Frontiers in Emergency Medicine (E-Journal)
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Prof. Abdelouahab Bellou, MD, MSc, PhD; Director of Quality & Safety, Administration & Leadership, and International Emergency Medicine Fellowship, Harvard Medical School, USA
Get PDFDo Patients with Chest Pain Benefit from Installing Triage System in Emergency Department?
Get PDFIntroduction: Chest pain, which can be cardiac or non-cardiac and either benign or life-threatening, needs appropriate diagnosis and treatment in emergency department (ED). Objective: The aim of this study was to compare delivery time of primary care for patients with chest pain before and after applying triage system in ED. Methods: Medical records were reviewed of thirty patients (group one) with chief complaint of chest pain who referred to ED between April and July 2008 (before installing triage system) and thirty-five patients (group two) with the same chief complaint who referred between August and September 2009 (after installing triage system). Time between patients’ arrival and beginning of diagnostic and therapeutic interventions including cardiac monitoring, first physician visit time, intravenous line insertion, and electrocardiogram performance were compared between the two groups. Results: Based on the findings, the mean age and sex ratio of studied patients in the two groups were not significantly different (p>0.05). Door to ECG performance, Door to intravenous line insertion, and Door to cardiac monitoring were significantly shorter in post triage installing period than previously (p<0.001). Door to first visit by physician was not statistically different in the two study periods (p=0.421). Conclusion: It is likely that patients with chest pain who referred to ED benefit from installing triage system in terms of performing some nursing care including ECG performance, starting cardiac monitoring, and IV insertion
A 27-years-old Man with Abdominal Pain; Lead Toxicity
Get PDFCase presentation: A 27-year-old man came to our emergency department with chief complaints of abdominal pain, nausea and vomiting, colicky pain in all area of abdomen without any radiation and generalized myalgia. In his background, he had no previous medical problem. In his social history he had worked in an automobile battery-reclaiming factory for 5 years. During his physical examination, his appearance was pale with perioral priority, ill and agitated but not toxic with a blood pressure of 127/85 mmHg and a pulse of 80 beats/min, respiratory rate of 14 breaths/min and oral temperature of 37.3 °C, mild generalized abdominal tenderness without rebound. No obvious signs of sensory and motor neuropathy were found. In the head and neck examination, we found lead-lined teeth.
Learning points: The most common cause of chronic metal poisoning is lead. Exposure occurs through inhalation or ingestion. Both inorganic and organic forms of lead that exist naturally produce clinical toxicity. Gastrointestinal manifestations occur more frequently with acute rather than with chronic poisoning, and concurrent hemolysis may cause the colicky abdominal pains. Patients may have complained of a metallic taste and, with long-term exposure, have bluish-gray gingival lead lines. In addition, constitutional symptoms, including arthralgia, generalized weakness, and weight loss raises the possibility of lead toxicity
A 58-year-old Man with Abdominal Pain; Acute Appendicitis due to an Appendicolith
Get PDFCase presentation: A 58-year-old man presented to the emergency department with abdominal pain, nausea and loss of appetite for the last 8 hours. He reported diffuse pain that had been localized to the right lower quadrant (RLQ). Physical examination revealed muscular defense and tenderness in the RLQ. Computed tomography (CT) of the abdomen and pelvis confirmed luminal distension with a thickened enhancing wall with an appendicolith.
Learning points: Appendicitis may be developed by an appendicolith, a calcified deposit within the appendix. It may be an incidental finding on an abdominal radiograph, ultrasound (US) examination or CT. It appears as echogenic focus and casts an acoustic shadow on US examination and manifests as a calcified mass on plain radiograph or CT. The incidence of appendicolith is higher among patients with a retrocaecal appendix. In our patient, a clinical diagnosis of acute appendicitis was made and the patient was immediately transferred to the operating room and an appendectomy was performed
Jejunal Perforation Following Blunt Abdominal Trauma; a Case Report
Get PDFIntroduction: The possibility of intestinal injury for all patients presenting to emergency department (ED) with blunt abdominal trauma, despite minimal physical signs should be considered. To highlight the patient management, hear, we report a case of hollow viscus injuries resulting from blunt abdominal trauma referring to a teaching hospital in Tehran, Iran. Case presentation: A 30-year-old man presented to the ED after “falling into a hole” with his back and had direct blunt abdominal trauma by a heavy bag of cement. In physical examination, there was a mild abdominal tenderness on right upper quadrant. On bedside ultrasonography, there was small free fluid in his Morison’s pouch without hypotension. So abdominal CT scan was performed which revealed free fluid in pelvic, perihepatic, and perisplenic spaces. Mural hematoma of proximal part of jejunum with mural wall hypodensity in mid jejunal loop were also revealed. The patient underwent surgery, and there was damage to the colon serosa and jejunal perforation which was primarily repaired. Conclusion: The presented case highlights the importance of obtaining history and physical exam and paying attention to the nature and mechanism of injury. Emergency physicians should be aware of hollow viscus injury in traumatic patients. Any delay in diagnosis and operative management are associated with an increase in mortality
Artificial Intelligence-Based Triage for Patients with Acute Abdominal Pain in emergency Department; a Diagnostic Accuracy Study
Get PDFIntroduction: Artificial intelligence (AI) is the development of computer systems which are capable of doing human intelligence tasks such as decision making and problem solving. AI-based tools have been used for predicting various factors in medicine including risk stratification, diagnosis and choice of treatment. AI can also be of considerable help in emergency departments, especially patients’ triage. Objective: This study was undertaken to evaluate the application of AI in patients presenting with acute abdominal pain to estimate emergency severity index version 4 (ESI-4) score without the estimate of the required resources. Methods: A mixed-model approach was used for predicting the ESI-4 score. Seventy percent of the patient cases were used for training the models and the remaining 30% for testing the accuracy of the models. During the training phase, patients were randomly selected and were given to systems for analysis. The output, which was the level of triage, was compared with the gold standard (emergency medicine physician). During the test phase of the study, another group of randomly selected patients were evaluated by the systems and the results were then compared with the gold standard. Results: Totally, 215 patients who were triaged by the emergency medicine specialist were enrolled in the study. Triage Levels 1 and 5 were omitted due to low number of cases. In triage Level 2, all systems showed fair level of prediction with Neural Network being the highest. In Level 3, all systems again showed fair level of prediction. However, in triage Level 4, decision tree was the only system with fair prediction. Conclusion: The application of AI in triage of patients with acute abdominal pain resulted in a model with acceptable level of accuracy. The model works with optimized number of input variables for quick assessment
Emergency Medicine as an Academic Discipline: Giants strides along an Endless Path
Get PDFFor many years, emergency care had been abandoned and left in the hands of practitioners whose main interest was not working in the not-so-much respected “emergency room (ER)”. They were usually obliged to serve the first years of their career in the ER, where senior colleagues did not want to be bothered with, before they were allowed to focus on their ultimate goals. This fact had led to delivery of a fragmented, suboptimal care to the patients who were seeking care for the most urgent threats to their health. Not only were these emergency physicians’ novice and inexperienced, but they also suffered from an inevitable tunnel vision rooted in their primary specialty, which adversely affected their practice by causing inability to take care of the often undifferentiated ER patients. Another issue, which resulted from this model of emergency care, was that some areas of emergency care did not fit well into the realms of the existing specialties and so had remained under-developed for many years. These included but were not limited to topics such as pre-hospital and disaster medicine, environmental and wilderness medicine. Last but not least on the list of problems that emergency care faced was the problem of stewardship and leadership, something that the emergency room urgently needed. With people considering the ER as a platform for their next move in their career, or as a marshland they were stuck in, one could not expect a long-term visionary, strategic plan. Being faced with these challenges, the community of medicine resigned itself to giving birth to a new specialty: “emergency medicine”. It was then that the now-called “emergency departments (ED)” were staffed by professionals whose first and ultimate work arena was the ED; their main interest and focus was to deliver high quality care to the critically ill and injured people who were brought to the EDs. Moreover, their training and experience were also related to the emergent situations and their broad vision and multi-tasking capabilities made them very suitable for work in the hectic environment of the ED. With increasing utilization of the EDs and diversity of the services provided, the role of these physicians in the healthcare system became more pronounced.
Although first created with an intention of service delivery in mind, this new specialty has experienced tremendous advancements; changes that not only have resulted in its further establishment, but also have transformed it into an “academic discipline”. Like any other academic discipline, emergency medicine incorporates elements such as expertise, people, communities, and research areas. Formation of communities such as American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), and International Federation for Emergency Medicine (IFEM) as well as the scientific bodies such as American Board of Emergency Medicine (ABEM) endorsed this position and emergency medicine successfully introduced itself to the academia. Emergency medicine residency programs flourished throughout the United States and around the world and new fellowships and subspecialties emerged. Emergency medicine programs were active and vigorous and contributed a lot to the field of medical education. Research activities were also part of this movement and led to the compilation of an enormous amount of evidence pertaining to the practice of emergency medicine. These pieces of evidence have found their way into the guidelines and protocols developed by well-known scientific organizations. This added to the reputation of emergency medicine among other disciplines.
In Iran, since the establishment of this specialty in the country about 25 years ago, a more or less similar path has been followed. Beginning with only one program, there are now 25 emergency medicine residency programs around the country with around 350 medical graduates entering these programs. The national board is well established and the Iranian Society of Emergency Medicine functions as a member of IFEM. Emergency medicine trained specialists are working in tandem with the most recent advances in emergency and critical care in highest volume emergency departments, which are now much better equipped than in the past. Emergency medicine has become an integral part of the medical curriculum at undergraduate level and now several other specialties also ask their residents to do a clinical rotation in the emergency department under the supervision of emergency medicine attending physicians. In addition to these achievements, one should not forget the huge share of this discipline in the research products. While there is still a long way ahead, many cutting-edge research projects have been accomplished and the results have been published in prestigious emergency medicine journals. However, the presence of a platform for dissemination of the results of these scholarly activities at a national level is an urgent need. Many researches are of interest to a national or local readership and not necessarily for a wider population around the world. Furthermore, many manuscripts are facing difficulty getting published due to non-academic reasons such as the problems with paying the publication fees or the reluctance of the journals to be in contact with scholars from Iran for political reasons (or excuses), including sanctions.
With the successful experience of the first Iranian emergency medicine journal, the emergency department of Tehran University of Medical Sciences decided to launch a journal that matches the high standards of this old and outstanding university. We hope that this endeavor will provide the scholars of the emergency medicine discipline as well as other investigators with an opportunity to publish their manuscripts and benefit from the input of other colleagues. We also hope to promote the position of this journal to a well-known academic journal in the region. In doing so, the editorial board will eagerly wait for the constructive feedback of our esteemed audience. 
Comparing the Effects of Hydroxyethyl Starch and Albumin in Cirrhotic Patients with Tense Ascites; a Randomized Clinical Trial
Get PDFIntroduction: Large-volume paracentesis is one of the usual treatments for cirrhotic patients with tense ascites, which may cause different complications including decreased cardiac preload, suppressed renin angiotensin system, inactivation of sympathetic nervous system, electrolyte imbalances, etc. Objective: The aim of this study was to compare the effects of administrating hydroxyethyl starch (HES) and albumin in cirrhotic patients with tense ascites in order to reduce the paracentesis complications. Methods: In the present randomized clinical trial, 108 cirrhotic patients with tense ascites were enrolled. The patients were randomly divided into 3 groups. In group A, albumin 20% with 5 g/L dose of paracentesis fluid, in group B, HES 6% dissolved in saline were administered, and in group C, a combination of albumin 20% and HES 6% with half the dosage administrated to two other groups were prescribed. Then biochemical panel, and liver function tests and renal and electrolyte complications were compared between the groups. Results: The results obtained after intervention did not show significant differences between the groups regarding weight (p=0.102), heart rate and platelet count (both p=0.094), hematocrit (p=0.09), creatinine (p=0.421), serum sodium (p=0.743) and potassium (p=0.147), total bilirubin (p=0.375) and urine volume (p=0.421). Additionally, we concluded that mean arterial pressure of patients who had received albumin was higher than the other 2 groups (p < 0.001). Conclusion: The results of the present study showed the similar effects of HES and albumin in cirrhotic patients with tense ascites undergoing large-volume paracentesis
Outcome of Trauma Patients Admitted to Emergency Department Based on Full Outline of Unresponsiveness Score
Get PDFoai:ojs.ajem.tums.ac.ir:article/1Introduction: Full Outline of Unresponsiveness (FOUR) score is one of the existing scoring scales, which has been used for evaluating the level of consciousness in recent years. Objective: The present study has been done with the aim of evaluating the ability to predict the outcome of patients with head trauma based on FOUR score on admission to emergency department (ED). Methods: In the present prospective cross-sectional study, head trauma patients with any changes in alertness level presenting to ED were evaluated. FOUR score measurement was done on admission and 6 hours after that. The studied outcomes in the current study included discharge without sequel, discharge with neurologic sequel, brain death or death during 1 month after admission of the patients. To evaluate the correlation between FOUR score and the studied outcomes, area under the receiver operating characteristic (ROC) curve was used. Results: In the end, 52 patients with the mean age of 32.67 ± 15.20 years were evaluated (84.6% male). Traffic accident with the frequency of 39 (75.0%) patients was the most common mechanism of trauma among the studied patients and finally, after 1 month follow up it was determined that 13 (25%) patients were discharged without sequel and 31 (59.6%) died. Area under the ROC curve for prediction of the final outcome of death using FOUR score on admission and after 6 hours were 0.889 (95% confidence interval: 0.800 - 0.977) and 0.974 (95% confidence interval: 0.938 – 1.000), respectively. Best cutoff points for FOUR score were the scores 8 and 9 on admission of the patients, and the score 5, six hours after admission. Conclusion: Based on the findings of this study, it seems that FOUR score is applicable for prediction of probable death outcome in patients with head trauma presenting to ED
Two Different Endotracheal Tube Securing Techniques: Fixing Bandage vs. Adhesive Tape
Get PDFIntroduction: Emergency physicians should secure Endotracheal tubes (ETT) properly in order to prevent unplanned extubation (UE) and its complications. Despite various available endotracheal tube holders, using bandages or tape are still the most common methods used in this regards. Objective: This study aimed to compare adhesive tape (AT) versus fixing bandage (FB) method in terms of properly securing ETT. Methods: This was an observational longitudinal trial. All patients older than 15-years-old admitted to the ED who had indication for ETT insertion were eligible. Patients were randomly assigned to one of the two groups in which AT or FB was applied. All patients were observed thoroughly in the first 24 hours after intubation. Using a pre-prepared checklist, encountered UE rate and other data were recorded. Results: Seventy-two patients with the mean age of 55.98 ± 18.39 years were finally evaluated of which 38 cases (52.8%) were male. In total, 12% of patients in our study experienced unplanned extubation. Less than 12% of the patients experienced complete UE; there was no statistically significant difference between the two groups (p = 0.24). Comparison of UE with age showed no significant difference (p = 0.89). Male patients experienced more UE, but this was not statistically significant (p = 0.44). Conclusion: It is likely that whether the AT method or FB was applied for securing the ETT in emergency departments, there was no significant difference in rates of unplanned extubation