Frontiers in Emergency Medicine
Year:2020 | Volume:4 | Issue:1|Papers Count:15

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,for an independent case-control study,for a diagnostic test accuracy study,and for a superiority clinical trial (1-5).In this article,we will explain how to calculate the sample size for a non-inferiority or equivalence clinical trial....

Introduction: There is no consensus on what the bases and criteria are for the dynamic process of maternity triage. Properly performing the maternity triage process requires reliable data to ensure the correct implementation of this process and the identification of existing deficiencies, and find strategies to modify, improve and enhance the quality of this process. Objective: The present study was conducted to explain the quality of the maternity triage process. Methods: The present qualitative study performed a directed content analysis on 19 maternity triage service providers and key informants selected through purposive sampling. The data were collected through semi-structured interviews in 2018 and analyzed using directed content analysis based on the Donabedian’ s model. The accuracy and rigor of the qualitative data were then investigated and confirmed. Results: The participants identified the most important factors affecting the quality of the services provided in maternity triage as two categories of measures and care, and interactions and communication. The category of measures and care included two subcategories of examinations and obtaining a medical history. Conclusion: The present study comprehensively identified different dimensions of the quality of maternity triage services at different levels. The participants identified the quality of the maternity triage process as a multi-dimensional and important concept. Different dimensions of the maternity triage process are recommended that be addressed when designing and implementing maternity triage guidelines and instructions so as to maintain the quality of this process and satisfy their needs.

Introduction: Electrolyte disorder is a prevalent complication in multiple trauma patients; nevertheless, the role of chloride has been rarely addressed in literature when evaluating serum electrolytes. Objective: The present study was conducted to determine the correlation between serum chloride changes and hospital mortality in multiple trauma patients. Method: The present cross-sectional study measured serum chloride levels in 100 multiple trauma patients upon their admission to the emergency department and 24 hours later. All these patients were followed up in terms of hospital mortality using their medical records. Exact logistic regression was used to measure the effects of independent variables on hospital mortality in the patients. Results: Hospital mortality was found to be 15 (15%), and the mean serum chloride level to be 106. 37± 4. 53 mmol/l upon admission and 112. 18± 6. 16 mmol/l 24 hours later. Although the univariate analysis suggested that serum chloride levels were independently associated with mortality 24 hours after admission (P=0. 005), this correlation was insignificant in the multivariate analysis. Conclusion: The present study rejected the hypothesis suggesting the potential role of serum chloride levels in predicting hospital mortality in multiple trauma patients.

Introduction: Currently, the most available treatment for acute ischemic stroke (AIS) is thrombolytic therapy with recombinant tissue plasminogen activator (r-TPA). A challenge in r-TPA therapy is the prediction of recovery in each case. Objective: The aim was to find a possible relationship between the cerebral oximetry indexes and the clinical outcome of r-TPA therapy to assess the cerebral oximetry as a non-invasive monitoring agent for therapy. Methods: The inclusion criteria were all patients with AIS who received r-TPA. The neurologic status was evaluated based on the national institutes of health stroke scale (NIHSS) score at arrival, and after a period of 24 hours. In addition, the levels of brain oxygenation in both hemispheres were measured before and continuously over the first 24 hours after r-TPA injection, using an oximetric sensor in the frontal lobes. The clinical success was defined as a 4-point improvement from the baseline NIHSS. Results: Total 44 patients with the mean age of 58. 2 ± 2. 18 years were enrolled, of whom 68. 18% were male. Twenty-eight patients remained clinically unimproved and 16 patients were improved. A significant difference was found in the mean surface area under the brain oximetric curve in the 24 hour, in the affected hemisphere in the improved group, compared to the unimproved group (P = 0. 007). There was a significant difference between the mean increase in brain oxygenation within 24 hours in the improved and unimproved groups (P = 0. 002). Conclusion: It is likely that, The cerebral oximetry could contribute to predict the likelihood of r-TPA prognosis in patients with AIS.

Introduction: Bidirectional ventricular tachycardia (BVT) is a rare arrhythmia characterized by QRS complexes with an axis in the frontal plane alternating polarity in the precordial leads and right bundle branch block (RBBB) morphology. To the best of our knowledge, there is no previous report in dilated cardiomyopathy or in the context of a probable peripartum cardiomyopathy. Case Presentation: A 26-year-old, 9-month female patient, with no significant past medical history (the patient denies medication intake, herbs like aconite, trouble during delivery, any heart issues or family history of sudden death or cardiomyopathies) who presents to the emergency room due to 11 days of dyspnea, exacerbated by daily activities, orthopnea, and paroxysmal nocturnal dyspnea. She presented with ventricular bigeminy and systolic dysfunction with left ventricular ejection fraction (LVEF) <20%. The patient later developed a stable ventricular tachycardia (VT) treated with amiodarone, which resulted in hemodynamic instability and BVT rhythm with VT paroxysms. Without the possibility of ablation, the use of high dose beta blockers and an implantable cardioverter defibrillator resulted in the same rhythm with a lower heart rate, better NYHA functional class, and less episodes of VTs. Conclusion: BVT is a rare type of tachycardia that can be present in dilated cardiomyopathy. In the absence of ablation capabilities, decreasing the heart rate with beta-blockers may reduce the rate of paroxysmal VTs.

CASE PRESENTATION A 14-year-old girl presented to the emergency department (ED) with a history of three episodes of seizure-like activity and no comorbidities at 2 am. The first episode had occurred at 6 am, the second at 12 pm and the third two hours before presenting to the ED. Each episode lasting less than 5 minutes, was associated with the limb and spinal rigidity and extension, the up-rolling of eyeballs and urinary incontinence. The patient reported no history of fever, recent trauma, previous febrile seizures, prodromal symptoms, tongue bite, headache or physical excretion before the episodes...

Animal Injuries; a Case Series of Bull Induced InjuriIntroduction: Bull injuries are common in India. An injury by a bull is more common in rural and agriculture dependent regions of the country. The incident causing injury by a bull can be sports related or work related. Work related injuries are almost mostly seen in farmers. Case presentation: We would like to present six cases of bull injury over a period of three years who reported to our EM. All six patients were admitted. Five out of six patients survived the hospital stay. Conclusion: Trauma sustained due to being hit by a large animal should be treated akin to a high velocity trauma and such a patient definitely warrants a period of observation even if the injuries are not life threatening. A high index of suspicion is needed for suspecting occult injuries. Fluid resuscitation and age of the patient are important considerations. es in India

Introduction: The association between chest compression fraction (CCF) and return of spontaneous circulation (ROSC) has been a controversial issue in literature; and both positive and negative correlations have been reported between CCF and survival rate. Objective: The present study was conducted to determine the relationship between the rate and outcomes of chest compression and between CCF and ROSC in patients with cardiac arrest. Method: The present prospective observational study was conducted during 2018 on patients with cardiac arrest aged 18-80 years. Participants with end-stage renal diseases, malignancies and grade IV heart failure were excluded. A stop watch was set upon the occurrence of a code blue in the emergency department, and time was recorded by the observer upon the arrival of the code blue team leader (a maximum permissible duration of 10 minutes). The interruptions in chest compressions were recorded using a stopwatch, and CCF was calculated by dividing the duration of chest compression by the total duration of cardiac arrest observed. Results: Totally, 45 participants were enrolled. Most of the patients had non-shockable rhythms and underwent CPR based on related algorithm. Hypoxia and hypovolemia were the two probable etiology of cardiac arrest; and coronary artery disease was the most prevalent underlying disease. All patients with ROSC had CCF more than 70%. A CCF below 70% was observed in 21 cases (46. 7%), and a fraction of at least 70% in 24 cases. All patients with ROSC had CCF more than 70%. A CCF below 70% was observed in 21 cases (46. 7%), and a fraction of at least 70% in 24. A significantly higher duration and fraction of chest compression was observed in the participants who attained ROSC (P<0. 001). Conclusion: Based on the findings of current study, it seems that significantly higher chest compression durations and fractions were found to be associated with ROSC, which was achieved in the majority of the participants with a CCF of at least 80%.

Context: This systematic review of clinical trials was conducted to compare the diagnostic accuracy of ultrasound in comparison to plain radiography in shoulder dislocation. Evidence acquisition: MEDLINE, Cochrane Database of Systematic Reviews, clinicaltrials. gov, Google scholar, and Scopus were searched for clinical trials. Diagnosis of shoulder dislocation and confirmation of shoulder reduction were the outcomes of interest. Sensitivity, specificity, positive predictive value and negative predictive value of included clinical trials were calculated. Results: Seven studies met our inclusion criteria and were analyzed. All included studies except two had a sensitivity and specificity of 100% for ultrasound (one with a sensitivity of 54% and one with a specificity of 60%). Conclusion: It can be suggested that ultrasound can be used as a reliable alternative diagnostic method for detection of both dislocation and reduction in shoulder joint. This may decrease the delay in treatment, cost, radiation exposure, and need for repeated sedation.

Introduction: Identifying the death reasons amongst elderly, may help prioritizing the research projects and interventions. Objective: This study purpose was to determine the death pattern and causes, and also its likely associated factors, in a mega hospital in western Iran. Method: This retrospective cross-sectional study, conducted on elderly died from April 2011 to March 2016, in Imam Reza hospital in Kermanshah, Iran. The data were collected about the demographic characteristics, medical information, and the main death causes. The causes-of-death was classified adopting the International Classification of Diseases, Tenth Revision (ICD– 10). The relationships between outcome and predicting variables were assessed by using Chi-square and Tukey's test in SPSS. Results: Totally, 2415 died elderly were registered during the study period. The participants mean age at the time of their death was 75. 35± 9. 15 years old. The diseases of circulatory system (dominancy of stroke), infectious diseases (leading by septicaemia and septic shock, respectively), and respiratory system diseases were the most common death causes, respectively. Age was the most important associated factor for the all-cause mortality related to the cardiovascular diseases (p=0. 001). Conclusion: The majority of deaths were the premature, which requires paying more attention. Although, cardiovascular diseases were the leading death causes and that is predictable, but the fatality of infectious diseases is still causing concerns.

Introduction: Various strategies could be considered dealing with penetrating thoracic injuries. Thoracoscopy is much less invasive than routine thoracotomy approach for managing such cases in which the sharp object remains in the body. The case presented in this article was managed with thoracoscopy for a penetrating dorsolateral thoracic injury. Case Presentation: A 35-year-old man with a penetrating dorsolateral thoracic injury referred to the emergency department. Despite an elevated pulse rate, the patient has proper blood pressure and O2 saturation. Considering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy. At thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space. There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications. Conclusion: Our experience of removing a retained knife by thoracoscopy showed that it can be an appropriate alternative for patients with penetrating thoracic injury who are hemodynamically stable and have appropriate conditions for thoracoscopy.

Context: An emergency is any medical problem that could cause death or permanent injury if not treated quickly. In some occasions, the kind of urgent intervention depends on patient’ s exact genetic background. Unfortunately, the importance of genes in medical emergencies has been forgotten in recent decades. Evidence acquisition: In order to find relevant articles, we searched two databases of Pubmed and Embase. The exact words of “ genes” , “ genetics” , “ epigenetics” , “ DNA” , and “ emergency” were used alone and in combination. All studies like randomized clinical trials (RCT), case/controls, case series, case reports, and review articles were studied to find the related data. No time limitation was considered for the studies. Results: Several aspects of genetic testing are newly considered in emergency departments including cell-free DNA (cfDNA) for disease diagnosis, pharmacogenetics for decreasing the adverse drug effects, and personalized medicine for exact emergency interventions in diseases like Vascular Ehlers-Danlos syndrome (vEDS). Data from genetic testing and genome wide association studies have yielded promising results to make medical emergency interventions more beneficial in the near future. Conclusion: Taking everything into consideration, several advanced genetic and epigenetic alteration technologies can change emergency medicine for the better. Personalized genetic data of patients can turn emergency medicine to personalized medicine.

Introduction: Acute gastric dilation following trauma is an unusual event that can occur in different settings, and can cause gastric necrosis as a rare though fatal condition. The present report involves a case of acute gastric dilation following multiple traumas, which caused gastric necrosis and total gastrectomy. Case presentation: A 19-year-old morbid obese male presented to the emergency department (ED) following a motor vehicle accident. He had a left lower extremity crash injury. In his serial examinations, he was complaining of upper abdominal pain with epigastric tenderness. After nasogastric tube (NGT) reinsertion, due to detecting coffee ground secretions in the drained fluid, the patient was transferred to the operating room. A midline laparotomy was performed that revealed dilation and discoloration of the stomach. Gastric decompression was performed. All the discoloration then disappeared except for that of certain suspicious areas, which necessitated evaluations. On the following day, given the lack of improvement in the patient`s condition, he was transferred to the operating room for a second laparotomy. Conclusion: The present report emphasized on the importance of NGT insertion in multiple-trauma patients, which is, however, neglected in many cases. Moreover, acute gastric dilation is recommended to be considered in the differential diagnosis of patients with multiple or abdominal trauma and complaints of vomiting or abdominal pains.

Introduction: In 2010, a national triage train-of-trainer (TOT) workshop was held in Tehran, Iran. Objective: The present study aimed to assess the validity of the triage performed by the nurses educated by those who participated in TOT workshop. Method: This cross-sectional study was carried out in 6 teaching hospitals from 4 universities in Iran. Inter-rater and intra-rater reliability of performed triage by participations was measured. Thirteen nurses were randomly selected. Thereafter, at the end of each working shift, patient data recorded in the daily data registry forms were collected. Then, duration of hospital stay, number of cases admitted to general wards or intensive care units, number of cases discharged from the ED within 12 hours and mortality rate were compared with the triage level determined by the nurse. Results: In total, 30 nurses with a mean age of 28. 4 ± 3. 7 years were enrolled. In this study, 1491 triage cases (61. 6% male) were evaluated, of which 4. 2% were triaged as level 1, 18. 3% as level 2, 37. 1% as level 3, 20. 4% as level 4 and 20. 0% as level 5. The following outcome was observed: 3. 64% were discharged, 6. 29% were hospitalized, 3% died and 2. 3% were discharged against medical advice without completing treatment. The correlation of determined triage level and patients’ duration of hospitalization was significant based on one-way ANOVA test (p = 0. 000). The outcome of the patients significantly correlated with the level of triage determined by the study nurses (p = 0. 000). Conclusion: Based on the findings, it appears that triage performed by the study nurses educated by those who participated in TOT workshop through cascade training system had perfect validity.

As important infrastructures in every community, hospitals and healthcare centers are required to continue their operation during normal and disastrous situations and respond to the situation and provide services for the injured. In 2008, the hospital safety index (HSI) was proposed by the Pan American Health Organization (PAHO) for evaluating the safety of hospitals and healthcare facilities in potential hazardous situations. The hazards threatening these facilities can be identified using a checklist, and categorized as structural, non-structural and functional vulnerability while considering their likelihood of occurrence, frequency, harmful outcomes and numerical estimate of damage (1)...