Frontiers in Emergency Medicine (E-Journal)
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Sample Size Calculation Guide - Part 4: How to Calculate the Sample Size for a Diagnostic Test Accuracy Study based on Sensitivity, Specificity, and the Area Under the ROC Curve
Get PDFIn the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion (part 1), for an independent cohort study (part 2), and for an independent case-control study (part 3). In this article, we will explain how to calculate the sample size for a diagnostic test accuracy study based on sensitivity, specificity, or the area under the ROC curve
Fitness Characteristics of Jordanian Emergency Medical Technicians
Get PDFIntroduction: Emergency medical technicians (EMTs) should be always prepared to deal with the stressful condition of treating patients with serious physical and emotional injuries. Given that EMTs consider safety the first priority, they must pay adequate attention to their own physical well-being and fitness to practice. Objective: The present study was conducted to analyze the fitness of Jordanian EMTs. Method: The present prospective study was conducted to evaluate the well-being of Jordanian paramedics. The survey was designed using Google forms, which were completed by the participants. The data collection tools comprised an already-designed checklist, including items such as age, gender as well as height and weight, which are used for calculating body mass index (BMI). In addition, the presence of chronic diseases such as hypertension, diabetes mellitus, renal failure and cardiorespiratory diseases as well as the history of surgeries and disabilities were investigated. The participants were also asked about their smoking status and other health-related habits. Results: Out of 115 surveys conducted, 7 were discarded owing to loss of information or making completion mistakes. Out of the remaining 108 respondents, 82 (75.9%) were male and below 10% were over the age of 30 years. BMI was over 25 in 40.7% of the respondents, and only 4 (3.7%) had chronic diseases. Moreover, 46 (42.6%) respondents were smokers, and only 30 (27.8%) performed regular exercise. Conclusion: The present findings suggest health problems in a small percentage of the EMTs, potentially due to the appropriate support provided by the employers or university authorities in this regard. The major health problem was overweight and unhealthy lifestyle, including smoking and not doing regular exercise
Large Laryngeal Lipoma with Extra Laryngeal Component Mimics Mixed Form Laryngocele: A Case Report
Get PDFIntroduction: Lipomas are the most common benign neoplasms, occurring in any part of the body where fat is present. Their occurrence in the head and neck is not common. Here, we report a large laryngeal lipoma with extra laryngeal component, mimicking mixed form of laryngocele. Case presentation: A 47-year-old man presented with a 3-year history of hoarseness, intermittent dyspnea and mass sensation in the neck. The patient was submitted to indirect laryngoscopy; a large submucosal mass obliterating the left side of the supraglottic larynx and partially obstructing the airway was found. Enhanced computed tomography (CT) scan demonstrated non-enhancing homogeneous hypodense fat density mass lesion measured 55*45*32 mm, extending through the thyroid membrane to parapharyngeal space and showing extra laryngeal component with an intact laryngeal mucosa lesion. Open surgery of the submucosal mass was performed. Pathology examination confirmed the diagnosis of lipoma. Conclusion: Neck lipomas are also typically asymptomatic, but can compress nearby structures, causing symptoms such as hoarseness, dyspnea and dysphagia. When symptomatic, they should be removed via surgery
Electrical Storm in the Absence of a Structural Heart Disease in a Young Girl
Get PDFA 14-year-old girl presented to the emergency department (ED) with a history of three episodes of seizure-like activity and no comorbidities at 2 am. The first episode had occurred at 6 am, the second at 12 pm and the third two hours before presenting to the ED. Each episode lasting less than 5 minutes, was associated with the limb and spinal rigidity and extension, the up-rolling of eyeballs and urinary incontinence. The patient reported no history of fever, recent trauma, previous febrile seizures, prodromal symptoms, tongue bite, headache or physical excretion before the episodes. No postictal confusion or tonic-clonic movements and significant family history were also reported. The initial examination found her to be conscious, oriented and hemodynamically stable, and the results of her systemic examinations were normal without any significant positive findings.
Evaluation of the patient initiated with the provisional diagnosis of new-onset seizures, followed by performing a computed tomography (CT) scan of the head, which was normal and ruled out any intra-cranial pathology. The results of the blood test involving serum electrolytes, calcium and magnesium were also normal.
Abrupt polymorphic ventricular tachycardia (VT) was identified on the monitor (figure 1) as a few second-episodes of posturing and stretching of the body with no peripheral and central pulses during the examination in the ED. The patient came around after undergoing cardiopulmonary resuscitation immediately followed by defibrillation at 200 J and reverting the rhythm to sinus. The patient had recurrent episodes of pulseless polymorphic VT, which required ten times of defibrillation for one hour and antiarrhythmic drug therapy with IV bolus of 300 mg and then again 150 mg amidaraone, and then infusion of 1 mg of magnesium sulfate diluted in 10 ml of D5W and also administration of 1 mg/kg of lidocaine.
The patient was electively intubated and ventilated under deep sedation, and transferred to the cardiac care unit (CCU). The two-dimensional echocardiography findings were revealed normal-sized heart chambers and good left ventricular function. Blood levels of high-sensitivity troponin I and CK-MB were also in their normal range. Despite performing repeated defibrillation and anti-arrhythmic therapy, the patient showed repeated episodes of pulseless VT. She was therefore referred to a higher-level center to be administered with left stellate ganglion block (LSGB). She withstood the procedure, and discharged from the hospital after a ten-day follow-up. An implantable cardioverter-defibrillator (ICD) was later planned for the patient, and she continued with taking oral antiarrhythmic drugs
The Accuracy of GAP and MGAP Scoring Systems in Predicting Mortality in Trauma; a Diagnostic Accuracy Study
Get PDFIntroduction: Trauma scoring systems help physicians and nurses to be informed of injuries to a patient and assist their decision making in the cases of trauma and importantly prediction of their outcome and prognosis. Objective: This study aimed to compare the accuracy of GAP and MGAP scoring systems as predictors of mortality in trauma patients. Methods: This diagnostic accuracy study was conducted amongst 1861 trauma patients admitted to Rajaee Hospital in Shiraz, Iran, during 2017. The data on demographic features were extracted from the patients’ records. Then, trauma scoring systems including injury severity score (ISS), GAP, MGAP, and Glasgow coma scale (GCS) were compared to evaluate their accuracy in predicting mortality. Area under the receiver operating characteristic (ROC) curve was used to evaluate the accuracy of different trauma scoring systems and detect the sensitivity and specificity in order to predict status of discharge after 24 hours. Results: Based on the results, the area under the ROC curve was 0.8 for GCS. Moreover, Area Under Curve (AUC) of GAP was 0.91 and amongst different values, GAP value of ≤18 was selected as the cut-off point, since it exhibited the best sensitivity and specificity (72.99 and 95.52, respectively). In addition, the area under the ROC curve was 0.9 for MGAP, and value of ≤23 was selected as the cut-off point because it showed the best sensitivity and specificity (81.04 and 87.70, respectively). Additionally, AUC of ISS was 0.88. Conclusion: Both GAP and MGAP methods were able to appropriately predict mortality and were not significantly different; hence, both can be used for the right triage of patients and to predict the severity of injuries and subsequent mortality. Moreover, GAP and ISS had the best specificity and sensitivity, respectively
Red Cell Distribution Width (RDW) Index as a Predictor of Severity of Acute Ischemic Stroke: A Correlation Study
Get PDFIntroduction: Globally, stroke is one of the leading causes of death and disability-adjusted life-years (DALYs). The red cell distribution width (RDW) is a readily available and inexpensive test which is done routinely as a part of complete blood count in these patients. Objective: In this study, we tried to correlate the RDW with severity of acute ischemic stroke (AIS). Methods: Patients presenting to emergency department (ED) within 24 hours of the onset of clinical signs and symptoms suggestive of AIS were assessed for Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) score followed by non-contrast computed tomography (NCCT) scan. RDW value for all the patients who were included in the study were co-related with the severity of the stroke. Results: The median (IQR) RDW in the patients with minor stroke on the basis of GCS was 13.5 (13.3-13.5), moderate stroke was 13.8 (13.5-14.4) and with severe stroke was 15.4 (15.1- 15.6) (p < 0.001). The median (IQR) RDW in the patients with minor stroke on the basis of NIHSS score was 13.4 (13.2 – 13.6), moderate stroke was 13.8 (13.5-14.3), and moderate to severe stroke was 14.7 (14.5-15.3) and with severe stroke was 15.5 (15.1-15.7) (p < 0.001). The median RDW in patients who were alive was 13.8 (13.5 -15.1) and in patients who expired was 15.5 (14.5 -15.7) (p = 0.048). Conclusion: Based on the findings of this study, RDW index has statistically significant correlation with the severity of AIS. So it can potentially be an important parameter to predict the prognosis of AIS patients
The Carotid Artery Thrombosis Following Blunt Neck Trauma; a Case Report
No full textIntroduction: This case emphasizes on the importance of detecting thrombosis and carotid artery injuries and the need for rapid treatment of blunt neck traumas. Case presentation: A 43-year-old male motorcyclist rider, rode into a rope and suffered blunt neck trauma. At admission to the emergency department (ED), he was fully conscious with Glasgow coma scale of 15. The biochemical tests and X-rays were normal, but initial examination revealed paresthesia in the right-hand fingertips, which exacerbated over the first 24 hours of admission. Doppler ultrasound of the neck arteries and computed tomography (CT) angiography reports showed thrombosis of the right common carotid artery, which spread to the right subclavian and vertebral arteries. Treatment was initiated with heparin injection followed by daily administration of oral warfarin, and seven days later, symptoms were relatively improved. Conclusion: Considering possible vascular injuries following blunt neck trauma should be kept in mind when dealing with such patients, and necessary physical examination required to rise the impression. By reviewing the literature, it seems that although CT angiography is usually used in screening carotid injuries, this modality appears to have poor sensitivity in this regard, and digital subtraction angiography (DSA) is still considered the gold standard for detecting carotid artery injury
Intravenous Acetaminophen vs. Ketorolac in Terms of Pain Management in Prehospital Emergency Services: A Randomized Clinical Trial
Get PDFIntroduction: Although pain management in EDs has been fully addressed in clinical trials, prehospital settings have rarely been investigated. Objective: The present study was conducted to compare the effectiveness of intravenous acetaminophen with that of ketorolac in pre-hospital pain control. Method: This randomized clinical trial (RCT) was performed at a prehospital setting during EMS missions in Tehran, Iran. The eligible candidates comprised all patients over the age of 7 years with a complaint of moderate to severe pain. The patients were randomly assigned to two groups, one receiving 30 mg of intravenous (IV) ketorolac and the other 1 g of IV acetaminophen. The pain intensity was measured using a visual analog scale (VAS) before administering the analgesic and upon admission to the ED. Results: The present study was conducted on 150 patients aged 8-81 years with a mean age of 40.4 ± 17.7, including 84 (56%) males. The mean reduction in the pain score was 14.9±8.6 in the acetaminophen group and 16.0±8.8 in the ketorolac group. Univariate analyses suggested no statistically significant differences between the two groups in terms of delta pain score (pain reduction) (P=0.429). Conclusion: Based on the obtained findings, both ketorolac and acetaminophen could be administered for pain management in prehospital settings in both traumatic and non-traumatic patients in case their contraindications are considered
Minimum Number of Required Sessions for Attaining Basic Skills in Laparoscopic Surgery by General Surgery Residents; an Experimental Report
Get PDFIntroduction: Training is the primary route of attaining required skills among residents in general surgery. Objective: This study was conducted to evaluate the minimum number of required sessions for attaining basic skills in laparoscopic surgery in a skill-lab among surgical residents. Method: This cross-sectional study was conducted in Imam-Khomeini Hospital during 2012. A total of 20 surgical residents were enrolled. There were 45–60 mins sessions weekly, which included the following seven elementary skills: first knot tie, second knot tie, peg exchange, peg drop, rope pass, needle pass, and paper cut. These skills were evaluated weekly, and qualitative evaluations were done every 2 weeks. Results: Mean age of the 20 surgical residents was 32.2 ± 4.7 years, and 55.6% of them were males. The median session counts were as follows: six sessions for first knot tie, six sessions for second knot tie, three sessions for peg exchange, eight sessions for needle pass, and five sessions for paper cut. Conclusion: Based on the obtained results, it may be concluded that relatively five sessions are required for acquiring basic skills in laparoscopic surgery by surgical residents
Comparing the Therapeutic Effects of Dexamethasone-Metoclopramide with Ketorolac in Relieving Headache in Patients with Acute Migraine Attacks Presenting to the Emergency Department
Get PDFIntroduction: Migraine is a frequent chief complaint of patients in the emergency department. A wide range of treatments are used for acute migraine. Objective: This study aimed to compare the therapeutic effects of a combination of metoclopramide + dexamethasone with those of ketorolac for treatment of acute migraine in the emergency department. Method: This quasi-experimental study enrolled patients identified as migraine headache cases admitted to the emergency departments of Shohadaye Tajrish and Sina hospitals, Tehran, Iran. The patients were divided into two groups and treated with either 8 mg Dexamethasone + 10 mg Metoclopramide or 60 mg ketorolac, and then compared regarding the rate of pain control based on visual analogue scale (VAS) on arrival and 1 and 2 hours afterward. Results: Overall, 86 patients were recruited, of whom 50 were male (58.1%). Their mean age was 37.6 ± 10.3 years. Thirty-five (40.7%) were in the ketorolac group and 51 (59.3%) were in the dexamethasone + metoclopramide group. Treatment success was defined as a reduction of at least 3 points in pain severity in comparison to the admission time. One hour after administration of medications, the reported pain intensity was 4.7 ± 2.0 and 6.2 ± 2.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. By the second hour, pain intensity was 3.4 ± 1.2 and 2.9 ± 1.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. The two groups did not show a significant difference in terms of the reported pain at this time (p= 0.04). Conclusion: Based on our findings, the pain reduction time was relatively shorter for ketorolac in acute migraine, but the final response was identical in the two groups