Frontiers in Emergency Medicine
Year:2019 | Volume:3 | Issue:3|Papers Count:13

Background: Endotracheal intubation is an important procedure in critical care and emergency medicine settings. Optimal depth of the tube placement has been a serious concern because of several complications associated with its malposition. Objective: The aim of the current study was to find a new formula to estimate the proper endotracheal tube depth when using ultrasonography or lighted stylet device in order to increase the accuracy of determining Endotracheal tube (ETT) depth and decrease the side effects of ETT misplacement. Method: Patients older than 18 years of age admitted to Imam emergency department who needed tracheal intubation were included. Tube’ s length at the angle of the mouth while the tube passed the suprasternal notch, ETT depth after insertion and the distance from ETT’ s tip to carina were recorded. Ultrasonography and portable chest x-ray were used as tools for measuring these lengths. Results: A total number of 91 patients including 55 men and 36 women were eligible for inclusion in the study. Not placing the tube at proper depth was considered as the failure of intubation. This failure rate was 9. 9% in the standard method which would have been 1. 1% if our proposed formula was used. Conclusion: The findings of this study suggest that the use of this new formula may help in predicting the proper intubation tube placement. Further studies are warranted to confirm these findings.

Introduction: Unintentionally retained foreign bodies (RFBs) can be accompanied with acute reactions such as inflammatory responses, infections and abscesses within a few days or weeks after surgery with adverse consequences for patients and surgeons. Case Report: An 84-year-old woman was admitted to hospital with weakness, lethargy and infectious secretions of the umbilicus. The patient had undergone hysterectomy 21 years before. Clinical examinations and accurate umbilicus explorations found a 0. 5-mm fibrin and smelly umbilical secretions. Dragging found the fibrin to be a surgical gauze thread. The patient was therefore identified as a candidate for laparotomy, which revealed a long gauze attached to a band and a metal ring in the umbilicus and hypogastric regions as well as a large abscess containing 200 ml of infectious secretions, severe adhesions of the intestines to each other and to the abdominal wall, a 10×10 cm cavity and an approximately 1-cm fistula or laceration in the Ileum due to the foreign body (long gauze). The patient was discharged from the hospital in good health conditions after the final surgery. Conclusion: Given the possibility of leaving foreign bodies in the surgery site, surgical teams are required to precisely control surgical instruments after surgery.

Context: This review discusses the range of clinical presentations seen with poisonings by the major toxic alcohols--methanol, ethylene glycol, and isopropyl alcohol. It outlines a straightforward diagnostic strategy and discusses in detail the current treatment recommendations. Evidence acquisition: The authors conducted a literature search of primary and secondary sources related to the topic. For treatment recommendations, search restrictions included articles published between 2008 and 2019. For background information, search restrictions included articles written from 1990 – present. Results: This review discusses in detail how the diagnosis can be made via clinical signs, symptoms, and laboratory values as well as the most recent treatment recommendations. This paper will also discuss the limitations of the emergency department workup and how the absence of particular laboratory findings does not necessarily rule out the diagnosis. Conclusion: Poisoning with methanol, ethylene glycol, and isopropanol present diagnostic and therapeutic challenges to emergency physicians. Toxic alcohol poisonings lead to an elevated osmolar gap and, with the exception of Isopropanol, a metabolic acidosis. In order for the timely initiation of life-saving treatment, emergency physicians need a solid understanding of the pathophysiology, clinical presentation, laboratory workup, and treatment.

To the Editor, The need to improve surgical care in low and middle income countries (LMICs) has been advocated recently (1, 2). The Global Neurosurg (GNS) collaborative is an international network that aims to advance neurosurgical practice worldwide, to highlight the variations in the current neurosurgical practice, and to address the gap in neurosurgical outcomes between highincome countries (HICs) vs. LMICs. GNS research activities are coordinated by the Neurological Surgery Department of Oregon Health and Science University, the USA....

Introduction: We describe a patient without a history of cardiovascular diseases as an example of Wellens’ syndrome (WS). Case Report: A 65-year-old man presented to emergency department due to intermittent chest pain. Physical examination and chest x-ray were unremarkable. Electrocardiogram (ECG) showed biphasic Twave in precordial leads V1-V4. Primary cardiac serum biomarkers including high-sensitive cardiac troponin T (hs-cTnT) and CK-MB were slightly elevated, that further assessment did not show any increases; while ECG recorded during a pain period revealed T-wave pseudo-normalization. The patient underwent coronary angiography that revealed a proximal left anterior descending artery lesion. Conclusion: WS is a diagnostic and management challenge and serial ECG evaluation is still essential for a possible acute coronary syndrome. Having knowledge of all subtle features of this syndrome, could avoid improper discharge of high-risk patients. Definitely, accurate risk stratification, and prompting these patients to an early coronary angiogram and treatment are mandatory to avoid development of a massive anterior myocardial infarction.

CASE PRESENTATION A 34-year-old pregnant woman was referred to our emergency ward, complaining of intensification of skin lesions which had started six days earlier. Initially, vesicular lesions had started from head and face accompanied by fever which turn to generalized pustular lesions expanded to the whole body within four days (figure 1). By investigating the patient's personal contact history, we found that same symptoms were detected in her 9-yearold child 19 days prior to admission which was diagnosed as chickenpox. The patient also had mentioned previous history of chicken pox infection at her age of seven....

Introduction: Acute kidney injury (AKI) is a common and devastating clinical issue in the community associated with high rates of morbidity and mortality. Objective: We aimed at estimating the frequency and levels of severity of AKI in trauma patients requiring hospital admission using the RIFLE criteria and assess their outcome. Method: Our retrospective record based study enrolled data of 80 participants aged 18-59 years who presented to the emergency department of KIMS hospital following an acute traumatic event. Participants with pre-existing renal dysfunction, chronic heart failure and chronic liver disease were excluded. Tests of significance were Chi square and independent sample t test, a p<0. 05 was considered statistically significant. Results: Participants with AKI had significantly lower age (p=0. 02) and lower revised trauma score (RTS) (p=0. 01). Significant association of AKI with hypotension (p=0. 01) and Glasgow coma scale (GCS) (p=0. 008) was observed. No association of AKI with gender was observed (p=0. 6). None of the AKI patients required renal replacement therapy and all participants attained normal renal function at discharge. Significantly longer mean duration of hospital stay (14. 4 days) was observed among AKI patients (p=0. 02). Totally, 6. 3 % mortality was observed among both participants with and without AKI. Conclusion: Forty percent of acute trauma patients had AKI (in risk and injury category); but none were in failure, loss or end stage renal disease. No association of AKI and mortality was observed. AKI was associated with age, RTS, hypotension and GCS.

INTRODUCTION In the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion, for an independent cohort study, and for an independent case-control study (1-3). In this article, we will explain how to calculate the sample size for a diagnostic test accuracy study based on sensitivity, specificity, or the area under the ROC curve....

Introduction: The Cumberland Ankle Instability Tool (CAIT) is a valid instrument for determining the presence and severity of functional ankle instability. This questionnaire was recently cross-culturally adapted into Persian; however, the reliability of the Persian version has not been examined in athletes. CAIT has also been used with various independently-selected cut-off scores to determine instability. Objective: The present study was conducted to evaluate the psychometric properties of the Persian version of CAIT and to determine its optimal cut-off score in athletic populations. Method: One-hundred and sixteen athletes (volleyball, basketball and track and field players) over 18 years old both with and without ankle instability completed the Persian version of the CAIT. The internal consistency, test-retest reliability and discriminative ability of the tool were assessed. A receiver operating characteristic (ROC) curve was drawn to confirm the cut-off point of the Persian version of CAIT using the Youden index. Results: The average CAIT score was 25. 14± 4. 98 for the right and 25. 76± 4. 94 for the left ankle. The Persian version of CAIT had a good internal consistency (Cronbach's α of 0. 78 for the right ankle and 0. 79 for the left ankle) and substantial reliability (ICC2, 1 = 0. 88; 95% CI: 0. 86 – 0. 90) in athletes. No ceiling or floor effects were observed. The optimal cut-off score for discriminating between athletes with and without FAI was 24. Conclusion: The Persian version of CAIT was shown to be a reliable tool for assessing functional ankle instability among Iranian athletes.

Introduction: Recent years have witnessed widespread reports on the effectiveness of nebulized morphine for dyspnea, yet there is no evidence for its effectiveness in analgesic therapy. Objective: This study aims to compare effectiveness and side effects of inhalation morphine with oral methadone and transdermal fentanyl in sequential days in end stage cancer patients. Method: This double-blind, randomized controlled study conducted between April and September 2017. Ninety eligible cancer patients presenting to Sayed al-Shohada Hospital were selected non-randomly according to inclusion criteria and then divided to 3 groups in random order. Pain severity was scored by Visual Analog Scale (VAS). Patients were followed up for 3 days and then data were analyzed by SPSS. The benchmark of success was set as marking 4 or below on VAS and a reduction ratio of 50 percent. Results: Pain severity was equal for 3 groups before the first administration (p>0. 05), but it decreased significantly from 8. 45 (range 6-10) at baseline to 2. 46 (range 1-4) at the end of the 3rd day in the nebulized group. The decrease ratio was equal to 70. 8% after three days (p<0. 05). Pain severity reduced from 8. 45 (range 7-10) to 1. 8 (range 1-3) (p<0. 05) in the methadone group, and reduced from 8. 5 (range 6-10) to 2. 13 (range 1-3) in the fentanyl group. Conclusion: Our study showed that nebulized morphine, just like oral methadone and transdermal fentanyl, is effective, safe, and well-tolerated for pain management in patients with cancer.

PATIENT’ S HISTORY: An 85-year-old female patient was brought to emergency department (ED) from a nursing home with altered mental status (GCS: 12/15) and hypotension (90/60 mmHg). Bilateral fine crackles in lungs and severe cachexia were obvious in her physical examination. The ECG showed only sinus tachycardia. Several attempts at peripheral vein cannulation failed due to poor visualization of severely atrophied and contracted subcutaneous veins. Therefore, on two attempts, a central venous catheter (CVC) was inserted into the right internal jugular vein (IJV) using the Seldinger technique...

Introduction: 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.

Introduction: Early diagnosis of pulmonary thromboembolism (PTE) is crucial in clinical medicine. Many para-clinical measurements are used to diagnose PTE. Objective: The present study was conducted to evaluate platelet indices in terms of diagnosing PTE. Methods: The present case-control study was conducted between May 2015 to July 2016 with 173 patients suspected of PTE in the emergency wards of Shahid Madani Hospital and Imam Reza Hospital affiliated to Tabriz University of Medical Sciences, Iran. The patients’ platelet indices were checked upon admission and they were evaluated in terms of diagnosing PTE. Platelet indices included mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PL-CR). PTE was diagnosed in 125 out of the 173 patients. Platelet indices were also compared between two groups. Results: No statistically significant differences were observed between the two groups in term of demographic variables (p>0. 05). MPV was found to be 10. 38± 8. 59 in the case group and 9. 46± 1. 11 in the controls (p˃ 0. 05). PDW was also found to be 12. 86± 5. 57 in the case group and 12. 32± 2. 48 in the controls (p>0. 05). Moreover, PL-CR was found to be 22. 59± 7. 32 in the case group and 21. 97± 8. 16 in the controls (p>0. 05). Conclusion: According to the obtained results, platelet indices do not increase in PTE. They cannot be therefore used to diagnose PTE in suspected patients.