research study designs. For more illustration, each educational note will be accompanied by a real-life example from the published articles in emergency medicine research. This is the first article of our educational series where we have explained the sample size calculation based on a prevalence rate
The Cost Analysis of Patients with Traffic Traumatic Injuries Presenting to Emergency Department; a Cross-sectional Study
Get PDFIntroduction: Road traffic traumatic injuries are the leading cause of death especially among young men who are mostly vulnerable victims. This catastrophe is more complicated in low to middle income countries. Objective: This study assessed the financial costs of traffic casualties in Iran. Method: One thousand trauma patients presenting to the emergency department of Shohaday-e-Tajrish Hospital were included in the study. The prehospital and hospital costs as well as the expenses of physiotherapy, rehabilitation, outpatient visits and further surgical interventions were considered as direct expenses. The costs of productivity loss were estimated as indirect expenses. Results: The direct and indirect costs were assessed 27.4% and 72.6% of total, respectively. The mean age of permanent disability was 43 years old. The average expenses of temporary and permanent disabilities were 2934.4 million rials (nearly 4.2 million rials per patient) and 23.9 billion rials (1.1 billion rials per person), respectively. Conclusion: The national burden of traffic injuries in Iran is significantly destructive as it consists of 2.19 % of Gross Domestic Product annually. Besides, young men are involved in most of the traffic accidents representing the need to establish rigorous preventive instructions and reduce human, and financial costs
Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study
Get PDFIntroduction: Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients’ flow in the ED is termed triage. Objective: This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%. Method: This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients’ charts, an expert panel evaluated the validity of the triage level. Results: During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel’s evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen’s weighted kappa being 0.966 (CI 0.985–0.946, p < 0.001) and 0.813 (CI 0.856–0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen’s weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001). Conclusion: The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses
Non-ST-Elevation Myocardial Infarction in a Case of Von Willebrand Disease: a Case Report
Get PDFIntroduction: Studies have shown that patients with Von Willebrand disease (VWD) have decreased prevalence of thrombotic events like myocardial infarction (MI). Here we describe a case of VWD with acute non-ST-elevation MI with ongoing bleeding manifestations. Case presentation: A 37-year-old female patient presented to the emergency department with a complaint of central chest pain since 7 days. She also had a history of hemoptysis since 8 days. Electrocardiogram (ECG) revealed ST-segment depression in leads I, aVL, II, III, aVF, and V4-V6 compatible with diagnosis of Non-ST-Elevation Myocardial Infarction (Non STEMI). She was started on nitroglycerine infusion, angiotensin II receptor blockers, and calcium channel blockers along with trimetazidine. Her chest pain and ECG changes settled after 2 days, and she was discharged in a stable condition. Conclusion: There are limited studies available regarding the management of acute MI in VWD patients with acute bleeding manifestations. Further studies have to be carried out to determine successful ways of managing thrombotic events like MI in this subset of patients
Current Medical Journalism Needs Major Revisions
Get PDFMedical journalism commenced during early nineteenth century as an impressive adjunct for medical education. It is considered as a platform to share the results of the research studies and to disseminate medical information that could impact the present concept and practice of the medicine field. Medical journalism gained immense attention over the years; however, the present scenario revealed certain limitations.
A rise in the number of researchers, by interest or forcefully, has led to an increase in the journal count, resulting in several fake research articles being published in the journals. This leads to inappropriate research and low quality of journals, where the data appearing in the research articles is not authentic; thus, the journals publishing such articles face several issues while verifying the authenticity of the data provided.
All journals, in particular, the recent ones strive to achieve immense importance in regards to the impact factor, h-index, and similar quality assessments; however, attaining similar scores as that of the well-known journals is impossible. Hence, as a futile effort, the editorial team of the new or latest journals consider adding more references in their articles in order to achieve a higher score; however, certain references from the previously published papers, may decode as a conflict of interest.
Based on an unwritten and unavailable rule, all new journals try to publish papers in same format as publishing in famous journals, and do not dare to deconstruct it. It seems that deconstruction should also be performed by the old journals founded the current style!
In order to avoid the aforementioned issues, the Advanced Journal of Emergency Medicine emerged with the concept of being different, deconstructive, and without any futile competition with the other journals. Accordingly, we consider a large audience with several degrees of medical education to participate in the field of research, make the journal a unique one aim to augment of medical education through medical research charm.
To the best of our knowledge, at present, we do not have appropriate solutions to aforementioned problems. We request the authors, directors, and editorial members of the journals to have a detailed discussion on this topic, and we are ready to publish articles on the topic that is briefly discussed in this article
Flight Attendant’s Perspective on the Medical Professional’s Presence During In-Flight Cardiopulmonary Resuscitation
Get PDFAbout 95% of the two billion airlines passengers suffered from health issues (1). Furthermore, a call center in North Carolina noted that there were 16 in-flight emergency cases for every 1 million airlines passengers (2). Cardiac arrest is one of these cases, which is a cause for mortality for about 1000 people during the flights (3). Cardiopulmonary resuscitation (CPR) can be demonstrated by the medical professionals or trained people such as flight attendants. Commercial flights usually do not have official medical staffs on board. Hence, whenever there are in-flight medical emergency cases, flight attendants should be trained to manage such cases. Flight attendants themselves are laymen who are trained to do basic medical emergency interventions, that is, even if they intervene in such cases, they cannot take an appropriate decision as the medical professionals.
During in-flight cardiac arrest, the flight attendants are mainly responsible to immediately contact the ground staff and voluntary medical professionals on board; besides, they also have a right to perform CPR (4). Certain airlines such as Air Canada and Scandinavian Airlines have policies related to medical supervision. They apply emergency telemedicine that involves emergency specialists as the commander (5). Furthermore, the specialists will assign some instructions for the flight attendants who manage the in-flight medical emergencies (5). In contrast, in Indonesia, in case of any in-flight medical emergency, the flight attendants would announce on call asking for the presence of any medical professionals on board; however, no official medical professionals are recruited on board by the airlines for any medical casualties or emergency.
Attendant expressed that the rescuer had many senses while helping people with in-flight medical emergency like shocked while looking at the victim. Contrary, the rescuer also determined to take her responsibility as a cabin crew by helping the victim. Furthermore, she had to manage her dilemma before doing that.
The flight attendant has already expressed her suggestion on having in-flight medical professionals so that she can focus on her responsibility as a cabin crew. NBAA (2016) declares that commercial airlines are suggested to make policies that involve medical professionals in managing in-flight medical emergency (6). These will make flight attendants feel comfortable in serving the passengers. Consequently, the flight attendant needs medical companionship while performing CPR on board. Hence, in-flight medical emergency management, which is part of prehospital management, can be guarantee
A Case of Cerebral Venous Sinus Thrombosis Presenting with Delirium
Get PDFA 73-year-old woman with no history of headache, seizure and trauma was admitted to the emergency department complaining about fever, vomiting and delirium for 3 days. She was lethargic upon admission and her blood pressure (BP) was recorded as 140/90 mm/Hg, her pulse rate (PR) as 75 beat/min and oral temperature as 38 °C. No localizing findings were observed in neurological examinations. Laboratory findings were as follows: White Blood Cell (WBC) count: 7,000/mm3, Hemoglobin: 13 g/dl, Platelet count: 300000. Lumbar CSF, blood and urine cultures were found to be negative for infections. Brain Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) were also performed. MRI showed filling defects in the left transverse sinus, the jugular bulb and the internal jugular vein. Moreover, hyper-intense signal was observed in the left temporal lobe (T1 sequence) suggesting hemorrhagic venous infarction (Figure1). The obtained results were confirmed by Magnetic Resonance Venography (MRV) of the brain (Figure2). The patient underwent anticoagulation therapy using LMWH and she was? hydrated using physiologic solution. The patient’s symptoms disappeared and she was then followed up regularly
Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles
Get PDFContext: The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods. Evidence acquisition: This review was conducted by searching “Violence,” “Aggression,” and “workplace violence” keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review. Results: Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint. Conclusion: In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients
Intranasal Ketamine Administration for Narcotic Dose Decrement in Patients Suffering from Acute Limb Trauma in Emergency Department: a Double-Blind Randomized Placebo-Controlled Trial
Get PDFIntroduction: pain management is an important and challenging issue in emergency medicine. Despite the conduct of several studies on this topic, pain is still handled improperly in many cases. Objective: This study investigated the effectiveness of low-dose IN ketamine administration in reducing the need for opiates in patients in acute pain resulting from limb injury. Method: This randomized, double-blind, placebo-controlled trial was conducted to assess the possible effect of low-dose intranasal (IN) ketamine administration in decreasing patients' narcotic need. Patients in emergency department suffering from acute isolated limb trauma were included. One group of patients received 0.5 mg/kg intravenous morphine sulfate and 0.02 ml/kg IN ketamine. The other group received the same dose of morphine sulfate and 0.02 ml/kg IN distilled water. Pain severity was measured using the 11 points numerical rating scale at 0, 10, 30, 60, 120, and 180 minutes. Results: Ninety-one patients with mean age of 31.59 ± 11.33 years were enrolled (38.8% female). The number of requests for supplemental medication was significantly lower in patients who received ketamine (12 patients (30%)) than those who received placebo (27 patients (67.5%)) (p = 0.001). Conclusion: It is likely that low-dose IN ketamine is effective in reducing the narcotic need of patients suffering from acute limb trauma