Frontiers in Emergency Medicine (E-Journal)
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Three Tier Screening Tool and Second Triage to Minimize the Spread of COVID-19 in Emergency Department of a Tertiary Hospital in India
Get PDFIntroduction: Since the outbreak of Coronavirus on December 31, 2019 in Wuhan, Hubei Province, People’s Republic of China, the number of cases from China that have been imported into more than 180 countries and regions around the world. Objective: The goal of this study is to flatten the curve of new infection, through nosocomial transmission by health care system along with early identification of asymptomatic COVID-19 cases. Methods: A Survey was conducted over a period of 35 days. A total of 1709 individuals were screened (647 patients and 1062 patient attendees) coming to emergency Department. The waiting area of Emergency Care was divided into 3 screening zones and a separate second triage is established. The individuals entering are ensured that they are screened at all the 3 zones. Individuals were divided into two Groups after screening: Group A (suspected COVID-19) and Group B (unsuspected COVID-19). In Acute emergencies, the patient was directly treated at second triage. Results: A total of 1709 individuals, 247 in Group A (Suspected COVID-19) and 1462 in Group B (Unsuspected COVID-19). Among 247 individuals, 141 were males and 106 were females. Age ranged from 14-72 years with a mean age of 46.7years. Among 247 individuals (Group A), 81 were patients, of which one case was found to be COVID-19 Positive. Two Health care workers (HCW’s) found to be positive. Conclusion: Challenges from the widespread pandemic underscores the importance of early implementation of a second triage and vigorous screening for all the individuals to minimize the spread of infection, failing which pandemic infection may turn into an epidemic
Evaluation of Mother and Fetus after a Traumatic Event: An Overview
Get PDFTrauma due to accidents or violence is a common complication during pregnancies. Every woman in reproductive age who has been admitted due to trauma should be considered pregnant until proven otherwise. A multidisciplinary approach is usually warranted to optimize the outcome for both the mother and her fetus and some headlines should always be taken into consideration when dealing with a pregnant trauma patient. In major trauma, obstetrician consultation should be done as soon as possible. You should not delay indicated radiographic studies due to concerns regarding fetal exposure to radiation. It is preferable to perform one computed tomography (CT) scan with iodinated contrast rather than multiple suboptimal imaging procedures without contrast. Physiologic changes during pregnancy put injured pregnant woman at increased risk, necessitates special attention. In this paper we try to overview on some important aspects of a pregnant trauma patient management
Lung Ultrasound Findings Compared to Chest CT Scan in Patients with COVID-19 Associated Pneumonia: A Pilot Study
Get PDFIntroduction: Lung US has been reported to be as useful as a chest CT scan and much better than a chest x-ray for the evaluation of pneumonia. Objective: This study aimed to compare the findings of lung ultrasound (US) and chest CT scan of patients with COVID-19-associated pneumonia in the Emergency Department (ED). Methods: This retrospective observational pilot study was carried out on confirmed COVID-19 patients in the isolation corona ward of the Imam Hussein Hospital ED from March 15 to March 22, 2020. After obtaining demographic data, the patients underwent a pulmonary bedside US examination, with the patients in the sitting position, turning their back to the examiner. A 10-point lung US was performed. Each lung was divided into two areas: posterior (three zones) and lateral (two zones). The patients’ lung ultrasound and chest CT scan as the standard imaging were blindly reviewed and recorded. The clinical value of ultrasound was evaluated with different severity of lung involvement according to CT severity score. Results: Nineteen patients (38 zones), including 13 males, were evaluated with a mean age of 62.5±16.8 years. B2 lines and consolidation observed in the US examinations were significantly correlated with ground-glass opacity and consolidation observed in CT scan examinations, respectively (p <0.0001). US sensitivity and specificity of finding B2 lines were 90% and 100%, respectively. Also, the sensitivity and specificity of US in identifying consolidation were 82% and 100%, respectively. In the lungs with moderate and severe lobar involvement, US findings were significantly correlated (p <0.05) with CT scan findings. Conclusions: Ultrasound evaluation is a safe, fast, and rapid technique for the evaluation of patients with moderate to severe COVID-19-associated pneumonia. It is a reproducible procedure and can be implemented by the operator after a short course of training
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
Prospective Evaluation of Safe Observation Period after Asymptomatic Penetrating Thoracic Injury: 1 Hour is Enough
Get PDFIntroduction: The observation period was recently challenged by some studies; and it has been suggested that a 1-hour observation period may be sufficient to allow safe discharge in asymptomatic patients with penetrating thoracic injury (PTI) and normal initial Chest X-Ray (CXR). Objective: The current study was performed to investigate if in asymptomatic and hemodynamically stable patients with PTIs who has an initial normal evaluation, 1-hour observation interval is safe to detect clinically significant injuries and is it possible to discharge these patients safely after a negative Extended – Focused Assessment with Sonography in Trauma (E-FAST) at hour1 instead of hour 3. Method: This cross-sectional study was performed on asymptomatic patients with penetrating thoracic injury, referred to emergency department (ED) and normal initial CXR and the Extended Focused Assessment with Sonography in Trauma (E-FAST). The second E-FAST was done 1 hour after the first one and the third repeat E-FAST and control CXR then performed 3 hours post-injury. 24 hours follow up by phone call was done for each patient after discharge. Results: Finally, 117 patients with the average ages of 25.9 ± 7.8 years were enrolled of whom 92.5% were male. Eight patients developed PTX or HTX during first hour of observation that were diagnosed by E-FAST or CT scan requested by the in-charge physician. One hundred-nine patient completed E-FAST and radiograph studies at times zero, 1 h, and 3 h. One patient had a normal initial evaluation but demonstrated a PTX on the 3-h managed without intervention. The rate of delayed abnormality after an initially normal study was 7.7 % (9/117). No discharged patients returned to our ED with delayed manifestations of either PTX or HTX. Conclusion: The results of our study have shown that asymptomatic patients with PTI with negative initial evaluation and no deterioration at intervals, about 1 hour may be sufficient for detection of clinically significant pathology, considered for safe and early discharge
Induced Demand after Implementing the Health Reform Plan in Selected Emergency Departments Affiliated to Isfahan University of Medical Sciences: a Cross-Sectional Study
Get PDFIntroduction: Exactly recognizing the effect of health reform plan (HRP) in emergency departments (EDs) is crucial given the large portion of budget assigned to this plan and the effect of introducing this plan on inducing demand and the associated potentially-unbearable costs. Objective: The present study was conducted to assess the demand induced after implementing the HRP in the selected EDs of Isfahan University of Medical Sciences, Isfahan, Iran. Method: The present quantitative and descriptive study collected data related to certain emergency services, performance indicators and working hours of emergency staff using a researcher-made checklist and based on hospital records and information in the years before and after implementing the HRP in Iran, i.e. 2013 and 2015. The data collected were analyzed in SPSS-21. Results: The obtained results suggested significant increases in emergency admissions (69.97%), radiographic images (65%), clinical tests (27.27%) and specialist visits (69.95%). Significantly increases observed in the performance indicators in the ED included the mean hospitalization duration by 61.14%, the bed occupancy rate by 15.71% and the working hours of the nursing staff by 11.43% and those of emergency medicine specialists by 44.72% in the first year after implementing the HRP compared to in the year before the implementation. Conclusion: Although implementing the HRP in Iran significantly changed the performance indicators in the ED, certain infrastructure such as human resource management and the increased demand are considered the main time-consuming and costly challenges in EDs
Knowledge, Attitude and Performance Associated with Disaster Preparedness in Iranian Nurses: A Systematic Review and Meta-analysis
Get PDFContext: Nurses are the largest group of health service providers with a vital role in assisting victims during disasters. They must be therefore appropriately prepared to respond to health requirements in these situations. Evidence acquisition: Three articles were ultimately extracted from a comprehensive search conducted in the present systematic review and meta-analysis in Google Scholar, SID, Magiran, Scopus, PubMed and Web of Science using English keywords and their Persian equivalents. The I2 index was used to evaluate the heterogeneity between the studies, and the analyses were performed in STATA 14. Results: This review was conducted on 586 nurses working in hospitals. The final meta-analysis included three articles. The matched mean scores of knowledge, attitude and performance concerning disaster preparedness were respectively found to be 43.49 (95% CI: 37.67-49.31, P=0.581, I2=0.0%), 68.81 (95% CI: 63.04-70.58, p=0.913, I2=0.0%) and 56.19 (95% CI: 53.95-58.42, P=0.001, I2=86.2%). Conclusion: The present findings suggested moderate levels of knowledge and performance and good attitudes associated with preparedness in disasters in the Iranian nurses. These parameters can be therefore improved to desirable levels and the overall preparedness for coping with disasters boosted in nurses by training nurses and performing hospital drills
Radiation Exposure in Patients with Multiple Trauma in Level 2 and 3 Triage During first 48 Hours of Admission; a Cross-Sectional Study
Get PDFIntroduction: Recently, radiological imaging could be help to diagnose injury in the patients with multiple trauma in the emergency department (ED). Objective: In this study, we aimed to compare the radiation exposure within 48 hours, in patients with multiple trauma in level 2 and 3 triage admitted to ED. Method: This cross-sectional study was conducted on patients with multiple trauma of Level 2 and 3 triage who were referred during 2014-2015 to the EDs of Imam Khomeini Hospital of Tehran and Alzahra hospital of Isfahan, Iran. Radiation exposure of radiographies and computed tomography (CT) scans in patients were calculated during the first 48 hours of admission.Results: In this study, 220 patients with the mean age of 35.41±15.04 years were studied of whom 120 patients (54.5%) were male. The mean radiation exposure was 3.43±3.12 mSv. The mean radiation exposure of CT-scan in level 2 was significantly higher than level 3 (p<0.001). On the other hand, the mean radiation exposure of radiography in level 3 was significantly higher than level 2 (p=0.022). Also, the mean radiation exposure of total radiation in level 2 was significantly higher than level 3 (p<0.001). Conclusion: In 48 hours admitting to emergency department, patients with multiple trauma in Level 2 had more radiation exposure than Level 3
Traumatic Brain Injury in Older Adults Presenting to the Emergency Department: Epidemiology, Outcomes and Risk Factors Predicting the Prognosis
Get PDFIntroduction: The continuing-to-grow number of older adults with traumatic brain injury (TBI) presenting to emergency departments (EDs) and hospitals necessitates the investigation of TBI in these patients. Objective: The present study was conducted to investigate the epidemiology of TBI and the factors affecting intracranial lesions and patient outcomes in older adults. Method: The present retrospective cross-sectional study was performed between March 2016 and March 2018. The study population comprised all TBI patients with a minimum age of 60 years presenting to the ED. The eligible candidates consisted of patients presenting to the ED within 24 hours of the occurrence of traumas and requiring head CT scan as part of their examination. The patients’ baseline information was also recorded. Results: A total of 306 older adult patients with a mean age of 70.61±8.63 years, of whom 67.6% were male, underwent CT scan for TBI during the study period. Falls were the major cause of head injuries, and intracranial lesions were observed in 22.9% (n=70) of the patients. Subdural hematoma (SDH) was observed as the most prevalent injury in 27.6% of the patients, 22.9% (n=16) were transferred to the operating room, and 7.5% (n=23) died. Moreover, the severity of trauma was significantly different between the two genders (P=0.029). Midline shift, SDH, subarachnoid hemorrhage (SAH) and moderate-to-severe head injuries were also significantly associated with poor outcomes (p<0.05). Conclusion: Death from TBIs was more likely in the patients with SDH, SAH and midline shift or in those with an initial Glasgow coma scale (GCS) of below 13. These predictions are clinically relevant, and can help improve the management of older adults with TBI
Spinocerebellar Atrophy Type-3 with Chiari Malformation in a Young Man: A Case Report
Get PDFIntroduction: Chiari malformations are a group of congenital anomalies which involve the hindbrain and the cervical spinal canal. Case presentation: Here, we describe a patient who presented with acute diplopia and gait unsteadiness which was first deigned with Chiari malformation type-1. However due to progression of the ataxia the full neurologic evaluation was considered which established the diagnosis of spinocerebellar ataxia type 3 (Machado-Joseph-Disease). Conclusion: We aim to highlight the importance of careful examination in order to avoid misdiagnosis of even rare diseases