Frontiers in Emergency Medicine (E-Journal)
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Effects of Chest Compression Fraction on Return of Spontaneous Circulation in Patients with Cardiac Arrest; a Brief Report
Get PDFIntroduction: The association between chest compression fraction (CCF) and return of spontaneous circulation (ROSC) has been a controversial issue in literature; and both positive and negative correlations have been reported between CCF and survival rate. Objective: The present study was conducted to determine the relationship between the rate and outcomes of chest compression and between CCF and ROSC in patients with cardiac arrest. Method: The present prospective observational study was conducted during 2018 on patients with cardiac arrest aged 18-80 years. Participants with end-stage renal diseases, malignancies and grade IV heart failure were excluded. A stop watch was set upon the occurrence of a code blue in the emergency department, and time was recorded by the observer upon the arrival of the code blue team leader (a maximum permissible duration of 10 minutes). The interruptions in chest compressions were recorded using a stopwatch, and CCF was calculated by dividing the duration of chest compression by the total duration of cardiac arrest observed. Results: Totally, 45 participants were enrolled. Most of the patients had non-shockable rhythms and underwent CPR based on related algorithm. Hypoxia and hypovolemia were the two probable etiology of cardiac arrest; and coronary artery disease was the most prevalent underlying disease. All patients with ROSC had CCF more than 70%. A CCF below 70% was observed in 21 cases (46.7%), and a fraction of at least 70% in 24 cases. All patients with ROSC had CCF more than 70%. A CCF below 70% was observed in 21 cases (46.7%), and a fraction of at least 70% in 24. A significantly higher duration and fraction of chest compression was observed in the participants who attained ROSC (P<0.001). Conclusion: Based on the findings of current study, it seems that significantly higher chest compression durations and fractions were found to be associated with ROSC, which was achieved in the majority of the participants with a CCF of at least 80%
The Relationship Between Premature Myocardial Infarction with TC/HDL-C Ratio Subgroups in a Multiple Risk Factor Model
Get PDFIntroduction: So far, there is no evidence available to demonstrate the relationship between five subgroups of total cholesterol/high density lipoprotein cholesterol (TC/HDL-C) ratio with premature myocardial infarction (MI). Objective: We conducted a case control study to probe more features of the relation between TC/HDL-C ratio and the five subgroups of the ratio with myocardial infarction under 55 years and above it. Method: A hospital based case control study with incident cases was designed. Cases and controls were comprised of 523 under 55-year and 699 above 55-year documented newly diagnosed MI cases, respectively. Standardized clinical and para clinical method were used to ascertain disease and risk factors. Independent sample t-test, Pearson chi square test, Odds ratios and Mantel-Haenszel test and logistic regression analysis conducted to evaluate relationships. Results: This study enrolled 1222 MI cases. Patients with very low risk category of TC/HDL-C ratio estimated OR=0.18 with 95% confidence interval (CI) (0.04-0.72) for developing MI under 55 years. Patients who had low risk category of TC/HDL-C ratio having OR=0.26 95% CI (0.07-0.89). Low risk and very low risk categories of the TC/HDL-C ratio compare to high risk subgroup of the ratio demonstrate decreased risk of developing MI under 55 years p<0.05. Conclusion: Our study results can be translated as an aggressive treatment for lowering TC/HDL-C ratio in both general population and victims of coronary events. Mitigation of the level of TC/HDL-C ratio from low risk to very low risk category will attenuate the risk of MI under55 years about 8% which is the immediate clinical implication of our findings
Acute Gastric Dilation Following Trauma: A Case Report
Get PDFIntroduction: Acute gastric dilation following trauma is an unusual event that can occur in different settings, and can cause gastric necrosis as a rare though fatal condition. The present report involves a case of acute gastric dilation following multiple traumas, which caused gastric necrosis and total gastrectomy. Case presentation: A 19-year-old morbid obese male presented to the emergency department (ED) following a motor vehicle accident. He had a left lower extremity crash injury. In his serial examinations, he was complaining of upper abdominal pain with epigastric tenderness. After nasogastric tube (NGT) reinsertion, due to detecting coffee ground secretions in the drained fluid, the patient was transferred to the operating room. A midline laparotomy was performed that revealed dilation and discoloration of the stomach. Gastric decompression was performed. All the discoloration then disappeared except for that of certain suspicious areas, which necessitated evaluations. On the following day, given the lack of improvement in the patient`s condition, he was transferred to the operating room for a second laparotomy. Conclusion: The present report emphasized on the importance of NGT insertion in multiple-trauma patients, which is, however, neglected in many cases. Moreover, acute gastric dilation is recommended to be considered in the differential diagnosis of patients with multiple or abdominal trauma and complaints of vomiting or abdominal pains
The Correlation of Serum Chloride Level and Hospital Mortality in Multiple Trauma Patients
Get PDFIntroduction: Electrolyte disorder is a prevalent complication in multiple trauma patients; nevertheless, the role of chloride has been rarely addressed in literature when evaluating serum electrolytes. Objective: The present study was conducted to determine the correlation between serum chloride changes and hospital mortality in multiple trauma patients. Method: The present cross-sectional study measured serum chloride levels in 100 multiple trauma patients upon their admission to the emergency department and 24 hours later. All these patients were followed up in terms of hospital mortality using their medical records. Exact logistic regression was used to measure the effects of independent variables on hospital mortality in the patients. Results: Hospital mortality was found to be 15 (15%), and the mean serum chloride level to be 106.37±4.53 mmol/l upon admission and 112.18±6.16 mmol/l 24 hours later. Although the univariate analysis suggested that serum chloride levels were independently associated with mortality 24 hours after admission (P=0.005), this correlation was insignificant in the multivariate analysis. Conclusion: The present study rejected the hypothesis suggesting the potential role of serum chloride levels in predicting hospital mortality in multiple trauma patients
Point-of-care Hemoglobin Measurement in Comparison with Hematology Analyzer: A Cross-sectional Study in Emergency Department
Get PDFIntroduction: Point-of-care hemoglobin testing devices can help emergency physicians to make their clinical decisions in a timelier manner. They can also improve the patient care process by decreasing the length of stay and costs. Although different devices are available now, their diagnostic accuracy remains still uncertain. Objective: This study compares the results of hemoglobin levels measured by a point-of-care hemoglobin testing device and central lab auto-analyzer. Methods: Hemoglobin level was measured both by a point-of-care device (Mission® Plus Hb) and the central laboratory auto-analyzer (Sysmex KX-21N™) in medical cases presenting to emergency department (ED) and requiring hemoglobin (Hb)/hematocrit (Hct) level measurement. The agreement of Hb and Hct between the two methods was assessed based on intraclass correlation coefficient (ICC), Bland-Altman analysis and the Mountain plots. Also, time gap between point-of-care testing and preparation of central lab results was measured. Results: Hb and Hct were measured in 86 cases mostly presented because of gastrointestinal bleeding. We found a good agreement between the two methods for hemoglobin (ICC=0.985) and hematocrit levels (ICC=0.991). The bias was 0.09 and 95% limits of agreement (LoA) were -0.89 to 1.07 for Hb level. Mean of time delay between point-of-care testing and preparation of central lab results was 207.31 minutes (SD=93.66) and this delay was clinically significant (p=0.001). Conclusion: Point-of-care measurement of Hb level provides proper quantitative results in ED patients. It significantly decreases laboratory turnaround time and may be used to improve the patient throughput by decreasing the length of stay in most clinical settings
Characteristics of Adolescent Patients Admitted to the Emergency Department due to Attempted Suicide by Poisoning; a Brief Report
Get PDFIntroduction: In the background of the increased suicide rate in the second decade of life, analysis of the characteristics of poisoning-related attempted suicide in adolescents and evaluation of the differences from adults may form an important basis for establishing measures to prevent deaths from poisoning. Objective: We aimed to investigate the types of toxic substances ingested for attempted suicide by poisoning in adolescents admitted to the emergency department (ED). Method: This cross-sectional study retrospectively analyzed and investigated the medical records of patients aged 13 or older, admitted to the ED of a tertiary medical institute over a period of 3 years, for attempted suicide by poisoning. Results: The psychiatric diagnoses among patients in the adolescent group included depression (75.8%), bipolar disorder (12.5%), and panic disorder (12.5%). In terms of the type of drug used for poisoning, antidepressants or anti-psychotics and sleeping pills were the most commonly used in the adolescent (43 subjects, 45.2%) and adult (286 subjects, 37.6%) groups, respectively. Conclusion: As there is a higher chance of poisoning by easily accessible drugs, the emergency physician needs to investigate any preceding diagnoses of psychiatric or medical illnesses in the adolescent patients attempting suicide with unknown drugs
Atypical Feature of Diabetic Ketoacidosis with Low or Normal Plasma Glucose: a Narrative Review
Get PDFContext: Diabetic Ketoacidosis (DKA) is a well-known emergency in diabetic patients. In a subgroup of patients ketoacidosis is present but is not accompanied by the marked hyperglycemia considered part of the diagnostic criteria for DKA. This is known as Euglycemic DKA (EuDKA). Evidence acquisition: We searched the PubMed for the existing literature on the topic of normoglymic ketoacidosis, including its prevalence, pathogenesis, and treatment. Results: The study showed that there are many reports of the cases in which diabetic patients developed ketoacidosis without experiencing hyperglycemia. Several predisposing factors have been proposed but the precise pathophysiologic mechanisms are still under investigation. Some pathways have been suggested. Timely diagnosis is of paramount importance. Treatment is similar to DKA. Conclusion: EuDKA is a medical emergency that should be considered when evaluating a diabetic patient with ketoacidosis. It should be diagnosed and treated promptly
Educational Intervention Effect on Pain Management Quality in Emergency Department; a Clinical Audit
Get PDFIntroduction: Pain is a frequent complaint of patients who are referred to the emergency department (ED), which is ignored or mismanaged and, almost always, approached in terms of determining the cause of pain instead of pain management. Pain management is a challenging issue in the ED. Objective: This study was conducted to determine the effect of emergency resident’s education about pain assessment and pain-relief drugs in the improvement in pain management. Method: A clinical audit was carried out during the year 2015 in the ED of Imam Hossein Hospital, Tehran, Iran. All patients over 16-year-old who had been complaining of pain or another complaint that included pain were eligible. Data were collected using a preformed checklist. One senior emergency medicine resident was responsible for filling the checklist. In the first phase, patients were enrolled into the study and were divided into two groups according to whether they had or did not have a pain management order. In the second phase, the first- and second-year emergency medicine residents were trained during the various classes that they were required to attend, through a workshop conducted by experienced professors, and based on existing valid guidelines. In the third phase, patients were enrolled into the study, and the same checklists were completed. Results: A total of 803 patients (401 before training and 402 after) were assessed. The mean age of the patients before and after training of the residents was 59.19 ± 44.45 and 40.24 ± 19.40 years, respectively. Table 1 illustrates the demographic information of patients that were not significantly different before and after the training period (p > 0.05). The most common cause of pain was soft tissue injury, both before (36.3%) and after training (34.3%). The most frequent drug that was administered for pain control was morphine, both before (62.5%) and after (41.4%) training. Although the number of patients with moderate pain intensity was higher during the after-training period, pain control quality was described to be better in this group and success rate of pain control was significantly increased after training (p < 0.001). Conclusion: Findings from the present study showed that there was a significant deficiency in pain management of the admitted patients, and the most common reason for this was the physician's fear of the drug’s side effects. However, significant progress was seen after the training regarding pain management process in ED
Preparation and Implementation of Intrahospital Transfer Protocol for Emergency Department Patients to Decrease Unexpected Events
Get PDFIntroduction: Most of the patients hospitalized in the emergency department (ED) are in need of transfer to other hospital wards or paraclinic units. This process is called intrahospital transfer (IHT) that may lead to a wide range of complications known as unexpected events (UE). Objective: In the present study we decided to evaluate the effect of using a pre-designed protocol on decrease of UEs and safety improvement of IHT among patients hospitalized in ED. Method: The present cross-sectional study was carried out in 2016 in the ED of Imam Khomeini Hospital, Tehran, Iran. All patients with triage levels of 1 and 2 who were in need of temporary or permanent transfer to other departments of the studied treatment center based on clinical indication as decided by the in-charge physician were enrolled in the study. This study was conducted in 3 phases of pre-intervention, intervention and post-intervention. Any UE was recorded in first phase. During intervention phase ED-IHT protocol was prepared and implemented. the checklist of complications and UEs during transfer was filled again and pre- and post-intervention results were compared. Results: In this study, 207 patients with the mean age of 58.9 ± 20.6 years were evaluated (61.4% male). Demographic data and baseline characteristics of the studied patients in the phases before and after implementation of the protocol has no significant difference. Overall, before implementation of the protocol out of the 105 studied patients, a total of 35 patients (33.3%) were affected by UE during transfer, but after implementation of the protocol this rate decreased to 11 patients (10.8%) out of the 103 studied patients and this decrease was statistically significant (p < 0.001). Conclusion: Based on the results obtained from this study, it seems that performing the IHT protocol specialized for ED patients has been effective in decreasing UE cases