Frontiers in Emergency Medicine (E-Journal)
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A Case Report of a Huge Mesenteric Cyst in a 5-Year-Old Girl: A Rare and Challenging Finding in Radiological Assessment
Get PDFIntroduction: Mesenteric cysts are rare benign intra-abdominal vesicles with various clinical presentations. They almost located in the mesentery of the small intestine. The selective therapeutic method is complete surgical excision, however more than half need resection and bowel anastomosis. Case presentation: Here, we presented a 5-year-old girl with a huge mesenteric cyst (15×14cm2) mesenteric cyst that was excised surgically., which the diagnosis confirmed by computed tomography scan and managed through surgical excision. Conclusion: Acute abdominal pain may be due to the presence of mesenteric cysts, but it is not always possible to differentiate and diagnose it preoperatively, and this challenge especially exists in the case of bulky masses. it is recommended to choose primary radical, surgical treatment in case of intra-abdominal cystic mass in the pediatric age
Management of a Penetrating Thoracic Injury with Thoracoscopy; A Case Study
Get PDFIntroduction: Various strategies could be considered dealing with penetrating thoracic injuries. Thoracoscopy is much less invasive than routine thoracotomy approach for managing such cases in which the sharp object remains in the body. The case presented in this article was managed with thoracoscopy for a penetrating dorsolateral thoracic injury. Case Presentation: A 35-year-old man with a penetrating dorsolateral thoracic injury referred to the emergency department. Despite an elevated pulse rate, the patient has proper blood pressure and O2 saturation. Considering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy. At thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space. There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications. Conclusion: Our experience of removing a retained knife by thoracoscopy showed that it can be an appropriate alternative for patients with penetrating thoracic injury who are hemodynamically stable and have appropriate conditions for thoracoscopy
A 21-year-old Pregnant Trauma Patient with Asymptomatic Fat Embolism; a Case Report
Get PDFIntroduction: Fat embolism syndrome (FES) is most often associated with orthopedic trauma that typically presents 24–72 hours after the trauma with a classic triad. Only few cases of fat embolism due to lower extremity venous system had been reported. Case presentation: The current case report presents a pregnant woman who was referred to our emergency department with bilateral femoral open fracture. After detecting fetal demise by abdominopelvic ultrasound, an area of fat density in right external iliac vein was detected in abdominopelvic contrast enhanced computed tomography (CT) scan which was considered as the probable diagnosis of fat embolism. While the patient did not show signs and symptoms of FES, the fat embolism was confirmed in further evaluations. Conclusion: In summary, although detection of fat embolus in CT scan in the emergency department is very rare, evaluation of lower extremity venous system in a posttraumatic patient seems to be crucial because early diagnosis of fat embolism can help the clinicians to prevent FES
Sample Size Calculation Guide - Part 6: How to calculate the sample size for a non-inferiority or an equivalence clinical trial
Get PDFIn the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion, for an independent cohort study, for an independent case-control study, for a diagnostic test accuracy study, and for a superiority clinical trial. In this article, we will explain how to calculate the sample size for a non-inferiority or equivalence clinical trial
The Relationship Between QT Interval and Intra-Hospital Mortality in patients with Spontaneous Intracranial Hemorrhage
Get PDFIntroduction: Repolarization abnormalities such as prolongation of QT interval and changes in ST segment and T wave are the most usual electrocardiogram (ECG) changes in patients with intracranial hemorrhage (ICH). It has recently been recommended that prolonged QTc interval raises the risk of death due to malignant ventricular arrhythmias or sudden cardiac death. Objective: The goal of this study was to evaluate the relationship between QT interval and death in patients with ICH. Method: This cross-sectional study was performed on patients with ICH who referred during 2015-2017 to Poursina Hospital, Rasht, Iran. The QT interval was manually measured based on the BAZETT formula. Max QT and Max QTc and QT dispersion were the variables evaluated by the ECG of the patients. The outcome under the study was the death or survival of patients during hospitalization. Results: Finally, 466 cases with the mean age of 69±12 years were studied of whom 68.7% were male. The average QT-Max interval was 350.4±56.5 milliseconds, and the average QTc-Max was 583.6±57.6 msec. Totally, 22.7% of the patients died. There was a significant statistical relationship between QTc-MAX and death (p=0.001). However, there was no statistically significant relationship between QT-MAX and the outcome (p=0.593). Conclusion: It is likely that, prolonged QT interval is correlated with in-hospital mortality of patients with ICH. Therefore, it can be expected that assessing ECG abnormalities, especially prolonged QTc could be valuable in these patients
ED Assembly: Introducing a Simple Method of Bringing Emergency Department Staff Together to Facilitate Improvement; A Report of a Real Experience
Get PDFIntroduction: The emergency department (ED) at Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH) is a medium size department which sees around 260-300 patients per day. As a result of sustained demand, we continue to struggle to meet the four hour waiting target and face similar challenges of those of ED’s nationally. Working in a busy ED is challenging and demanding. specific challenges around communication and risks arise directly from the unique contextual demands of the ED environment. Objective: Aim being to improve the productivity of the ED team and find a mechanism to create a more supportive and enjoyable working environment within the department. Method: Our clinical leadership started looking for answer to improve communication among team members and to create a platform where there was no hierarchy and all team members could be directly involved in problem solving. With the support of the quality improvement (QI) team, ED assembly was born. The assembly is a simple method of regularly bringing together staff to facilitate improvement and better team working. It is a platform for effective communication and innovation, in which there is no hierarchy and everyone is encouraged to contribute. Results: The assembly runs to a routine; every other Wednesday at 11am, the team come together for just half an hour. The agenda is set by the team in advance and everyone is encouraged to contribute their ideas and items they wish to contribute to others. Here are some examples of the quality improvement initiatives that have been born out of ED assembly: ED board rounds, coding information, overdose proforma, timely completion of standard investigations, access to fracture clinic appointments, nil-by-mouth communication, safety huddles, patient safety and sepsis, inclusive improvement, adoption of the ED assembly model by other teams and etc. Conclusion: ED assembly has supported many small but effective QI initiatives and regular communications support timely feedback on progress and update on plan-do-study-act (PDSA) cycles, resulting in changes in the everyday practice and improved pathways of patient care
An Interventional Study on Comprehensive Emergency Care and Trauma Registry for Road Traffic Injuries in India: A Protocol
Get PDFRoad traffic injuries (RTIs) stands as one of the leading causes of mortality and morbidity across the globe. Effective injury surveillance systems and pre-hospital and in-hospital interventions set up in developing countries have shown promising results in controlling the problem. This study aimed to standardise and evaluate an evidence-based intervention for safety, efficacy and quality of post-crash pre-hospital and in-hospital trauma care services to improve the outcome in RTI victims. In addition, it establishes the android-based trauma registry for effective RTI surveillance.
This multi-centric, prospective, observational study is commissioned by the Indian Council of Medical Research (ICMR) as a National Task Force Project. This study is being conducted in five sites, viz., Anand, Bengaluru, Delhi, Lucknow and Thrissur located across India. Each centre will have a level I, two level II and three level III trauma hospitals. The study will be carried out in four phases namely: i) preparatory phase, ii) trauma registry establishment and pre-intervention data collection, iii) intervention and iv) impact evaluation. The preparatory phase, which lasts for four months includes the situational analysis pertaining to managing RTIs. Trauma registry will be initiated from the fifth month. Pre-intervention data will be collected for six months. The intervention will be conducted for six months in the form of prehospital notification, training for trauma care providers and trauma care quality improvement. Post-intervention data collection will continue for 12 months and the impact of the intervention will be assessed. The primary outcome measure will be early preventable mortality, defined as death at 24 hours after admission for patients with a calculated probability of survival >50% based on their injury severity score
Operational Strategies for Establishing Disaster-Resilient Schools: A Qualitative Study
Get PDFIntroduction: Resilient schools can warranty students’ health and survival at disasters. It is obligatory that schools be prepared for natural challenges through local programs. Considering the great population of students, disaster-resilient schools can be a safe and suitable environment for students at the time of disaster. Objective: This study aims to identify certain operational strategies for establishing schools resilient to natural disasters. Method: This qualitative study was based on conventional content analysis. Using purposive sampling method, 24 experts in the fields of health in disasters, construction engineering, psychology, teaching, and administrative management participated in the study. Maximum variation sampling continued until data saturation was achieved. The data collected via unstructured interviews were analyzed with Graneheim and Lundmen’s conventional content analysis. Results: Content analysis resulted in four main categories as operational strategies for establishing disaster-resilient schools including: 1) “construction and non-construction optimization”, with four subcategories of construct risk management, optimization of construct architecture and physical structure, correct construct localization, and promotion of non-construct safety, 2) “promotion of organizational coordination and interactions” with two subcategories, namely improvement in intra-organizational communication and improvement in extra-organizational communication, 3) “improvement in education” with three subcategories of holding educational courses for families and students, holding educational courses for managers and personnel, and holding simulated exercises, and 4) “process promotion” with four subcategories of increased preparedness, correct planning, creation of organizational structure, and rehabilitation facilitation. Conclusion: Various factors affecting schools’ response to disasters form operational strategies to establish disaster-resilient schools. These strategies influence pre- and post-disaster preparedness. Awareness of these components followed by preparedness prior to disasters can save students’ lives, improve school performance after disasters, and aid in establishing disaster-resilient schools as safe lodgings
Animal Injuries; a Case Series of Bull Induced Injuries in India
Get PDFIntroduction: Bull injuries are common in India. An injury by a bull is more common in rural and agriculture dependent regions of the country. The incident causing injury by a bull can be sports related or work related. Work related injuries are almost mostly seen in farmers. Case presentation: We would like to present six cases of bull injury over a period of three years who reported to our EM. All six patients were admitted. Five out of six patients survived the hospital stay. Conclusion: Trauma sustained due to being hit by a large animal should be treated akin to a high velocity trauma and such a patient definitely warrants a period of observation even if the injuries are not life threatening. A high index of suspicion is needed for suspecting occult injuries. Fluid resuscitation and age of the patient are important considerations
Intranasal versus Intramuscular/Intravenous Naloxone for Pre-hospital Opioid Overdose: A Systematic Review and Meta-analysis
Get PDFContext: The present systematic review and meta-analysis aims to perform an extensive search in databases to compare the efficacy of the intranasal administration of naloxone with its intramuscular/intravenous administration in the pre-hospital management of opioid overdose. Evidence acquisition: This meta-analysis included controlled trials conducted on the efficacy of naloxone administration in the pre-hospital management of opioid overdose. A search was carried out in electronic databases on relevant articles published by the end of 2018. After data collection, analyses were performed in STATA 14.0 software and the efficacy and side-effects of the two administration routes of naloxone, i.e. intranasal and intramuscular/intravenous, were compared. An overall effect size with 95% confidence interval (95% CI) was provided for each section. Results: Eventually, data from six studies were included in this meta-analysis. The success rate of the intranasal and intramuscular/intravenous administration of naloxone in the management of opioid overdose in pre-hospital settings was 82.54% (95% CI: 57.97 to 97.89%) and 80.39% (95% CI: 57.38 to 96.04%), respectively. There was no difference between injectable (intramuscular/intravenous) naloxone and intranasal naloxone in the pre-hospital management of opioid overdose (Odds Ratio=1.01; 95% CI: 0.42 to 2.43; P=0.98). The onset of action of intranasal naloxone, however, was slightly longer than injectable naloxone (Standardized Mean Difference=0.63; 95% CI: 0.07 to 1.19; P=0.03). Additionally, the odds of needing a rescue dose was 2.17 times higher for intranasal naloxone than intramuscular/intravenous naloxone (OR=2.17; 95% CI: 1.53 to 3.09; P<0.0001). The prevalence of major side-effects was non-significant for both intranasal (0.00%) and intramuscular/intravenous (0.05%) routes of naloxone administration and there was no difference in the prevalence of major (OR=1.18; 95% CI: 0.38 to 3.69; P=0.777) and minor (OR=0.64; 95% CI: 0.17 to 2.34; P=0.497) side-effects between the two routes. Conclusion: The present meta-analysis demonstrated that intranasal naloxone is as effective as injectable naloxone in the pre-hospital management of opioid overdose complications. Consequently, intranasal naloxone may be an appropriate alternative to injectable naloxone