Frontiers in Emergency Medicine (E-Journal)
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Necrotizing Fasciitis in a Patient with Diabetes Mellitus
Get PDFCase presentation: A 46-year-old man was admitted to the emergency department with complaints of fever and skin lesions in the right leg since 3 days before. Moreover, he revealed a history of 5 years of poorly controlled diabetes mellitus despite being on oral medication. On physical examination, he was oriented and the following vital signs were observed: blood pressure: 80/60 mmHg; pulse rate: 90 beats/min; respiratory rate: 18 breaths/min; and oral temperature: 38 °C. Two large erythematous lesions with central necrosis in the upper segment of the right leg were noticed. Further examination revealed crepitation of the same right leg segment. Laboratory findings revealed the following: white blood cell (WBC) count, 17,000/mm3; hemoglobin, 15 g/dl; sodium, 125 meq/l; potassium, 3.8 meq/l; blood glucose, 400 mg/dl; blood urea nitrogen, 45 mg/dl; creatinine, 2.4 mg/dl; and bicarbonate,13 meq/l. Plain X-ray of right leg revealed gas formation in the soft tissues, which was a diagnostic criterion for necrotizing fasciitis (Figure 1). The patient was treated immediately with intravenous fluid, broad spectrum empiric antibiotics (meropenem plus vancomycin), and insulin infusion; moreover, urgent surgical consultation was requested. He underwent emergency debridement within few hours of hospitalization
Effect of Implementation of Standard Clinical Practice Guideline on Management of Gastrointestinal Bleeding Patients in Emergency Department; a Cross-Sectional Study
Get PDFIntroduction: A clinical practice guideline (CPG) is developed with the aim of improving the quality of health care and reducing unnecessary interventions, hospitalization time, and related costs. Objective: This study attempted to design a standard protocol for gastrointestinal bleeding (GIB) patients. Method: This was a cross-sectional study conducted during 2013 and 2014 in an educational medical center in Isfahan, Iran. A checklist containing questions about waiting time for the services, hospitalization time, and costs was completed for the GIB patients. After this primary data gathering, a CPG was designed, codified, underwent several revisions, and finally implemented. Thereafter, the checklist was completed by GIB patients and compared with the previous ones. Result: Fifty patients in each of the two phases were included. The mean age and sex of the studied patients were not different. The time from emergency departments (ED) arrival until the first visit (14 ± 9.8 Vs. 19.4 ± 13.4 minutes; p = 0.03), hospitalization (73.7 ± 49.2 Vs. 116.2 ± 7.2 hours; p=0.003) and costs (1.3 ± 0.81 Vs. 3.68 ± 3.51 million rials; p < 0.001) were significantly reduced following the CPG implementation. The time from admission until conducting endoscopy was not different in the two study periods (16.5 ± 7.8 Vs. 23.9 ± 24.5 hours, p = 0.89). Conclusion: The implementation of the CPG for the management of GIB patients in the ED resulted in a reduction in the waiting time for the services and, further, reduction of hospitalization time and related costs
Sample Size Calculation Guide - Part 1: How to Calculate the Sample Size Based on the Prevalence Rate
Get PDFSample size calculation is an essential methodological issue in clinical research. It is crucial to ensure that the study has sufficient participants in order to detect the expected effect estimate. Moreover, it has been advocated that the underpowered clinical trials lead to wastage of time, money, and resources, and are not ethical as they do not generate expected results and expose the patients to a higher risk. Considering the importance of this methodological point, we shall commence the research methodology section of the Advanced Journal of Emergency Medicine with a series of educational letters explaining the method to calculate the sample size for various clinical research study designs. For more illustration, each educational note will be accompanied by a real-life example from the published articles in emergency medicine research. This is the first article of our educational series where we have explained the sample size calculation based on a prevalence rate
Upper Gastrointestinal Bleeding as Delayed Presentation of Traumatic Diaphragmatic Hernia: a Case Report
Get PDFIntroduction: Traumatic diaphragmatic hernia (TDH) is one of the critical complications resulting from penetrating chest trauma. The rate of undiagnosed TDH equivocates 12-60%. The significant part of complications happens 1-4 years after the primary damage. Here, we report a case of delayed TDH presented with upper gastrointestinal bleeding (GIB) as an excuse to discuss this issue. Case presentation: The patient was a 35-year-old man, admitted with objection of abdominal pain. A nasogastric tube was inserted and fixed that resulted in drainage of about 500cc dark blood. He was candidate for emergent endoscopy due to upper GIB. During resuscitation measures, he suddenly developed respiratory distress that could not be justified by upper GIB alone. Therefore, bedside sonography discovered some soft tissue apart from lung tissue in the left hemithorax. After performing diagnostic measures, with diagnosis of diaphragmatic herniation and strangulation he underwent emergent surgery. Conclusion: Small diaphragmatic lesions, which usually result from stab wounds, may develop into larger injuries if left untreated and they might lead to a diaphragmatic hernia with a potential risk of early or late complications and mortality. One of the rare complications is GIB, which should be considered in a patient with past history of trauma and presentation of GIB
Reverse Triage to Increase the Hospital Surge Capacity in Disaster Response
Get PDFIntroduction: Successful and effective management of large-scale disasters and epidemics requires pre-established systematic plans to minimize the damage and control the situation. With an increasing number of people in need of urgent medical care, hospitals must improve their response capacity, being at the forefront of responding to disasters and incidents. One way to develop the hospital capacity in disaster response is by reverse triage (RT). Objective: The current study was conducted to investigate the role of RT to create additional hospital surge capacity in one of the major referral academic hospitals of Isfahan, Iran. Method: This cross-sectional study was conducted in 2015 at Al-Zahra Subspecialty Hospital, Isfahan, Iran. The ten most common diseases leading to hospitalization in each ward of the hospital in 2014 were reviewed and, based on the prevalence, sorted and listed. Academic instructions for making a decision and possibility of early discharge was written and approved by an expert panel. On a day that was not set previously, the pre-selected in-charge person of each department was asked to run the RT following the instructions, and the number and percentage of those who were eligible for discharge via RT were determined. Results: The total BOR in Al-Zahra Hospital in 2014 was about 80%, so it was estimated that almost 140 out of 700 beds are vacant. The results showed that by using RT, 108 (20%) hospitalized cases could be discharged, and considering the bed occupancy rate of about 80% and 140 vacant beds, a total of 248 beds could be provided following RT. Conclusion: Running RT in 41 wards and units of Isfahan Al-Zahra Hospital, on average, added 108 beds to the hospital capacity. This increment is not the same in all wards, as the role of intensive care units in RT for surge capacity is insignificant
Accuracy of Extended Focused Assessment with Sonography in Trauma (e-FAST) Performed by Emergency Medicine Residents in a Level One Tertiary Center of India
Get PDFIntroduction: It could be claimed that extended focused assessment with sonography for trauma (e-FAST) is the most important use of ultrasound in every emergency department (ED). It is a rapid, repeatable, non-invasive bedside method that was designed to answer one single question, which is, “whether free fluid is present in the peritoneal, pleural and pericardial cavity or not?” This examination may also be used to evaluate the lungs for pneumothorax. Objective: The current comparative study was conducted to assess the accuracy and reproducibility of e-FAST performed by emergency medicine residents (EMRs) and radiology consultants (RCs) in multiple trauma patients. Method: This diagnostic accuracy study was conducted prospectively in patients presenting over a period of 12 months from January 1, 2013, to December 31, 2013 to the ED of Kerala Institute of Medical Sciences (KIMS), Kerala, India. All multiple trauma patients older than 18 years of age presenting within 24 hours of their traumatic event, who underwent both e-FAST and thoracoabdominal computed tomography (CT) scan were included. The e-FAST exams were first performed by the EMRs and then by RCs. The thoracoabdominal CT scan findings were considered as the gold standard. The results were compared between both groups to assess the inter-observer variability. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated both for EMRs and RCs. Results: In the study period, 150 patients with a mean age of 42.06 ± 18.1 years were evaluated (76.7% male). Only 19 cases (12.7%) had a history of fall from a height, and the others were admitted due to RTA. Thirty-four cases (22.7%) did not require surgery; but the others underwent various interventions. Both EMRs and RCs reported positive findings in 20 cases (13.3%) and negative findings in 130 cases (86.7%). The correlation of e-FAST done by EMRs with that by RCs was 100%. E-FAST exam had a sensitivity of 90.4%, specificity 99.2%, PPV 95.0%, NPV 98.4%, and accuracy 98%, both for EMRs and RCs. Conclusion: Based on the findings, the sensitivity, specificity, and accuracy of e-FAST exams performed by EMRs were equal to those performed by RCs. It seems that e-FAST performed by EMRs were almost accurate during the initial trauma resuscitation in the ED of a level one trauma center in India
A Case of Cerebral Venous Sinus Thrombosis Presenting with Delirium
Get PDFA 73-year-old woman with no history of headache, seizure and trauma was admitted to the emergency department complaining about fever, vomiting and delirium for 3 days. She was lethargic upon admission and her blood pressure (BP) was recorded as 140/90 mm/Hg, her pulse rate (PR) as 75 beat/min and oral temperature as 38 °C. No localizing findings were observed in neurological examinations. Laboratory findings were as follows: White Blood Cell (WBC) count: 7,000/mm3, Hemoglobin: 13 g/dl, Platelet count: 300000. Lumbar CSF, blood and urine cultures were found to be negative for infections. Brain Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) were also performed. MRI showed filling defects in the left transverse sinus, the jugular bulb and the internal jugular vein. Moreover, hyper-intense signal was observed in the left temporal lobe (T1 sequence) suggesting hemorrhagic venous infarction (Figure1). The obtained results were confirmed by Magnetic Resonance Venography (MRV) of the brain (Figure2). The patient underwent anticoagulation therapy using LMWH and she was? hydrated using physiologic solution. The patient’s symptoms disappeared and she was then followed up regularly
Coagulation Disorder following Red Clover (Trifolium Pratense) Misuse: a Case Report
Get PDFIntroduction: An increasing variety of alternative health care products and supplements known as over-the-counter (OTC) or non-prescription herbal medicines are taken by patients for different reasons. Unfortunately, these self-prescribed remedies have many food and drug interactions and unknown adverse effects and can lead to some important consequences. Case presentation: Here a case of bleeding disorder in a 28-year-old woman taking red clover is reported. She had no history of warfarin use, but warfarin was detected in her blood serum analysis. Conclusion: This agent is a source of natural coumarin and can cause an increase of international normalized ratio (INR) and bleeding. It is important that prescribers be alert to the possible disadvantage of herbal remedies and also probable herb-drug and herb-food interactions
Pituitary Macroprolactinoma with Mildly Elevated Serum Prolactin: Hook Effect
Get PDFA 45-year-old man was admitted in our department with complaints of severe headache for over 6 months period. He also suffered from several problems such as visual field defect, decreased energy and libido, body hair loss, cold intolerance, decreased appetite and dry skin. On physical examination, he was afebrile: BP (blood pressure): 110/70 mm/Hg, PR (pulse rate) :65 beat/min, BMI (body mass index): 24. He had no terminal hair on face or chest and subcutaneous adipose tissue mass had been decreased substantially. Laboratory tests revealed; Hb: 12 g/dL (N: 14–17 g/dL), Total testosterone: 1.2 ng/mL (N:–-10 ng/mL), Luteinizing hormone (LH):3.3MIU/mL (N:1–8 MIU/mL), Follicle Stimulating hormone (FSH):1.3 MIU/mL (N:1–7 MIU/mL), T4:3.4 micg/dL (N:4–12 micg/dL), TSH:0.6 MIU/mL (N:0.5–5 MIU/mL), Prolactin:100 ng/mL (2–24 ng/mL), serum cortisol:6 MIU/mL (N:4–21 MIU/mL), IGF1:162 ng/mL (50–245). Pituitary MRI showed macroadenoma (29*16*14 mm) in left side of sella turcica which bulged to suprasellar cistern with pressure effect on left optic nerve (Figure 1, 2). Visual field examination revealed mild temporal hemianopia. These findings are consistent with macroadenoma and mild prolactin elevation. We also observed a discrepancy between pituitary tumor size and prolactin level. The correct estimate of serum prolactin was obtained after serial dilutional measurement. Serum prolactin after dilution was 6470 ng/mL. With these findings pituitary macroadenoma was diagnosed and treatment with cabergoline (dopamine agonist) 0.5 mg/week was started. After one month follow-up he had no symptoms, visual field defect was improved and pituitary MRI showed significant shrinkage of tumor
The Relationship between Orotracheal Intubation Difficulty Scoring Systems and Anthropometric Factors
Get PDFIntroduction: Although rare, but it is very important to understand that intubation will be difficult for which of the patients. Some scoring systems are available in this regard that influenced by many factors such as body anthropometric factors. Objective: This study was conducted to investigate the relationship between Mallampati score, biting the upper lip as well as 2-3-3 maneuver with body anthropometric factors in different population of society. Method: This cross-sectional study was conducted during the years 2014-2015 in Yazd, Iran. The subjects using simple randomized sampling method, and they were included in study after obtaining their informed consent. Demographic (age and gender) as well as anthropometric parameters of body, including weight, height, neck, waist circumference, hip circumference, body mass index (BMI) and waist-to-hip ratio (WHR) were collected in a pre-prepared checklist. Then, Mallampati score, biting the upper lip score, maneuver 2-3-3 were examined and calculated by researchers. The results of these examinations were recorded for each person in checklist. Results: In this study, 498 people with mean age of 42.1 ± 16.1 were enrolled (51% female). Based on results of this study, although all three methods significantly correlated with age but none had any relation with gender. Significant relationship was found between upper lip biting and Mallampati score and all body anthropometric factors evaluated in this study (p < 0.05). By increasing the mean of these factors, Mallampati score increases, while this relationship is reverse in the case of height. In addition, significant correlation was found between maneuver 2-3-3 and weight, height, waist circumference, hip circumference and BMI, while it showed no correlation with neck circumference (p = 0.328) and WHR (p = 0.121). Conclusion: Based on findings of current study, it is likely that upper lip biting test and Mallampati score have significant relation with all body anthropometric factors evaluated in this study. But maneuver 2-3-3 has no correlation with neck circumference and WHR