Frontiers in Emergency Medicine (E-Journal)
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Exploring drivers' willingness to pay for safer roads in Iran: a discrete choice experiment on reducing injury and mortality risks
No full textBackground: Road traffic injuries (RTIs) are a leading global health challenge, with Iran facing significant economic and social costs due to these incidents. This study investigates Iranian drivers' preferences for road safety and their willingness to pay (WTP) to reduce injury and mortality risks. It also examines the influence of demographic and driving-related factors on these preferences. Method: A discrete choice experiment (DCE) was conducted among Shiraz residents to analyze route preferences. Participants evaluated hypothetical commuting scenarios characterized by variations in travel time, cost, injury risk, and fatality risk. Using a D-efficient fractional factorial design, 10 two-alternative choice scenarios were developed. Data were collected through interviews in five districts, achieving an 81% response rate. A mixed logit regression model was employed to assess how route attributes influenced participants' decisions. Results: Key factors driving route choices included the number of deaths, injury rates, travel time, and cost, with fatalities being the most influential. Participants were willing to pay 8.98 for routes with fewer than 10 annual injuries, and $11.83 for routes with fewer than 5 annual deaths. WTP varied significantly across demographic groups: men prioritized reduced travel time, while women emphasized safety. Personal-use drivers exhibited higher WTP compared to professional drivers like taxi operators. Larger family sizes correlated with lower WTP, whereas individuals in excellent health or with supplementary health insurance displayed higher WTP for safer and faster routes. Conclusion: This study underscores the utility of DCEs in capturing drivers' preferences for road safety and efficiency in Iran. By highlighting the trade-offs drivers are willing to make and identifying key factors, these findings offer actionable insights for policymakers to design transportation systems that align with public safety and mobility priorities
Acute mesenteric infarction presenting with portomesenteric venous gas: a case report
No full textA 72-year-old woman presented to the emergency department with fatigue and epigastric pain. Imaging revealed pneumatosis intestinalis and portomesenteric venous gas (PMVG), ultimately diagnosed as mesenteric infarction. The case highlights PMVG as an urgent radiological sign requiring prompt recognition and surgical consultation in emergency settings
Massive hemorrhage update: what is known and what we should know?
Get PDFMassive hemorrhage protocol (MHP) is an updated term for the formerly used massive transfusion protocol, highlighting crucial aspects of hemorrhage management other than the transfusion itself. This complex intervention includes acute hemorrhage control; administering tranexamic acid (TXA), preventing hypocalcemia, hypothermia, and acidosis; reversing anticoagulation or correcting coagulopathies; and planning for the next steps in definitive hemorrhage control. Here, we discuss exciting frontiers and challenges of MHP
Diltiazem vs metoprolol for atrial fibrillation with rapid ventricular response in heart failure with reduced ejection fraction in emergency departments
Get PDFObjective: As emergency department (ED) visits for atrial fibrillation (AF) grow, comorbidities lead to challenging treatment scenarios. There are limited data evaluating the safety of diltiazem in the acute management of AF with rapid ventricular rate (RVR) in patients with heart failure with reduced ejection fraction (HFrEF). The objective of this study was to evaluate the safety of diltiazem vs metoprolol in patients presenting to the ED with AF with RVR with HFrEF. Methods: This multicenter, retrospective, cohort study evaluated patients with AF with RVR with HFrEF who received either intravenous (IV) diltiazem or metoprolol in the ED. The primary endpoint was worsening heart failure, defined as an increase in supplemental oxygen requirement, acute kidney injury (AKI), or inotrope administration. Secondary endpoints included bradycardia, systolic blood pressure (SBP) <90 mmHg, or atropine administration. Results: Of the 5,465 patients screened, 62 (1.1%) patients were included for analysis. Forty-nine (79%) patients received IV diltiazem and 13 (21%) received IV metoprolol. The primary endpoint of worsening heart failure occurred in 26.5% in the diltiazem cohort and 15.4% in the metoprolol cohort (P=0.493). There were no differences in increased need for supplemental oxygen, incidence of AKI, or inotropic support. There were no differences in the secondary safety endpoints. Conclusion: For ED management of patients with AF with RVR with HFrEF, treatment with IV diltiazem did not lead to an increase in worsening heart failure compared to IV metoprolol. Future prospective trials are needed to evaluate this treatment approach in this population
Predictive factors of spontaneous circulation return following in-hospital cardiac arrest: a cross-sectional study
Get PDFObjective: Existing predictive models for in-hospital cardiac arrest (IHCA) outcomes are mainly based on out-of-hospital cardiac arrest (OHCA) studies. This study aimed to identify factors that can independently predict the sustained return of spontaneous circulation (ROSC) following IHCA. Methods: This retrospective cross-sectional study included all patients aged 18 or older who underwent cardiopulmonary resuscitation (CPR) following IHCA in the emergency departments of two general hospitals in Tehran, Iran, from March 2021 to April 2024. The association of patient baseline characteristics, type of cardiac arrest, CPR characteristics, time-related parameters, and laboratory data with sustained ROSC were evaluated using multivariate logistic regression analysis trying to identify independent associated factors of sustained ROSC following IHCA. Results: 614 patients with a mean age of 68.23±17.65 (range: 18-115) years meeting the eligibility criteria were included (59.28% Male). 184 (29.96%) cases experienced sustained ROSC. Multivariate logistic regression analysis revealed a significant association between sustained ROSC and CPR duration less than 30 minutes (coefficient=4.38, 95% CI: 3.70,5.06, P<0.001), arrest due to cardiac etiologies (coefficient=1.05, 95% CI: 0.35,1.74, P=0.003), and administration of IV bicarbonate (coefficient=1.42, 95% CI: 0.72,2.13, P<0.001). Administration of amiodarone showed a borderline association with sustained ROSC (coefficient=1.07, 95% CI: -0.03,2.18, P=0.05). Conclusion: CPR duration of less than 30 minutes, arrest with cardiac etiologies, administration of bicarbonate and amiodarone were independent predictors of sustained ROSC
Transvaginal evisceration after laparoscopic hysterectomy: case report
Get PDFTransvaginal evisceration is a rare condition characterized by the externalization of abdominal viscera through the vagina. Menopause and hysterectomy are the primary risk factors. A postmenopausal woman presented to the emergency department with evisceration of the small intestine through the vagina three hours post-coitus. She had a history of laparoscopic hysterectomy performed three years prior. The patient underwent prompt laparotomic repair of the vaginal cuff. The diagnosis of transvaginal evisceration is primarily clinical, and immediate treatment aims to maintain intestinal viability and repair the vaginal cuff. The surgical approach is based on the surgeon’s experience, the patient's clinical condition, and resource availability
COgnitive crisis: unveiling neurological consequences of carbon monoxide poisoning: a case report
Get PDFCarbon Monoxide (CO) is commonly emitted by vehicles, industrial processes, and heating systems. It can lead to unintentional poisoning in enclosed spaces. Common findings include tachycardia, hypotension, hypoxemia, headache, dizziness, seizures, or coma. A thorough history is essential to suspect potential CO poisoning. Confirmatory tests include measuring carboxyhemoglobin levels in blood. The first step of management is to remove the patient from the source, followed by oxygen supplementation. In severe cases, hyperbaric oxygen therapy may be indicated. Prognosis depends on the level of exposure, as well as the promptness of treatment. Early intervention leads to better outcomes. Delayed neurological deficits are potential long-term outcomes. Prognosis for recovery improves significantly with the use of CO detectors in homes and education about the risks of CO exposure. We present a case of a 15-year-old male who presented with acute encephalopathy
Epidemiology of injuries among patients admitted to Imam Khomeini Hospital, Urmia, affiliated with the national trauma registry of Iran
Get PDFObjective: Trauma is one of the major causes of mortality and morbidity globally. The current study aimed to improve the understanding of characteristics, severity of injuries and outcomes of trauma patients admitted to Imam Khomeini Hospital, Urmia, Iran. Methods: Data were obtained from the trauma registry of Imam Khomeini Hospital, a level 1 trauma referral center, for all patients admitted to the center from 17 september 2016 to 21 January 2023. Patients’ demographics, injury mechanisms, and patients' outcomes were analyzed. Results: The emergency department attended to 5555 trauma patients. The gender distribution was with 3998 (71.9%) males and 1557 (29.1%) females. Patients' age ranged from 1 to 101 years, with a mean±standard deviation (SD) of 33.1 (±20.7) years. Road traffic accidents followed by falls were the most common causes of traumas reported in 2138 (38.5%) and 1298 (23.4%) trauma patients, respectively. The in-hospital mortality rate was 0.9% (53 patients). The mean (±SD) age of death was 43.5 (±22.4) years. 569 (10.2%) patients were admitted to the intensive care unit (ICU). The univariable logistic regression models showed that there were significant associations between age (P<0.001), Glasgow coma scale (GCS) (P<0.001), injury severity score (ISS) (P<0.001), and mechanical ventilation (P<0.001) as independent variables and death outcome. The univariable and multiple logistic regression analyses showed statistically significant associations between age, cause of trauma, ISS, GCS and body site injury with ICU admission. The odds of ICU admission in patients after being adjusted for age, ISS, GCS, cause of trauma and type of transportation was 1.73 times higher in head, face, and neck injuries compared to limb injuries. (adjusted OR: 1.73, [95% CI: 1.23,2.42]; P<0.01). Conclusion: Older age, low GCS, higher ISS and mechanical ventilation were associated with higher mortality. Older age, higher ISS, lower GCS, body site injury, type of transportation, and cause of trauma were all significant independent predictors of ICU admission
Simulation training improves resident physicians’ confidence in managing first trimester bleeding in the emergency department
Get PDFFirst trimester bleeding is commonly encountered in pregnancy and can be potentially life-threatening. Simulation training provides an ideal opportunity for resident medical learners to improve clinical knowledge and gain confidence in managing life-threatening causes of first trimester bleeding in a realistic but safe clinical environment. The objective of this study was to assess the effectiveness of simulation in improving family medicine residents’ confidence and knowledge in identifying and managing first trimester bleeding in the emergency department (ED). The intervention was a two-hour educational simulation focusing on management of unstable first trimester bleeding. Twenty-one family medicine residents (67% female) at the University of Toronto participated in the simulation and completed pre- and post-simulation questionnaires assessing their confidence and knowledge in management of first trimester bleeding. This study demonstrates that simulation training improves resident physicians’ confidence in managing first trimester bleeding in the ED. Additionally, it improves their objective history taking skills. Post-graduate medical programs should consider developing structured simulation, particularly for high-yield clinical cases residents may not otherwise have acute exposure to and are required to be competent in managing
Kounis syndrome in the era of COVID-19: pathophysiology, clinical challenges, and therapeutic approaches
Get PDFKounis syndrome, first described in 1991, refers to allergic or hypersensitive reactions that result in acute coronary syndrome (ACS). In addition to SARS-CoV-2, this disease has enhanced our comprehension of viral infections, inflammatory reactions, and cardiovascular repercussions. The COVID-19 pandemic has exposed the occurrence of cardiac damage, arrhythmias, and thrombotic events that are associated to the SARS-CoV-2 virus, thereby making the understanding of their development more complex. This research explores the complex correlation between Kounis syndrome and COVID-19, encompassing the phenomena of cytokine storms and endothelial dysfunction. Diagnosing Kounis syndrome in the context of COVID-19 presents challenges, nevertheless, it is imperative to distinguish it from other cardiovascular disorders. The identification of risk factors and predisposing situations that can exacerbate Kounis syndrome in COVID-19 patients is highlighted, with a particular focus on patient assessment. The care of Kounis syndrome in COVID-19 necessitates a multidisciplinary strategy that involves collaboration among cardiologists, allergists, and other specialists. Possible therapies encompass epinephrine, antihistamines, corticosteroids, cardiovascular interventions, as well as long-term surveillance and measures to reduce risk. Additional investigation should include epidemiological enquiries, experimental frameworks, and advancements in diagnostic and therapeutic approaches. Comprehending the connection between viral infections and coronary syndromes caused by allergies is crucial for clinical practice and the well-being of patients. This review explores the neurobiological similarities and clinical implications of Kounis syndrome and COVID-19, aiming to enhance comprehension and treatment of this intricate clinical scenario