Frontiers in Emergency Medicine (E-Journal)
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Comparison of infusion of dexmedetomedine and magnesium sulfate on the stability of hemodynamic status during emergency orthopedic surgery: a randomized double-blind clinical trial
Get PDFObjective: Preparing patients for emergency surgeries requires accurate consideration of their clinical condition and medical history to avoid potential hemodynamic instability and compromise the immune system. This study aims to compare the effects of dexmedetomidine and magnesium sulfate infusions in maintaining stable hemodynamics during emergency orthopedic surgery. Methods: The present study was conducted as a randomized and double-blind clinical trial with the participation of 80 patients who were candidates for an emergency orthopedic surgery during 2021. Magnesium sulfate was administered as an intravenous bolus at a loading dose of 50 mg/kg over 10 minutes, followed by a continuous infusion at a rate of 15-20 mg/kg/hour. Dexmedetomidine was administered as an intravenous bolus at a loading dose of 1 mcg/kg over 10 minutes, followed by a continuous infusion at a rate of 0.2-0.7 mcg/kg/hour, depending on patient response. These infusions were initiated 15 minutes before induction of anesthesia and continued until the end of surgery. All drugs (dexmedetomidine and magnesium sulfate) were diluted in a 50-cc syringe and infused. The hemodynamic status (diastolic blood pressure (DBP), systolic blood pressure (SBP) mean arterial pressure (MAP) and heart rate (HR)) of the patients between the two groups was recorded and finally compared with each other. Results: The hemodynamic status (DBP, SBP, MAP and HR) between the two groups at all (perioperative time) times were without significant statistical differences (P˃0.05). Conclusion: Both dexmedetomidine and magnesium sulfate are effective and safe options for achieving hemodynamic stability during emergency orthopedic surgery
A tremendous year terminated, and a bright future is expected
Get PDFThe year 2023 terminated and we need to prepare ourselves for a fresh start and a bright future in the coming year. To accomplish this task, the editorial team of Frontiers in Emergency Medicine (FEM) looks back on the past and reflects on the successes and failures of the journal
Difficult intubation in critical patient: how can we manage it? a case report
Get PDFDifficult airway management represents a challenge. Guidelines recommend choosing the airway technique based on physicians’ skills, equipment, available devices and context. Supraglottic airway devices are recommended in cases of unanticipated difficult intubation after endotracheal intubation failure. They are used to ensure satisfactory oxygenation and occasionally to guide the endotracheal tube. Fiberscope is useful to ensure vision of larynx and trachea in these scenarios. This is a unique case of emergency and difficult airway management using this combined approach. In our experience, oxygenation with laryngeal mask and intubation through the mask under endoscopic vision is valid combination technique
Comparison of intranasal versus intravenous dexmedetomidine in postoperative pain control in traumatic mandibular fractures surgery: a randomized clinical trial
Get PDFObjective: Effective pain management in mandibular fractures is crucial due to the complications associated with opioids, such as respiratory depression and re-intubation. Non-opioid methods are therefore important. This study aims to compare the effectiveness, safety, and efficiency of intranasal (IN) versus intravenous (IV) dexmedetomidine (Dex) for reducing acute pain following mandibular surgery. Methods: This study was a randomized, double-blind clinical trial. All patients underwent general anesthesia, laryngoscopy, and intubation in a standardized manner. For the IN administration group, Dex was prescribed at a dose of 0.2 µ/kg (in the form of drops) half an hour before the start of anesthesia. For the IV administration group, Dex was administered at a dose of 0.5 µ/kg intravenously over ten minutes, half an hour before anesthesia. During the first 24 hours after surgery, pain intensity and the total amount of opioid medication (measured in mg of pethidine) were recorded for each patient. Results: There was no significant difference in pain intensity between the two groups in the post-anesthesia care unit (P=0.898), one hour (P=0.052) and 24 hours post-surgery (P=0.898). However, pain intensity was significantly lower in the IN Dex group at the second (P=0.044), fourth (P=0.041), sixth (P=0.048), and twelfth (P=0.025) hours. Total pethidine injected in the IN Dex group was significantly lower than in the IV Dex group (P=0.041). Conclusion: This study underscores the efficacy of IN Dex as a viable alternative for postoperative pain management in traumatic mandibular fracture surgeries
Hospital safety index: evaluation of the readiness and safety of hospitals in Isfahan province, Iran
Get PDFObjective: Hospitals play a vital role in disaster management and their function must be maintained during crises. Isfahan province is susceptible to major crises and disasters at any time of the year. The study aimed to investigate the hospital safety index (HSI) in hospitals in Isfahan province. Methods: This cross-sectional study was conducted using the HSI questionnaire of the world health organization. The safety of all 55 hospitals in Isfahan province was evaluated with the Persian version of the questionnaire from 2017 to 2022. In this study, all hospitals were evaluated by a group of experts from the emergency operations center (EOC) of Isfahan University of Medical Sciences, and the checklists were completed with the cooperation of the hospital disaster committee, visiting the hospitals, and interviewing the personnel. Results: The safety level of hospitals has improved from 2017 to 2022 so in 2022, 38 hospitals (69.09%) had a high safety level, and 17 hospitals (30.91%) had a medium safety level. This increase in safety has happened in all three components of safety (functional, non-structural, and structural safety). There was no significant difference in the overall hospital safety score between academic-educational, non-academic governmental, social security and military, and private and charity hospitals (P<0.05). Conclusion: Although the safety in the hospitals of Isfahan province has improved due to the continuous disaster prevention and preparedness activities, hospitals still need to improve to achieve higher levels of safety. The HSI shows how well a hospital can maintain its organization and performance during disasters. This index will be useful for decision-making and policy-making to prioritize administrative and civil interventions
The level of education of drivers is a main human factor in road traffic crashes
Get PDFI read Zemestani et al.'s paper titled ''Measuring the effect of vehicle safety on road traffic crash severity in Iran: using structural equation modeling'' with interest and enjoyed it a lot. The authors studied the association between vehicle safety and the severity of traffic crashes and evaluated the effects of various variables, including human factors, on the outcomes of road traffic crashes. Although the researchers investigated various human factors using different questionnaires and provided great information, they did not assess the drivers’ educational attainment as a potential human variable. If they had assessed the level of education of the drivers as a human factor, they could have improved the results of their study.Haddon provided a matrix to explain the determinants influencing injuries and classified them into human, vector, physical, and social factors in 1980. Furthermore, researchers showed that the socio-demographic status of drivers (e.g., their educational attainment) is a human factor influencing road traffic accidents (RTA). Murray evaluated the school background of 2,980 male and 1,054 female young drivers who injured due to traffic accidents in Sweden. The educational attainment of the drivers was compared with representative samples of the same gender and age groups. The results showed that educational attainments were powerful determinants explaining RTA risk.Moreover, Spoerri and colleagues assessed some demographic factors of RTA mortality in Switzerland. They showed that the risk of RTA was higher in those with primary education compared to people with higher educational attainment (hazard ratio=1.53; 95% CI: 1.29,1.81). Likewise, Arroyave et al. studied the association between educational level and premature mortality for specific causes of death, including RTA, in Colombia. They confirmed that RTA were more common in those with primary and secondary education than those with tertiary education. Furthermore, Harper and colleagues investigated educational level differences among those with fatal motor vehicle accidents from 1995 to 2010. They found an increase in adjusted death rates among people with less than a high school diploma compared to all other groups of educational levels.Also, my colleagues and I studied such a relationship based on the national trauma registry of Iran (NTRI) and published the results recently. In the study, using multiple logistic regression, we showed that the odds of fatal injuries among victims with no formal, primary, and secondary education levels were significantly more than the odds of deaths among those with higher education levels. Moreover, in another study, my colleagues and I found a negative association between years of schooling and the risk of road traffic deaths. In conclusion, appreciating the onerous efforts of Zemestani and colleagues, they had to consider the education variable in their analysis. The results can inform policymakers and health authorities to provide more training courses for people with lower educational levels. I hope our previous studies at the NTRI can be helpful to the Frontiers in Emergency Medicine’s readers
Effects of altitude on biceps brachii and erector spinae muscles oxygen saturation during basic cardiopulmonary resuscitation: a simulation study
Get PDFObjective: To assess biceps brachii and erector spinae muscular oxygen saturation (SmO2) by near infrared spectroscopy (NIRS), during 10 minutes of resuscitation at simulated altitudes of 600, 3000 and 5000 m before and after carrying out a simulation program for adaptation to hypoxia. Performing and maintaining a good-quality cardiopulmonary resuscitation (CPR) at higher altitudes may pose a significant challenge to resuscitators due tom decrease in arterial oxygen saturation. This fact adversely effects the quality of resuscitation. Methods: Participants performed 10 minutes of CPR on a mannequin in the laboratory in environments that simulated altitudes. Subsequently, a standardized altitude conditioning protocol was carried out using intermittent hypoxia. The participants performed CPR again under the conditions and altitudes previously referred to. Results: Initial heart rate (HR) at 5000 > 3000 m, and both > 600 m. HR at each altitude was higher conditioning at the end of CPR. The SmO2 of both muscles showed no differences at the beginning and at the end of CPR and was higher in both muscles after the conditioning program before and at the end of CPR. In both muscles, SmO2 values before and after conditioning show a slightly increasing trend during CPR. Conclusion: NIRS use allows developing an optimum training plan. The rescuer will know his limits and optimize his performance. The improvement in physical performance and recovery capacity induced by intermittent hypoxia conditioning programs increases the quality of CPR in prolonged cardiac arrests and in adverse conditions, such as at high altitudes
The challenges of children's safety in pre-hospital emergencies: a qualitative study
Get PDFObjective: Exploring the challenges experienced by the pre-hospital emergency personnel to prevent the secondary injuries and provide more effective services to children can be helpful. This study aims to explain the safety challenges of children in the pre-hospital emergencies. Method: This qualitative study, which was conducted with the content analysis approach, was a semi-structured, and in-depth data collection process with the field notes for pre-hospital emergency personnel in Dezful city in 2022. Sampling was done in a targeted and available manner. The sampling process continued until the data saturation was reached. The trustworthiness of data was improved by reviewing and revising the data, experience and expertise of the interviewer, review of research participants and researchers. The research data, including interview texts and field notes, were divided into the semantic units, and then summarized by compression, and then abstracted in the order of subclasses, main classes, and finally themes. Results: Qualitative data analysis of interviews and notes led to the extraction of eight themes, which expressed the nature of children's safety challenges in the pre-hospital emergency: the lack of pre-hospital equipment for children, physical and mental characteristics of children, the lack of safety of vehicles for children, the lack of clinical skills of personnel for children, anxiety and non-cooperation of parents, operational and legal problems, the lack of attention to professional responsibility and high work pressure in children's missions. Conclusion: This study’s results showed that identifying children's safety challenges for pre-hospital emergency personnel can help better understand the care needs of this age group and help managers plan in order to reduce children's safety challenges in the pre-hospital missions
Utilizing Design Thinking in the Administration of Emergency Departments
Get PDFEmergency Departments (EDs) are the primary access point of medical resources for patients who need urgent care. These departments face numerous administrative obstacles and challenges, such as managing large patient populations, providing timely access to treatment availability, and coordinating various medical and non-medical staff. Our ED is in a tertiary-care referral hospital with more than 70,000 visits annually. Despite moving the ED to a space of about 4000 square meters and doubling the number of beds in the past two years, the overcrowding problem still exists and has even worsened. Solutions that have been proposed to reduce this problem, such as reducing the length of stay of patients by increasing the discharge of patients by emergency specialists or other specialists responsible for patients, limiting the number of emergency beds to reduce the workload of nurses, interacting with hospital outpatient clinics for visiting patients with lower acuity. However, these efforts have not been successful and have increased the dissatisfaction of patients, nursing staff, and physicians. Therefore, it seems that there is a need for innovation in providing solutions to solve the problems. While traditional administrative methods may not help address these issues comprehensively, design thinking (DT), a human-centered approach to innovation, offers a talented alternative. This method focuses on understanding what users need, redefining problems in a human-centric way, and creating innovative solutions. It can significantly improve patient care and ED efficiency. DT entails five steps:
Empathy (understanding patient and staff needs): Administrators can use interviews, patient and staff observations, or surveys to understand the experiences of both patients and staff in their facility. This stage is crucial for understanding the 'true problem' and creating user-centric solutions.
Definition (problem identification): Identify the core problem(s) by analyzing insights, looking for trends, or combining prominent issues.
Ideation (brainstorming solutions): In this step, multidisciplinary teams organize to generate numerous and different ideas, often through workshops involving healthcare professionals, administrative staff, and patients.
Prototyping (developing solutions): Promising ideas are transformed into prototypes. These models are typically low-fidelity and inexpensive for easy testing and iteration.
Testing (pilot testing and continuous modification): Feedback is collected from users in real-world settings to test the prototype to determine how well it achieves its goal. The Discovery workshop is an ongoing process rather than a one-time event. Solutions are continuously adjusted based on current and future ED staff input. One of the principles behind DT is that it evolves with time, which means it develops and improves according to needs.
Empathy and user-centered design of emergency departments can create responsive and cooperative spaces for patients while reducing overall stress. If bottlenecks and inefficiencies are recognized, they can be resolved to streamline processes, resulting in reduced wait times and increased efficiency. A culture of creativity and teamwork can be established by including staff in the brainstorming and initial design steps. This leads to greater job satisfaction and reduced turnover. The solutions created through DT are likely to be more scalable and generalizable across other departments or hospitals, thus driving broader systemic change.While DT has many benefits, its application in EDs is challenging. This refers to any change that is challenging for an organization to implement. It requires significant time and money and can be particularly difficult because it involves integrating long-standing solutions with new capabilities. Solutions to these challenges will require strong leadership, ongoing capacity building, and a dedication to progressive change.DT in ED management holds great promise for improving patient care and efficiency. While hospitals will never operate like startups, prioritizing human-centered design approaches outside of the ED can result in solutions that enable us to address the meaningful and unique challenges faced within them. These solutions often lead to improved patient care, reduced disagreement, and a more satisfying work environment for the staff. Assessing its long-term effects through longitudinal studies and evaluating its impact on populations within real-world contexts will enrich our understanding of this area
Road traffic accidents and injuries, 2018: a multi-centric epidemiological study from India
Get PDFObjective: Road traffic injuries (RTIs) have been recognized globally as an important public health problem. Effective road safety initiatives should address the traffic system as a whole to find a solution and look at the traffic system as a collective to discuss interactions between vehicles, road users and road infrastructure. Therefore, epidemiological data from different geographies of the country should be available. Hence, an electronic-based comprehensive and integrated RTI surveillance system was established in five centres located across the country to assess the burden of RTIs, including the outcome. Methods: This paper is a cross-sectional multi-centric study conducted using an electronic-based comprehensive and integrated RTI surveillance system. Results: A total of 15,319 participants were enrolled under the surveillance of road traffic events for a period of one year. Self-fall/skid was the most common (34.87%) type of accident, followed by a crash between two vehicles (25.77%) and a crash with a pedestrian (16.59%). Among them, 88.94% were the injured, who were alive with or without rehabilitation, and 673 (4.43%) were dead. Mostly, two-wheelers (geared or non-geared) were involved in the accident as they shared a significant portion (75.54%) of the total accidents. Conclusion: The study highlights the epidemiological issues related to road accidents and RTIs that need to be addressed in order to find appropriate solutions for reducing the RTI burden. It gives an understanding of the manner of trauma, the pattern of injuries, and the outcome of road traffic accidents required to adopt efficient preventive and comprehensive trauma care