Frontiers in Emergency Medicine (E-Journal)
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Blunt, Penetrating and Strangulating; Suicidal, Homicidal, Accidental and Sport-Related Neck Injuries: a Case Series and Literature Review
Get PDFIntroduction: Presentation of neck injuries in ER can be with or without neurological deficit. Trauma victims with multiple injuries should be examined for neck injuries as these injuries are potentially life threatening. Further neck movement should be restricted by applying the cervical collar until further radiological investigations rule out the spine injury. Early identification and treatment of neck injuries whether spine, vascular, or muscular injury improve the morbidity and mortality in polytrauma patients. Case presentation: In a series of case presentations of neck injuries through various modes, the first case of neck injury was related to road traffic accident presented with neck pain and paraplegia. In the second case, neck injury was due to suicidal hanging presented with ligature mark over the neck. Third case was related to Indian traditional sport-related neck injury presented with severe neck pain stiffness. In the fourth case, neck injury was due to gunshot and presented with bullet entry wound and quadriparesis. Conclusion: Neck injury in the absence of associated injuries is rarely seen after blunt and penetrating trauma, but can result in devastating outcomes if left unrecognized. A high index of suspicion and early intervention are critical
Diagnostic Accuracy of Focused Assessment with Sonography for Blunt Abdominal Trauma in Pediatric Patients Performed by Emergency Medicine Residents versus Radiology Residents
Get PDFIntroduction: Focused assessment with sonography for trauma (FAST) has been shown to be useful to detect intraperitoneal free fluid in patients with blunt abdominal trauma (BAT). Objective: We compared the diagnostic accuracy of FAST performed by emergency medicine residents (EMRs) and radiology residents (RRs) in pediatric patients with BAT. Method: In this prospective study, pediatric patients with BAT and high energy trauma who were referred to the emergency department (ED) at Al-Zahra and Kashani hospitals in Isfahan, Iran, were evaluated using FAST, first by EMRs and subsequently by RRs. The reports provided by the two resident groups were compared with the final outcome based on the results of the abdominal computed tomography (CT), operative exploration, and clinical observation. Results: A total of 101 patients with a median age of 6.75 ± 3.2 years were enrolled in the study between January 2013 and May 2014. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. A good diagnostic agreement was noted between the results of the FAST scans performed by EMRs and RRs (κ = 0.865, P < 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy in evaluating the intraperitoneal free fluid were 72.2%, 85.5%, 52%, 93.3%, and 83.2%, respectively, when FAST was performed by EMRs and 72.2%, 86.7%, 54.2%, 93.5%, and 84.2%, respectively, when FAST was performed by RRs. No significant differences were seen between the EMR- and RR-performed FAST. Conclusion: In this study, FAST performed by EMRs had acceptable diagnostic value, similar to that performed by RRs, in patients with BAT
Interstitial Nephritis Presenting as Acute Kidney Injury Following Ingestion of Alternative Medicine Containing Lead: A Case Report
Get PDFIntroduction: Some studies have shown that patients consuming alternate medicine can suffer from complications like acute kidney injury (AKI) due to heavy metal poisoning. The use of traditional ayurvedic herbal remedies may be difficult to identify as a source of toxicity, especially if the treating doctor is not aware of this habit, unless a detailed history is taken. In this report, we describe a patient who had consumed ayurvedic supplements for treating fever and abdominal pain and presented to our emergency department (ED) with AKI. Case presentation: A 24-year-old male presented to the ED with complaints of abdominal pain, fever and loose stools. His blood tests revealed AKI and he was started on emergency hemodialysis. His renal function improved after only one cycle of dialysis and he was discharged in a stable condition. Conclusion: Acute lead toxicity should be suspected in patients with abdominal and neurological dysfunction who have a history of chronic ayurvedic medicine intake and thus should be promptly treated. Physicians should rule out potential toxicity from these supplements and have a heightened level of suspicion for lead toxicity in patients presenting with abdominal pain and AKI without any obvious cause
Propofol-Ketamine vs. Propofol-Fentanyl Combinations in Patients Undergoing Closed Reduction: A Randomized, Double-blind, Clinical Trial
Get PDFIntroduction: Painful surgical procedures require adequate sedation and analgesia. A vast array of medications can be used for Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs). Objective: The present study was conducted to compare Propofol-Ketamine (PK) and Propofol-Fentanyl (PF) compounds in patients undergoing closed reduction in EDs. Methods: This randomized, double-blind, clinical trial was conducted on 110 consecutive patients who required sedation for closed reduction. The patients were randomly divided into two groups of equal sizes. The PK group received an intravenous bolus of 1 mg/kg of propofol plus 0.5 mg/kg of ketamine, and the PF group received an intravenous bolus of 1 mg/kg of propofol plus 1 µg/kg of fentanyl. The analgesic effect and success rate were the primary outcomes under study. Results: The PK group achieved more effective analgesia at the end of the experiment. The success rate was almost the same in both groups Shivering (p=0.005) and a drop in oxygen saturation to below 92% (p=0.048) were two side effects that were more prevalent in the FK group . The mean recovery time was significantly shorter in the PK group (p<0.001). The patients in the PK group were more satisfied. Conclusion: In comparison with the PF compound, the use of KP leads to better pain relief and greater patient satisfaction and shorter sedation time in PSA
The Effective Method to Control Bleeding of the Ruptured Hepatic Hemangioma
No full textIntroduction: Hepatic hemangioma is the most common benign tumor in the liver. Although intra-abdominal bleeding associated with its rupture is rare, but life-threatening. Here we report a case of ruptured hepatic hemangioma and applied method for controlling its bleeding. Case Report: The patient was a 45-year-old man who was referred after crashing his motorcycle into a car. The patient’s primary survey revealed intra-abdominal free fluid, but stable vital signs. Thirty minutes later, the patient’s systolic blood pressure dropped to 85 mmHg. Laparotomy was performed a large hemangioma was observed involving almost the entire left lobe of the liver. Using a liver needle and 2-0 chromic suture, we entered the hemangioma at the perforation site of the lower portion of the liver and exit from the upper part. Then, we entered the upper part of the liver and exited from the lower part, and then it was tied. According to this approach, hemangioma was packed from the lower segment of the liver. Conclusion: In this case, the patient’s abdomen was primarily closed without extra packing and embolization. The proposed method thus may be more effective compared to conventionally used methods
Correlation of Patients’ Baseline Characteristics with Success Rate of Cardiopulmonary Resuscitation; a Cross-Sectional Study
Get PDFIntroduction: Many advances have been made in method, applied medications and the skill of the treatment staff for performing cardiopulmonary resuscitation (CPR), yet the rate of mortality following cardiac arrest is still high, which is affected by many factors. Objective: This study was designed and performed aiming to evaluate the effective factors in the success rate of CPR. Method: This cross-sectional study was performed on patients who had undergone CPR in Dr. Shariati Hospital, Isfahan, Iran, from March 2017 to March 2018. A pre-designed checklist was used for data gathering, which included questions regarding demographic data and medical history of the patients, data related to CPR and the final outcome of resuscitation. Results: A total of 190 patients with the mean age of 69.4±17.7 years were evaluated in the present study, 115 (60.5%) of which were male. Overall, 28.9% of CPRs were initially successful and 5.3% of the cases were finally discharged from the hospital. There was no significant correlation between CPR success and age, sex, hospitalization ward, time interval between hospitalization and cardiac arrest, the number of CPR attempts, or working shift (p > 0.05). On the other hand, CPR success significantly correlated with underlying illnesses and the first cardiac rhythm recorded before the initiation of resuscitation (p < 0.05). Conclusion: Based on the findings of the present study, it seems that underlying illness and the initial cardiac rhythm recorded correlate with the probability of CPR success
Good Interdepartmental Relationships: The Foundations of a Solid Emergency Department
Get PDF“No man is an island” said the English poet, John Donne, and nowhere can that statement be better appreciated than in a modern emergency department (ED). As emergency physicians, we work in the setting of a close knit team involving nurses, technicians, consultants, clerks, security guards and many more. On a macroscopic level as well, the ED itself needs productive relationships with every other department in the hospital. Back when the ED was staffed by physicians-in-training, general practitioners and moonlighting specialists, the care of patients was jealously divided between the long-entrenched traditional specialties. Anesthesiologists handled difficult airways; Surgeons took care of trauma; Radiologists did the ultrasounds and read all the films, and so forth. Emergency medicine—a specialty that encompassed parts of many disciplines—was initially met with skepticism and resistance from the traditional fields.
I have been in practice long enough to remember when anesthesiologists fought against emergency physicians doing RSI and how they tried to stop us from using propofol or ketamine for procedural sedation. Orthopedists wanted to be consulted before we reduced a shoulder. Surgeons got angry if you gave morphine to a belly pain patient. In the early 1990’s at the University of Rochester, my colleague, Dr. Steve White, had to sneak into the ED with his own portable ultrasound device (with its postage stamp sized screen), because to have done so openly would have brought down the wrath of radiologists who believed that ultrasonography belonged to their department alone.
These turf battles are mostly a thing of the past, thanks to clinical studies conducted by our specialty that proved what we can and should do. But challenges regarding interdepartmental relationships still remain. In the following discussion we will look at current friction points between the ED and other departments, including radiology, anesthesia, surgery, obstetrics/gynecology, cardiology, and the internal medicine admitting services
Intranasal Ketamine Administration for Narcotic Dose Decrement in Patients Suffering from Acute Limb Trauma in Emergency Department: a Double-Blind Randomized Placebo-Controlled Trial
Get PDFIntroduction: pain management is an important and challenging issue in emergency medicine. Despite the conduct of several studies on this topic, pain is still handled improperly in many cases. Objective: This study investigated the effectiveness of low-dose IN ketamine administration in reducing the need for opiates in patients in acute pain resulting from limb injury. Method: This randomized, double-blind, placebo-controlled trial was conducted to assess the possible effect of low-dose intranasal (IN) ketamine administration in decreasing patients' narcotic need. Patients in emergency department suffering from acute isolated limb trauma were included. One group of patients received 0.5 mg/kg intravenous morphine sulfate and 0.02 ml/kg IN ketamine. The other group received the same dose of morphine sulfate and 0.02 ml/kg IN distilled water. Pain severity was measured using the 11 points numerical rating scale at 0, 10, 30, 60, 120, and 180 minutes. Results: Ninety-one patients with mean age of 31.59 ± 11.33 years were enrolled (38.8% female). The number of requests for supplemental medication was significantly lower in patients who received ketamine (12 patients (30%)) than those who received placebo (27 patients (67.5%)) (p = 0.001). Conclusion: It is likely that low-dose IN ketamine is effective in reducing the narcotic need of patients suffering from acute limb trauma
Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study
Get PDFIntroduction: Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients’ flow in the ED is termed triage. Objective: This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%. Method: This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients’ charts, an expert panel evaluated the validity of the triage level. Results: During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel’s evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen’s weighted kappa being 0.966 (CI 0.985–0.946, p < 0.001) and 0.813 (CI 0.856–0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen’s weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001). Conclusion: The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses
A Rare Case of Gorlin-Goltz Syndrome Presented to the Emergency Department as Facial Swelling
Get PDFIntroduction: Gorlin-Goltz syndrome (GGS), also known as basal cell nevus syndrome, is a very rare autosomal dominant inherited disorder that is characterized by the development of numerous basal cell carcinoma. This article reports a case of GGS, emphasizing its clinical and radiographic manifestations. Case presentation: We report here the case of a 35-year-old man who visited the maxillofacial emergency department due to left facial swelling. According to his clinical and radiographic examination we diagnosed him with GGS with no family history. The patient has multiple odontogenic keratocysts, rib anomalies, calcifications of the falx cerebri, lower jaw prognathism, frontal bossing, macrocephaly, and thick eyebrows. Conclusion: A definitive diagnosis of GGS should be made by a multidisciplinary team including a maxillofacial surgeon and medical specialists. Early diagnosis, treatment, and regular follow up are important to decrease complications, including oromaxillofacial deformation and destruction, and possible malignancy