Frontiers in Emergency Medicine (E-Journal)
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Facilitating the Diagnostic Process of the Patients with Complaint of Acute Limb Swelling in Emergency Room; a Brief Report
Get PDFIntroduction: Limb swelling is among the frequent complaints of patients referring to the emergency room (ER). Objective: We decided to take a step towards facilitating the diagnostic process of patients who refer to ER with such complaint, and find out whether emergency medicine physicians (EMPs) can play an effective role in this regard. Methods: This was a diagnostic accuracy study in which all patients who referred to the ER with a complaint of unilateral leg swelling were studied. The patients underwent bedside sonography by the researchers, who were emergency medicine physicians (EMPs), and also underwent a second sonography by the in-charge radiologist using the same device and probe. The accuracy of the diagnoses made by researchers was evaluated using the radiologists’ opinion as the gold standard. Results: In this study, the data of 52 patients were analyzed. In general, the agreement rate between the EMPs and radiologists was 0.863, which indicates a proper agreement. Based on the findings, Kappa agreement for the four differential diagnoses ranged from 0.639 to 0.919 and the AUC was between 0.750 and 0.976. Conclusions: In this study, the overall agreement between the EMPs and radiologists was appropriate
Seven Criteria of Severe COVID-19 (SCSC): A New Pre-Hospital Prognostic Scoring Tool Suggested for Screening of Probable/Confirmed COVID-19 Patients with Severe Outcomes
Get PDFIntroduction: COVID-19 pandemic led to various consequences in medical care that had been long provided for the patients referred to the hospitals. Objective: We conducted this study to derive and validate a new scoring system that can accurately differentiate COVID-19 patients who may have a worse outcome from others at the prehospital stage. Methods: This study was performed on probable/confirmed COVID-19 patients, who were transferred to the hospitals by Tehran emergency medical services (EMS). Occurrence of one of the items including: in-hospital death, intensive care unit (ICU) admission, or hospitalization for more than 20 days was considered to indicate a “severe disease”. Univariate and multivariate logistic regression were used for assessment of the relationship between all independent variables and the outcome. In the validity assessment step, area under the receiver operating characteristic (ROC) curve was calculated for a data set independent from the data based on which the model was designed. The sensitivity and specificity were also presented based on the best suggested cut-off point. Results: In this study, the data of 557 cases were analyzed in the derivation step and 356 cases were assessed in the validation step. The univariate logistic regression showed that age, weakness and fatigue, disease history, systolic blood pressure, SpO2, respiratory rate, and Glasgow coma scale (GCS) were statistically significant in severe disease group. The area under the ROC curve (AUC-ROC) of the tool was 0.808 (95% CI: 0.779, 0.834). The best cut-off point for screening was the score of ≥4, in which the sensitivity and specificity of the tool for the best cut-off point were 71.87% and 78.06%, respectively. In the validation step, the AUC-ROC of the tool was 0.723. Conclusions: Seven criteria of severe COVID-19 (SCSC) tool could properly differentiate probable/confirmed COVID-19 patients with severe outcomes in the pre-hospital stage
The Role of Respiratory System Surface Area and Ventilation Volume in Severity and Mortality of COVID-19 Infection
Get PDFAccording to epidemiologic and analytic studies of different countries during coronavirus disease 2019 (COVID-19) pandemic, high prevalence of the disease, more hospitalization, getting a more severe form of the disease, diffused peripheral distribution of opacities, more need to receiving ICU care, poor prognosis, and high mortality rate in men compared with women were obtained. The causes of the above gender differences in subsequent studies were attributed to several factors including behavioral use of masks or handwashing, as well as genetic, hormonal, and immunological factors. Also in the past epidemiologic studies, a higher prevalence of severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS) among men was shown than women. Despite the lack of accurate statistical studies, some evidence shows high severe COVID-19 incidence and mortality rate in athlete’s society compared with non-athletes. Respiratory sex-related differences in women include smaller lung volumes, smaller-diameter conducting airways, smaller radial rib cage dimensions, shorter diaphragm, and fewer lung function parameters such as ventilation volume. Originally and typically, athletes have high lung volumes and capacities such as forced expiratory volume in 1 second (FEV1), especially high ventilation volume. It is well-known that in COVID-19 infection, the main route of transmission is respiratory droplets and direct contact with infected people. Hence, this hypothesis is raised that higher lung ventilation volume ratio of men than women and athletes than non-athletes may be the major reason for the difference of COVID-19 infection based on sex. In other words, in the same condition, men expose more viral load than women, also athletes receive more viral load than non-athletes. Viral load is a critical parameter in the severity and mortality of COVID-19 infection. The offered hypothesis may recognize a potential approach in future studies and investigations of COVID-19 infection. Confirmation of this theory in comer studies may update health advice and improve precaution recommendations between athletes and non-athletes as well as men and women based on the surface area of the respiratory system
Demographic information and risk factors of stroke patients younger than 65 years old
Get PDFObjective: The main objective of this study is to evaluate the prevalence of risk factors for and demographics ofpatients younger than 65 years old with stroke. Methods: This retrospective cross-sectional study took into consideration all patients younger than 65 years old who were admitted to the emergency department from 2016 to 2018. Some significant criteria such as age, sex, type of stroke, stroke risk factors, and modified Ranking Scale (mRS) were extracted from patients’ medical records. Based on their age, these patients were divided into three groups: younger than 35 years old (Group A), between 35-50 years old (Group B), and older than 50 years old (Group C). Data analysis was carried out using IBM® SPSS® Statistics 20.0 software. Results: A total of 392 patients with stroke were included in this study. Groups A, B, and C included 31, 124, and 237 patients, respectively. Among them, 313 patients (79.84%) were admitted to the hospital in cold seasons, while 73 patients (18.6%) had no symptoms related to stroke at the time of admission. The most common adjustable risk factor among the patients was hypertension (HTN) with a frequency of 230 (58.7%). Of note, the frequency of HTN, diabetes, atrial fibrillation (AF), oral contraceptive pill (OCP) consumption, and coronary artery disease (CAD) in patients was significantly different among these three groups. Conclusion: According to the findings of the present study, the prevalence rate of stroke probably varies for male and female (gender) in the studied groups, which is significantly correlated with age. Among the adjustable risk factors for stroke, HTN, diabetes, AF, OCP consumption, and CAD are significantly correlated with the age
COVID-19 related hospitalization costs; assessment of influencing factors
Get PDFObjective: Our aim is to assess the effective factors on hospitalization costs of COVID-19 patients. Methods: Data related to clinical characteristics and cost of hospitalized COVID-19 patients from February 2020 until July 2020, in a public teaching hospital in Tehran, Iran was gathered in a retrospective cohort study. The corresponding factors influencing the diagnostic and therapeutic costs were evaluated, using a generalized linear model. Results: The median COVID-19 related diagnostic and therapeutic costs in a public teaching hospital in Iran, for one hospitalized COVID-19 patient was equal to 271.1 US dollars (USD). In patients who were discharged alive from the hospital, the costs increased with patients’ pregnancy (P<0.001), loss of consciousness during hospitalization (P<0.001), a history of drug abuse (P=0.006), history of chronic renal disease (P<0.001), end stage renal disease (P=0.002), history of brain surgery (P=0.001), history of migraine (P=0.001), cardiomegaly (P=0.033) and occurrence of myocardial infarction during hospitalization (P<0.001). In deceased patients, low age P<0.001), history of congenital disease (P=0.024) and development of cardiac dysrhythmias during hospitalization (P=0.044) were related to increase in therapeutic costs. Conclusion: Median diagnostic and therapeutic costs in COVID-19 patients, hospitalized in a public teaching hospital in Iran were 271.1 USD. Hoteling and medications made upmost of the costs. History of cardiovascular disease and new onset episodes of such complications during hospitalization were the most important factors contributing to the increase of therapeutic costs. Moreover, pregnancy, loss of consciousness, and renal diseases are of other independent factors affecting hospitalization costs in COVID-19 patients
Comparison of Video Laryngoscopy and Direct Laryngoscopy in the Success of Intubation Performed by Novice Personnel in Patients with Cervical Immobilization: A Manikin Study
Get PDFIntroduction: Pre-hospital intubation is a challenging but essential intervention. During intubation, it is difficult to identify vocal cords when using a cervical collar and trauma board. Therefore, the success rate of intubation by paramedics decreases in trauma patients. Video laryngoscopy increases intubation success rate and has been recommended for difficult airways in studies. Objective: In this study, we compared the intubation success rates when using a video laryngoscope and a direct laryngoscope in a manikin with simulated cervical immobilization. Methods: In this cross-sectional study, the manikin’s neck collar and spine board created a complicated airway model with cervical immobilization. Inexperienced paramedic students tried intubation with both methods, and their trial periods were recorded. Students answered a question evaluating the convenience of the procedure for both methods after the trial. Results: In this study, 83 volunteers, who were first-year and second-year paramedics, participated; 32 (38.6%) of the volunteers were first-year students, while 51 (61.4%) were second-year students. All volunteers had previous intubation experience with direct laryngoscopy, but not with video laryngoscopy. There was a statistically significant difference in the first-attempt success rates of the procedure between the groups in favor of video laryngoscope (p=0.022). Note that there was no significant difference between the groups in terms of first attempt durations (p=0.337). Conclusion: Video laryngoscopy in airway management can increase the success rate of first-attempt intubation by inexperienced pre-hospital healthcare personnel
Brachial plexus injury following blunt trauma; an anatomical variation in electrodiagnostic findings
Get PDFDamage to the brachial plexus branches is one of themost important events during traumatic events, whichmaycause various disabilities. Electrodiagnostic testing is the preferred method to evaluate the extent of damage tothe brachial plexus following trauma. The case presented in this paper, is a 26-year-old man who had nearnormal function of pronator teres and flexor carpi radialis muscles on electrodiagnostic testing following a rightupper limb severe blunt injury at the level of his arm. After surgical investigation, we found a rare variationin the proximal part of the median nerve. In this case, branches to the pronator teres muscle and flexor carpiradialis had emerged from the proximal section of themedian nerve in the armregion. This new variation holdsimportant clinical implications especially in trauma patients presenting with weakness in forearmflexion
Comparison of the effectiveness of ondansetron versus metoclopramide in hyperemesis gravidarum: a randomized clinical trial
Get PDFObjective: Nausea and vomiting are the most common complications and the first cause of hospitalization of pregnant women in the first trimester of pregnancy. Given the maternal and fetal complications as well as the negative psychosocial and economic effects of nausea and vomiting, the present study aimed to compare the antiemetic effects of ondansetron and metoclopramide. Methods: The present double-blind randomized clinical trial study was conducted on 153 pregnant women with a complaint of nausea and vomiting during pregnancy referred to the obstetrics and gynecology ward. Patients were randomly divided into two metoclopramide and ondansetron groups. The outcomes of interest were nausea and vomiting, the number of used doses of the drug, and the length of hospital stay. The Pregnancy-Unique Quantification of Emesis (PUQE) questionnaire was used to assess the severity of nausea and vomiting. Results: The mean age was significantly higher in the metoclopramide group (28.44±6.45 vs. 25.43±5.42 years, P=0.004). On day 3, the PUQE score was significantly higher in the ondansetron group (6.60±1.10 vs. 6.56±0.88, P<0.001). The decrease in the severity of nausea and vomiting was significantly higher in the ondansetron group (5.29±1.35 vs. 4.90±1.17, P=0.05) in the second day compared to the first day. In the repeated measure analysis, significant differences were found between the two treatment groups (F=7.01, P=0.009). There was no significant difference between the two groups in terms of the length of hospital stay (P>0.05). Conclusion: In this study, ondansetron revealed more efficacy than metoclopramide on the nausea and vomiting of pregnancy (NVP) management. Ondansetron may, therefore, be considered as a safe and effective alternative for metoclopramide in the treatment of NVP
An interesting case of an atraumatic painful swollen limb in a pregnant woman
Get PDFPhlegmasia cerulea dolens is an uncommon complication of deep venous thrombosis. This is associated with high rates of morbidity if not treated effectively. We present a young lady 13 weeks pregnant with one-day history of left lower limb swelling with pain and discolouration. Bedside ultrasonography revealed thrombosis occluding the common femoral vein and collateral femoral vein. She had history of neonatal alloimmune thrombocytopaenia (NAIT), and had immunotherapy previously. The safest option was to give low molecular weight heparin (LMWH) on an inpatient basis. Anticoagulation with LMWH has been well established as thromboprophylaxis during pregnancy, however, the safety profile of systemic anticoagulation is matter of debate. As highlighted in this scenario the management needs to be tailored on an individual basis. The cause for the extensive deep vein thrombosis could be possibly due to the recent immunoglobulin therapy, undiagnosed prothrombotic state (outwith pregnancy) or the procoagulant state associated with pregnancy
Patient Safety Culture in Emergency Departments of Yemeni Public Hospitals: A Survey Study
Get PDFIntroduction: Quality and safety is an important challenge in healthcare systems all over the world particularly in developing parts. Objective: This survey aimed to assess patient safety culture (PSC) in emergency departments (EDs) in Yemen and identify its associated factors. Methods: A questionnaire containing the Hospital Survey on Patient Safety Culture (HSOPSC) was distributed to ED physicians, nurses, and clinical, and non-clinical staff at three public teaching general hospitals. The percentages of positive responses on the 12 patient safety dimensions and the summation of PSC and two outcomes (overall patient safety grade and adverse events reported in the past year) were assessed. Factors associated with PSC aggregate score were analyzed. Results: finally, out of 400 questionnaires, 250 (64%) were analyzed. In total, 207 (82.3%) participants were nurses and physicians; 140 (56.0%) were male; 134 (53.6%) were less than 30 years old; and 134 (53.6%) had a university degree. Participants provided the highest ratings for the “teamwork within units” PSC composite (67%). The lowest rating was for “non-punitive response to error” (21.3%). A total of 120 (48.1%) participants did not report any events in the past year and 99 (39.7%) gave their hospital an “excellent/very good” overall patient safety grade. There were significant differences between the hospitals’ EDs in the rating of “handoffs and transitions” (p=0.016), “teamwork within units” (p=0.018), and “frequency of adverse events reported” (p=0.016). Staff working in intensive care units (8.4%, n=21) had lower patient safety aggregate scores. Conclusions: PSC ratings appear to be low in Yemen. This study emphasizes the need to create and maintain a PSC in EDs through the implementation of quality improvement strategies and environment of transparency, open communications, and continuous learning