JournalTOCs

Journal of Emergency Practice and Trauma
Number of Followers: 6

This is an Open Access Journal

Open Access journal
ISSN (Online) 2383-4544
Published by Kerman University of Medical Sciences

[5 journals]

Purtscher’s retinopathy following trauma: A case report
- Abstract: Objective: Purtscher’s retinopathy is the retinal damage following trauma or non-traumatic systemic disease, which may contain cotton-wool spots (CWSs), and may cause Purtscher flecken, atrophy of the optic nerve, and hemorrhage of the posterior pole of the eye.Case Presentation: A 28-year-old male patient fell down from a height of 10 m and was admitted with swelling and ecchymosis of the peri-orbit of the right eye. The patient’s vision was at the level of light perception. A mild subconjunctival hemorrhage and hyphema were seen in the right eye. In the fundus, the hemorrhage, edema, and CWS were seen in the posterior pole and around the optic disk. Macular thickness (MT) in Purtscher’s retinopathic eye was 353 μm. Also, the patient had a nose and mandibular fracture and was hospitalized for several days.Conclusion: The findings indicate a decrease in the vision due to Purtscher’s retinopathy caused by trauma. There was no improvement spontaneously
Case report of unusual presentation of COVID-19 in a patient with
pulmonary hypertension
- Abstract: Objective: COVID-19 has now become a worldwide health problem with many new cases diagnosed every day. people with underlying heart diseases are more likely to get infected and have poor prognosis. Of them, adult patients with congenital heart disease need special attention due to their different symptoms and course of the disease.Case Presentation: Here, we report the unusual presentation and course of COVID-19 disease with rapid progression of right ventricle failure and pulmonary hypertension in patient who was infected with new SARS-CoV-2 virus. She is a 39-year-old woman, known case of ventricular septal defect and pulmonary hypertension with a history of open-heart surgery at the age of seven that arrived to our clinic due to exacerbation of dyspnea; progressive lower extremity edema and mild ascites from 10-days ago.Conclusion: Any changes in the condition of adult patients with congenital heart disease in this epidemic should be considered as a potential infection by this virus and the necessary and accurate evaluation should be done
Aprospective risk stratification and validation of HEART,GRACE
- Abstract: Objective: Chest pain is amongst the most frequently occurring symptoms in patientspresenting to the emergency department (ED). Accurate and fast risk stratification isparamountforidentification of patients with immediate risk of acute coronary syndrome(ACS). The present study has compared different scoring systems like HEART (History,ECG,Age,Risk factors, Troponin), ThrombolysisinMyocardial Infarction (TIMI), andGlobalRegistryofAcuteCoronaryEvents(GRACE)scores andtheir efficacyinpredicting incidenceof major adverse cardiac events(MACE).Methods: The present prospective observational study was conducted on 199 patientswho presented in the ED with complaint of chest pain. HEART, GRACE and TIMI scoreswere calculated with collected patient data which was further evaluated for efficacy bycalculating area under ROC curves (AUCs). Data were analyzed by using R statisticalsoftware version 4.0.3 and Microsoft Excel. P value less than or equal to 0.05 indicatesstatistical significance.Results:Inthecurrentstudy,76(38%)patientsreportedMACE.TheHEARTscoreidentifiedthelargestnumberofpatientsashighrisk74(37%)andamongthem69patientsdevelopedaMACE.TheAUCofHEART scorewasthehighestwith0.96(95%CI:0.93-0.98),followedbyTIMIscore with 0.815 (95% CI: 0.75-0.873) and the GRACE score with 0.814 (95% CI: 0.75-0.813). The sensitivity of HEART score of ≥7 for MACE wasfound to be 90.78%,specificitywas 95.96%, positive predictive value (PPV) was 93.24% and negative predictive value(NPV) was 94.4%. The sensitivity of GRACE score was 39.4%, specificity was 95.16%, PPVwas 83.3% and NPV was 71.95%. The sensitivity of TIMI score was 30.2%, specificity was95.96%, PPV was 82.14% and NPV was 69.18%.Conclusion:TheHEARTscoreshowedhigherefficacyinpredictingrisklevelsinpatientsandincidenceofMACE incomparisonwithGRACE andTIMIscoresintheincludedstudy cohort.
Platyceps karelini a nonvenomous snake (Ophidia: Colubridae) from Kashan
county (Isfahan–Iran)
- Abstract: Objective: Snakes are among the predators of any ecosystem and have been seen in different parts of Iran. The report on their distribution in Isfahan province was taken into consideration because of the importance of regional knowledge of these animals.Case report: During this survey, a sample of snakes was collected from north of Isfahan province, Kashan city, the University site of Medical Sciences and the sample was studied. The snake was identified by morphological and habitat characteristics and compared to other photos and data. The specimen belonged to the Colubridae family and non-venomous snakes. This species is distributed in the tropical climatic zone of the province. The species of the tropical region of Kashan city was identified as Platyceps karelini. or spotted snakeConclusion: We identified the habitat of this animal in Kashan city in Isfahan province. By identifying the species of Spotted Desert Racer from the Colubridae family, the number of non-venomous snakes in Kashan reached eight species.
A 10-year-old girl with red eyes and hypothyroidism
- Abstract: Objective: Hypothyroidism has many causes and manifestations in children. One of the causes is autoimmunity, which is known as autoimmune thyroiditis or Hashimoto thyroiditis. Pseudotumor cerebri is a rare manifestation of Hashimoto thyroiditis. Here we report a 10-year-old girl with asymptomatic papillary edema who was treated with levothyroxine and acetazolamide.Case Presentation: A 10-year-old girl suffered from left eye trauma while playing volleyball and went to an ophthalmology center due to redness in the same eye. During the examination, they noticed a bilateral optic disc swelling without ocular inflammation and the other eye examination was within normal limits. Encephalopathy may rarely occur during autoimmune thyroiditis, which is known as Hashimoto encephalopathy, and it is stated that the autoimmune disorder is not related to the thyroid dysfunction characterized by the symptoms of decreased level of consciousness and seizures.Conclusion: The diagnosis of hypothyroidism in children is usually made by examining the thyroid-stimulating hormone (TSH), and T4 in which TSH is elevated and T4 is decreased as in our patient.
Sudden calf swelling and pseudo-thrombophlebitis in rheumatoid arthritis:
an uncommon emergency spot diagnosis
- Abstract: A 52-year-old male presented with atraumatic left side calf swelling for the last three months. The swelling had acute onset and increased gradually in size. He had a history of rheumatoid arthritis with treatment options limited to physiotherapy sessions and pain medication as he could not continue disease modifying anti-rheumatic drugs regularly. There was no history of co-morbidities like hypertension, tuberculosis, diabetes mellitus or bleeding diathesis. He neglected the swelling initially due to mild pain and little impact on activities of daily living till swelling increased to be apparent.
Risk factors, clinical, and laboratory characteristics of patients with a
diagnosis of COVID-19
The influence of cold versus room temperature charcoal on reducing nausea
of poisoned patients: A randomized clinical trial
A new method to predict the in-hospital outcome of multi-trauma patients:
R-GAP
Periorbital emphysema and pneumomediastinum following blunt orbital
fracture: A case report and review of the literature
Seizure after a massive infusion of N-acetylcysteine and successful
treatment with a good outcome
- Abstract: Objective: N-acetylcysteine is frequently used as an efficacious antidote for acetaminophen toxicity. It prevents liver injury induced by paracetamol and in most cases the overdose of acetylcysteine produces mild clinical effects.Case Presentation: Here we describe a patient who self-treated himself by acetylcysteine after acetaminophen toxicity. Approximately 5 hours after receiving 140 g of acetaminophen, the patient developed confusion, hypotension as well as seizures and also had coagulopathy and acute kidney injury. Other causes of these symptoms were overdose of acetaminophen and amoxicillin. Finally, the patient was treated by extensive supportive therapy and got healed.Conclusion: This case suggests that massive IV acetylcysteine overdose can cause serious life-threatening conditions. The purpose of reporting this case is to increase the awareness among medical staff concerning adverse reactions revealed after a massive overdose of N-acetylcysteine and their arrangement as well as describing the way of management of such problems. The seizure was one of the manifestations in our case and it is so rare. This indicates that massive dosing of acetylcysteine could form irreversible damages in the brain, so it is very important to start the management as soon as possible and monitor patients precisely.
Renal infarction mimicking cholecystitis: a case report of a patient
presenting with stroke
- Abstract: Objective: Renal infarction which is a rare phenomenon can be missed on the patient’s work up making its incidence low.Case Presentation: We report a 68-year-old lady with known history of hypertension presented with epigastric pain and vomiting for 4 days. During her stay in the emergency room, she developed sudden onset of left-sided weakness. Electrocardiogram was normal sinus rhythm. Computed tomography scan of the abdomen showed acute pancreatitis with partial impingement of superior mesenteric vein.Conclusion: Imaging s showed cholelithiasis without evidence of cholecystitis and lower pole right renal infarct likely secondary to obstruction of the right lower renal artery due to calcified plaques at their origin from the aorta. Subsequently, the patient was kept on antiplatelets and planned for discharge uneventfully.
Cellulitis: when to say its treatment failure
- Abstract: Cellulitis is treated with antibiotics as routine management and based on the literature the cellulitis hospitalization can be avoided by 11% if appropriate antibiotics are used.1 Randomized clinical trials and Cochrane reviews have suggested that oral antibiotics are non-inferior to intravenous administration (1). We would like to highlight here the unrequired use of intravenous antibiotics in cellulitis. Intravenous antibiotics are recommended in patients with sepsis. This is supported by a study done on 1800 patients with cellulitis diagnosis, where one third of patients were hospitalized
Subcutaneous emphysema and pneumomediastinum in COVID -19 patients: ICU
course of four cases and review of literature
- Abstract: Objective: Since April 2021, there has been significant increase in number of COVID-19 cases in India. As the caseload increased, so did the complications like pneumomediastinum (PM) and subcutaneous emphysema (SE).Case Presentation: We present clinical course of 4 patients as case series of COVID-19 pneumonia who developed PM and SE during their management. Two cases with the need of non-invasive ventilation (NIV) recovered and two cases that needed invasive mechanical ventilation (IMV) ultimately expired.Conclusion: This case series highlights the importance of positive pressure ventilation via NIV and IMV as a predisposing factor for PM and SE as well as the need of strict vigilance by clinicians managing COVID-19 patients in IMV.
Clubfoot management during COVID-19 times: An Indian scenario
- Abstract: The coronavirus disease 2019 (COVID-19) pandemic has been universal and swift inits spread. As orthopaedic surgeons, for the most of us this timeframe has reduced ouractivity to emergency and trauma cases only, with virtual outpatient clinics and no electivesurgeries. With some of the common deformity problems including clubfoot etc, whichcomprises a large number of children in the developing world, the management has beendeferred, without any regional and national guidelines being framed. Updated guidelinesrelating to the management of clubfoot patients, in which parents can safely consultwith the orthopaedic surgeon and physical rehabilitation specialists will allow them tocope with this unprecedented situation. We revisit the current scenario and the possiblemanagement protocol in the context of COVID-19 pandemic.
The role of ProBNP in differentiation of cardiogenic and non-cardiogenic
syncope: A diagnostic accuracy study
- Abstract: Objective: The significance of diagnosing the root reason for syncope and taking therequired preventive or treatment measures cannot be overlooked when it comes tooutcome prediction. This study endeavors to examine the role of proBNP in differentiatingcardiogenic and non-cardiogenic syncope in patients presenting to the emergencydepartment (ED).Methods: We prospectively performed a cross-sectional study on patients presentingwith acute syncope. All the patients for this investigation were followed up until thedefinite cause of their syncope (cardiac or non-cardiac) was diagnosed and the screeningperformance characteristics of proBNP in differentiation of cardiogenic and noncardiogenic syncope were evaluated.Results: Three hundred patients with syncope were studied (64.7% male). In the end,the cause of syncope was determined to be cardiogenic in 133 cases (44.3%). The areaunder the ROC curve of proBNP in the differentiation of cardiogenic syncope from noncardiogenic was estimated to be 78.9 (95% CI: 73.5 – 84.3). The optimal cut-off point forproBNP in this regard was 143.5 pg/mL point. Sensitivity, specificity, positive and negativepredictive values, and positive and negative likelihood ratios of proBNP in the mentionedcut-off point were 75.39% (95% CI: 67.61–82.73), 75.44% (95% CI: 68.07–81.62), 71.12%(95% CI: 62.82–78.26), 79.74% (95% CI: 72.46–85.54), 2.46 (95% CI: 1.86–3.25), and 0.25(95% CI: 0.18–0.34), respectively.Conclusion: The accuracy of proBNP in differentiation of cardiogenic and non-cardiogenicsyncope is fair. ProBNP concentration equals to or higher than 143.5 pg/mL can differentiatecardiogenic syncope from non-cardiogenic with 75% sensitivity and 76% specificity. Itseems that its use for this purpose should be considered with caution and along with othertools
Compsobuthus matthiesseni sting from Bazoft: A case report
- Abstract: Objective: A Scorpion sting is one of the most important health and medical problems in most parts of Iran.Case Presentation: This case report occurred in Chaharmahal Bakhtiari province of Bazoft city. The injured person was a 48-year-old woman, weighing about 69 kg. Two documentary filmmakers were on their way to work and suddenly one of them felt pain caused by a sting in the thigh area of her lower limb. The patient was referred to the medical center with the ‘scorpion’ sample, where she was examined by a doctor. The doctor prescribed some medicine for the patient. The pain from the sting lasted for about three hours. The patient recovered after taking the medication and received counseling three days after the sting. A photo of the dorsal and ventral surface of the scorpion specimen was sent to the animal identification specialist along with the size and color record. Scorpion specimen with a size of 4 cm was identified as Compsobuthus matthiesseni.Conclusion: According to the findings of this report, the clinical signs of C. matthiesseni sting are mild in the injured person and comparable to the stings of yellow bees Vespa germania. There is local pain two to three hours after the sting. Other systemic clinical manifestations can improve after a maximum of 2 to 3 days.
Electrocardiographic abnormalities and troponin levels provide insight on
the prognosis of COVID-19 patients: A single center experience from Iran
- Abstract: Objective: Coronavirus disease 2019 (COVID-19) is an infection which can present itself bythe involvement of various organs, but the most common manifestations are respiratorysymptoms, fever and dyspnea with a high mortality rate. In order to study the prognosis ofpatients and also to determine the treatment plan, we need non-invasive methods whichcan be easily used in the triage of patients. In this study, we investigated the diagnosticvalue of electrocardiographic (ECG) changes and troponin levels in patients with thisdisease.Methods: This is a descriptive study. Confirmed COVID-19 patients participated in thepresent study. Data were collected by taking history and referring to medical records. Weanalyzed data by using chi square, t test and logistic regression through SPSS softwareversion 22.Results: One hundred and five patients with COVID-19 disease were examined. Mostpatients were men (53.3%) and the mean age was 54.53 years. The most common underlyingdiseases were hypertension and diabetes mellitus. Ninety-five patients had abnormalelectrocardiography including eleven with long QT; seven with arrhythmia; 78 with sinustachycardia; 7 with hemi-block; 1 with hemi-block and first degree atrioventricular block;4 with abnormal axis and 28 with ischemic changes. Eleven patients (10.5%) had positivetroponin level, whose length of hospital stay was higher (12.73 vs. 12.07 days). Furthermore,their mean length of intensive care unit (ICU) stay was also higher. In addition, among thetroponin-positive group, 100% had abnormal electrocardiography.Conclusion: The findings of the present study showed that ECG abnormalities and troponinlevels could provide good information about the prognosis of patients. Moreover, it seemsthat ECG changes in COVID-19 patients, whether indicative of underlying heart disease orresulted from infection, can affect the prognosis of patients. Therefore, considering ECGfindings and troponin levels can help select patients at a higher risk for triage.
Implementation and evaluation of the five-level emergency triage
(emergency severity index tool): A hospital-based, prospective,
observational study in Bangalore
- Abstract: Objective:To implement the 5-level Emergency Severity Index (ESI) triage tool into nursingpractice in the emergency department (ED) and validate it with a population-based cohortusing hospitalization and length of stay (LOS) as outcome measures.Methods: The study included 850 patients, irrespective of age and gender, reporting tothe ED of a tertiary care hospital. Each patient was assessed by the triage nurse as perthe 5-level ESI triage tool and categorized. The number and type of resources used by thepatient, LOS in the ED and the outcome were noted. Data were statistically analyzed byusing RStudio Team software, 2015. A P value of < 0.05 was considered to be statisticallysignificant.Results: The majority of patients belonged to ESI-4 (46.82%), followed by ESI-1 (19.41%),ESI-2 (17.06%), ESI-3 (10.35%), and ESI-5 (6.35%). In most patients, the LOS in the ED was<120 minutes (55.65%). ESI showed a statistically significant association with all the clinicalcharacteristics, as well as resources used, interventions needed, maximum time allowedbefore initiating physician assessment, duration of stay in ED, and patient outcomes(P=0.000). ESI was found to have a sensitivity of 100% and specificity of 78%.Conclusion: ESI is a useful and valid tool for the emergency triage and has the potential tobecome the standard triage acuity assessment in EDs in India.
Utility of type and screen policy for pretransfusion compatibility testing
at an urban level Ι apex trauma center
- Abstract: Objective: Type and crossmatch (TC) policy is the most common approach for pretransfusion compatibility testing prior to issue of blood for transfusion. As it involvesreserving of the blood units (usually up to 72 hours) prior to issue or un-reserving, it can leadto excessive blood cross matching, inventory management problems, undue workload,blood outdating and reagent wastage. Type and screen (TS) policy is an alternativeapproach without the need to cross match and reserve blood units prior to issue. The aimof the current study was to retrospectively assess the impact of the implementation of TSpolicy for pre-transfusion compatibility testing on blood transfusion services at an urbanlevel Ι trauma center.Methods: The study was done in two phases in the Department of Transfusion Medicineat Jai Prakash Narayan Apex Trauma Center AIIMS, New Delhi, India. Transfusion data wascollected and compared during two phases: initial phase (Oct 2016-Mar 2017) of TC policyand second phase (Apr 2017-Sept 2017) of TS policy.Results: TS policy resulted in the reduction of C:T ratio from 5.3 to 1.9. Transfusionprobability increased to 29.5% during TS policy from 23.6% during TC policy. Issuable stockindex (ISI) also showed reduction from 12.5 to 11.4 after TS policy. Wastage as percentageof issue (WAPI) was reduced from 2.3% (TC) to 1.3% (TS). TS policy also led to reductionin expenses incurred on pre-transfusion compatibility testing by 35%. No hemolytictransfusion reaction was reported during the study.Conclusion: TS policy was found to be a safe and an efficient alternative approach to TCpolicy for pre-transfusion compatibility at our center. We recommend the implementationof TS policy, but each center should first assess its feasibility based on patient population,blood bank resources and staff knowledge
Candida isolation from peritoneal fluid: Its role in the outcome of
patients with perforation peritonitis
- Abstract: Objective: Perforation peritonitis is a common surgical emergency which is treated bysurgery and antibiotics. Candida isolation in peritoneal fluid and antifungal treatment isnot a norm. The aim of this study was to determine the incidence of Candida in peritonealfluid and its role in the outcome of patients with perforation peritonitis.Methods: This prospective observational study was conducted on 70 patients withperforation peritonitis from October 2016 to February 2018. Intraoperatively, peritonealfluid was taken and sent for microbiological culture and sensitivity. Perforation wasmanaged according to the site of perforation and condition of bowel.Results: The mean age of the patients was 38.74 years with male predominance (58,82.85%). Forty-seven (67.14%) patients had positive peritoneal cultures. Escherichia coliwas the most common bacteria (n=29), while Candida was found to be the most commonfungi and was found in 18 patients. The incidence of Candida was higher in upper gastroduodenal perforation (30, 42.85%). Patients found positive for Candida had APACHE IIseverity score 10 or more which was higher than the rest of the patients. The mortality washigher in patients with positive peritoneal cultures (10/47) as compare to negative ones(2/23, P<0.001). The mortality in mixed bacterial and fungal-positive cultures (7/18) wasalso higher as compared to isolated bacterial culture (3/29, P <0.001). The overall mortalityrate was 17.14%.Conclusion: Patients with Candida positive peritoneal culture had a significant mortalityand morbidity as compared to Candida negative. Peritoneal fluid culture and sensitivity forbacterial and fungal were helpful in the early diagnosis and treatment
The effect of chit powder technology in the treatment of burn hazards
victims: A systematic review
- Abstract: Objective: In order to heal burn wounds, many researches have been done, including the use of biological scaffolds due to their ability to achieve the desired properties. Owing to the appropriate biological properties of chitosan such as biocompatibility and antimicrobial properties as well as the promotion of wound healing in biomedical applications, we aimed to perform a systematic review to investigate the effect of this technology on the treatment of burn hazards victims.Methods: The present research was conducted in 2020 as a systematic review of studies related to the effect of chitosan on burns. In this study, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Critical Appraisal Skills Programme (CASP) guidelines were used to assess the articles. The key words “Chitosan,” “Chitin,” “victim,” “Injury,” “Burn,” “Heal,” “wound” “treat,” “hazard,” and “care” were used in combination with the Boolean operators OR and AND. The ISI web of science, PubMed, Scopus, Science Direct, Ovid, Pro Quest, Wiley and Google Scholar were searched.Results: Recently, chitosan and its derivatives have been proposed as suitable candidates for scaffolding and can be used as temporary scaffolds to modify and stimulate the growth of new tissues. Studies to demonstrate the use of chitosan in the treatment of burns have been limited to research on animal models and have been superior to conventional therapies in terms of time, pain, and efficacy.Conclusion: The effect of chitosan on burns has been positive in animal models and has accelerated wound healing. Since the main ingredient of chit powder is chitosan and due to the limited studies done on humans, it cannot be said with certainty that the use of chitosan and its derivatives to treat burns is better than other ways to treat burns.
Urologic oncology during the COVID-19 pandemic
- Abstract: The COVID-19 pandemic will have numerous consequences in the management of patientswith genitourinary cancers. As we are struggling to best exploit our limited health-careresources in managing COVID-19 infected patients, we need to rethink our approach toprovide the best medical care for cancer patients in the time of this global crisis. Thereis a need for a decision-making algorithm which takes into account the age, presentingsymptoms, comorbid illnesses, access to health-care services, and availability of qualifiedhealth-care personnel. We must provide support, a clear and comprehensible informationalong with essential care to the patients seeking medical opinion during a time of thisunforeseen global health crisis. In this mini review we have made an attempt to prioritizethe necessity of intervention in urological oncology patients as per various national andinternational guidelines. This approach should be tailored as per locally available healthcare resources and the burden of COVID-19 infected cases in that region.
Pneumoperitoneum due to pneumothorax in blunt thoracoabdominal trauma: A
diagnostic challenge
- Abstract: Objective: A Perforation of hollow viscus is the most common cause of pneumoperitoneumafter a blunt thoracoabdominal trauma and demands prompt surgical exploration.Alternative routes into the peritoneal cavity, such as the presence of a diaphragmaticlaceration associated with pneumothorax, although rare, should be considered whenapproaching these patients.Case Presentation: We present the case of a 78-year-old male admitted to the emergencydepartment after being ran over by a car resulting in right thoracoabdominal trauma,presenting with dyspnea and signs of peritoneal irritation. CT scan identified rightpneumothorax, pneumoperitoneum and free abdominal fluid. The pneumothoraxwas drained and posteriorly he underwent exploratory laparotomy where a traumaticlaceration of the diaphragm was identified as the cause of pneumoperitoneum.Conclusion: Alternative causes of pneumoperitoneum should be considered in bluntthoracoabdominal trauma with possibility of conservative management in the absenceof peritoneal irritation signs. Pneumothorax drainage is mandatory before intubation toavoid creation of a tension pneumothorax.
Association between a history of child neglect, abuse and the suicidal
patient: a cross-sectional study
Frequency of opium use in traumatic patients admitted to Shahid Rahnemoon
hospital
- Abstract: Objective: Narcotic and alcohol use are recognized as the two important underlying factors in all types of trauma. In this study, the prevalence of opium consumption was investigated in traumatic patients who referred to Shahid Rahnemoon hospital in Yazd in 2018.Methods: In this descriptive cross-sectional study, 252 patients with trauma admitted to Shahid Rahnemoon Hospital from October to December 2018 were studied. In order to collect the data, a checklist was administered including the patients’ demographic information (age and gender), opium consumption, location of trauma, day of occurrence of trauma and cause of trauma.Results: The mean of patients’ age was 31.33 ± 19.46 years ranging from 2 to 90 years and 71.4% of them were males. The most common causes of trauma included accidents with motor vehicles (56%), falls from height (19.8%), and intimate partner violence (6%), respectively. Regarding opium consumption, 87.3% of patients did not use it, while 10.3% consumed opium. Narcotic abuse was significantly different with regard to the patients’ gender (P = 0.000) and age (P = 0.000).Conclusion: Opium consumption increases the risk of error and accident while driving. People on methadone treatment also show high-risk behaviors and are at greater risk of accidents.
Challenges of prehospital emergency staff in the COVID-19 pandemic: A
phenomenological research
- Abstract: Objective: Pre-hospital emergency staff are involved in the front line of care for COVID-19 patients and face many challenges. The aim of this study was to explore the challenges of prehospital emergency staff in the COVID-19 pandemic.Methods: This qualitative research was conducted with a descriptive phenomenological approach. Purposeful sampling was applied and data collection was done through semi-structured interviews. Participants consisted of 16 pre-hospital emergency staff. Data analysis was performed using the Colaizzi approach.Results: Data analysis revealed five main themes including safety against COVID-19, knowledge deficit, fear and worry, challenges of transporting patients to the hospital, and selflessness.Conclusion: Pre-hospital emergency staff face many problems in personal, professional, equipment and cultural fields in the COVID-19 epidemic. In this regard, special attention from health systems is mandatory.
An unusual case of both bones forearm shaft fracture with ipsilateral
distal radio-ulnar joint disruption
- Abstract: Objective: Distal radioulnar joint (DRUJ) subluxation with associated both bones forearm fracture is a rare clinical entity and is easily missed, leading to significant functional limitations.Case Presentation: A 28-year-old male fell on the outstretched hand and suffered left side both bones forearm shaft fracture with ipsilateral DRUJ disruption. Operative intervention in the form of plating was done for both bones forearm shaft fracture and DRUJ was stabilised with one k wire and above elbow plaster splint in full supination was given for 6 weeks. At one-year follow-up, fracture was united and Disabilities of the Arm, Shoulder and Hand (DASH) score was 11.7, and he was well satisfied.Conclusion: DRUJ disruption should be carefully evaluated in all the patients with associated shaft fractures of radius and ulna. Timely diagnosis and optimal intervention may prevent any functional limitations.
Three patients with acute appendicitis diagnosis following blunt abdominal
trauma
- Abstract: Objective: One of the most prevalent surgical emergencies is appendicitis, caused by different factors. However, its relation to trauma has not been well-known yet. Here we have described three cases with blunt abdominal trauma and a secondary diagnosis of appendicitis that were transferred to the operation room.Case Presentation: Three patients suffering from blunt trauma and abdominal pain were referred to the emergency department (ED). Of these patients, one of them was transferred to the operation room (OR) with a peritonitis diagnosis and the other two patients had appendicitis signs and symptoms. The abdominal pain and related signs and symptoms of these three patients were due to appendicitis. All three patients were discharged from the hospital with normal vital signs.Conclusion: Traumatic appendicitis might be regarded as one of the differential diagnoses of the patients referred to the ED with blunt abdominal trauma and abdominal pain; hence, appendicitis and blunt abdominal trauma have some unknown relations.
When numbers can be misleading: lithium induced irreversible neurotoxicity
at therapeutic drug levels
- Abstract: Objective: Lithium is a principal drug used in the treatment of bipolar disorder (BPD). Due to its narrow therapeutic index, serum levels need to be monitored regularly. In elderly patients with renal dysfunction lithium toxicity can develop paradoxically within the therapeutic range. This can lead to erroneous diagnosis and delayed treatment resulting in irreversible neurological sequelae as is described in our case.Case Presentation: A 65-year-old hypertensive female, with a 7-year history of BPD presented with decreased oral intake since 5-7 days, followed by altered sensorium. Neurological examination revealed coarse tremors in bilateral upper and lower limbs with spasticity, hyperreflexia, bilateral knee clonus. Twenty-five days earlier, she was prescribed Lithium carbonate. On evaluation she was found to have chronic kidney disease. Serum lithium levels came out to be 1.18 mg/dL (borderline high). After ruling out other differentials, a diagnosis of lithium toxicity was considered and she underwent two sessions of hemodialysis (HD) leading to significant improvement in sensorium; however, the patient had persistent dysarthria, difficulty in walking and proximal myopathy predominantly in the lower limbs. Nerve conduction studies confirmed the presence of axonal neuropathy. These findings of peripheral neuropathy (both sensory and motor) were suggestive of SILENT (syndrome of irreversible lithium-effectuated neurotoxicity).Conclusion: Unintended lithium toxicity can occur even at therapeutic levels especially in the elderlies owing to its narrow therapeutic window, complex pharmacokinetics and numerous drug interactions. Lithium can result in irreversible neurotoxicity including SILENT; therefore, a high level of suspicion is required to prevent such permanent disability.
An acute ST-elevation myocardial infarction which went viral
- Abstract: Objective: ST-elevations in electrocardiogram (ECG) secondary to an acute myocarditis may mimic ST-elevation myocardial infarction (STEMI). It is vital to distinguish between the two entities to avoid inappropriate clinical management and complications.Case Presentation: A previously well 19-year-old male presented with two episodes of central chest pain which were resolved spontaneously. His presentation was preceded by multiple episodes of vomiting, diarrhoea and abdominal pain. Physical examination was unremarkable except for a low-grade temperature of 37.7°C. The first ECG revealed ST-segment elevations in anterior leads without reciprocal changes. Serial ECGs showed increasing ST elevations and his cardiac markers were significantly raised. As the initial clinical presentation was potentially an acute coronary syndrome, he was instinctively treated with anti-platelets. Fortunately, this patient was not given thrombolysis as there were clinical suspicions of an acute myocarditis due to his young age, presence of viral symptoms, and absence of cardiac risk factors. Subsequent cardiac MRI confirmed the diagnosis of an acute myocarditis.Conclusion: An acute myocarditis is well known but less common presentation of viral infections. ST-segment elevations in ECG of any young patients with chest pain but without risk factors for acute coronary syndrome should always raise the suspicion of acute myocarditis especially in the presence of viral symptoms. Investigations such as cardiac magnetic resonance imaging (MRI) should be carried out emergently to distinguish both conditions.
Base of skull fracture leading to pneumomediastinum and
pneumo-retroperitoneum: a case report with review of literature
- Abstract: Objective: The presence of air within the mediastinal compartment and retro-peritoneal compartment, in the setting of trauma, can be because of visceral and skeletal injuries. However, in absence of a local site injury, an approach based on anatomical communication between various body compartments should be utilized and all potential sites of injuries must be reviewed.Case Presentation: We present a case of a 40-year-old male patient with a history of trauma (fall from height), presenting to the emergency department with loss of consciousness and ear bleed. Chest radiographs showed pneumomediastinum. On cross-sectional imaging, pneumomediastinum and pneumoretroperitoneum were seen, however no esophageal, tracheal and skeletal injuries could be identified. On careful evaluation, fractures involving the base of skull were identified as a source of ectopic air.Conclusion: This case represents a situation where the fascial connections between various compartments of the body were utilized to find the site of injury and hence the source of ectopic air. Base of skull fractures are important to be identified since these require surgical attention at an early stage.
Predictive value of HEART score in the outcome of acute coronary syndrome
and disposition
The Challenge of Medication Errors in the Emergency Department Setting
- Abstract: Medication errors (MEs) are considered the most common medical errors and as one of the major challenges threatening the health system, which can be also reduced. MEs threaten patients' safety and may increase the length of hospital stay, lead to unexpected complications, mortality and side costs. In 2017, the World Health Organization launched Medication without Harm to reduce severe avoidable medication-related damage by 50%, globally in the next 5 years. Emergency Departments (EDs) are stressful care environments which making EDs more prone to MEs. Therefore, EDs need to be seriously considered to reduce MEs and increase patients' safety. In this regard, it is of great significance to know about the most common stage of error in pharmacotherapy, the most common type of medication error and the most common causes of MEs in the emergency department practice setting. in conclusion, the most common types of MEs in EDs include drug omission error, wrong dose and strong infusion rate. In addition, the administration and prescribing are the most common stages of MEs in EDs. Also, the most common causes of MEs in EDs in Iran include nursing shortage (fatigue) and poor medication knowledge .
Pattern of injuries in blunt trauma abdomen: A retrospective evaluation of
imaging findings at a high-volume tertiary care trauma centre
- Abstract: Objective: Contrast-enhanced computed tomography (CECT) is the investigation of choice in trauma patients. The purpose of this study was to retrospectively evaluate the pattern, severity and association of abdominal injuries based on imaging at a high-volume tertiary trauma care centre. Methods: Retrospective evaluation of the CT records of patients over a period of 5 years was done at our institute. A total of 1519 patients who had undergone contrast-enhanced abdominal CT at a 64-slice Multidetector CT for abdominal trauma were included in this study. Inclusion criteria were: 1) History of blunt abdominal trauma, 2) Patients who had undergone a biphasic CECT abdomen scan. Exclusion criteria were: 1) Patients with penetrating injury, 2) Patients with incomplete data set/records. Results: Liver was the most common injured organ in both adult (38.8%) and paediatric population (40.9%). Significant higher incidence of mesenteric injury, bladder injury, spinal and rib fractures were seen in adult patients. Significant association of anorectal injuries (P=0.003) and bladder/urethral injuries with pelvic fractures was also seen (P <0.001). Conclusion: Our study provided important insights about the pattern, severity and association between the various abdominal injuries based on imaging findings in a large patient population. Larger studies with incorporation of clinical outcome in such patients can help in formulating appropriate management strategies.
The effect of teacher-made simulation moulage on learning cricothyrotomy
skills in emergency medicine physicians
- Abstract: Objective: Nowadays, simulation of clinical environment in medical education system (simulation-based learning) has led to a huge revolution in the quality of education and has increased the safety of educators and patients. In this study, we investigated the effect of teacher-made neck and lung simulators in teaching cricothyrotomy skills for emergency medicine residents.Methods: In this pre-post test study, all faculty member of emergency medicine of Tabriz University of medical sciences specialty were invited to participate. After holding an educational and training session for assistants on a teacher-made moulage, all emergency medicine residents performed a tracheostomy on the commercial moulages of the skill lab unit for the second time and their scores were recorded.Results: In this study, 23 emergency medicine residents participated. The mean ± standard deviation of age was 35.91 ± 3.57 years. There was a significant difference between the mean duration of cricothyrotomy before and after the training (P value = 0.006). There was also a significant difference between the mean scores obtained by residents in the pre- and post-training evaluation (P value < 0.001).Conclusion: Findings showed that the moulages constructed by teachers not only can be effective in improving the cricothyrotomy skills in emergency medicine residents but also can reduce the likelihood of failure in performing cricothyrotomy.
Assessing the effectiveness of ketorolac in pain management of traumatic
injuries in prehospital emergency care services
- Abstract: Objective: Pain is usually one of the most common symptoms among all traumatic injuries. One of the drugs that has recently entered the Iranian prehospital emergency system is ketorolac. Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) that inhibits prostaglandin synthesis by inhibiting cyclooxygenase activity and reduces pain and inflammation. It can be considered as the strongest analgesic drug in this category. The aim of this study was to evaluate the effectiveness of ketorolac in pain management of traumatic injuries in a prehospital setting.Methods: This descriptive cross-sectional study was undertaken to evaluate the effectiveness of a treatment method in the pain management of traumatic injuries in the prehospital environment of Lorestan province in Iran. We included 134 injured patients from road emergency bases of Lorestan province. In order to control the pain of these injured patients, 30 mg of ketorolac was injected slowly intravenously in one minute. Pain was measured in the time interval of zero minutes (before injection), 15 minutes, 30 minutes, and 45 minutes by visual acuity scale (VAS). The analysis of the obtained data was performed by SPSS software version 23.Results: The mean age of participants was 37.42±23.6. There were 47 female injuries (35.1%) and 87 male injuries (64.9%). In terms of pain intensity, 49 patients (36.6%) had moderate pain (VAS = 4-6) and 85 patients (63.4%) had severe pain (VAS = 7-10). The average of pain relief in the injured group with severe and moderate pain 15 minutes after the injection was 0.471 and 0.878 (P = 0.001), respectively. In addition, the mean of pain relief in the injured group with severe and moderate pain 30 minutes after the injection was 1.124 and 1.796, respectively (P = 0.001). Pain reduction in the group of severely injured patients with moderate pain in the first 30 minutes was statistically significant.Conclusion: Findings revealed that ketorolac is a suitable drug in pain management for trauma patients with moderate and severe pain in trauma patients. On the other hand, due to the peak effect (more than 30 minutes), it is not an effective drug for trauma patients with severe pain in a short period transferred to the prehospital environment.
Pseudo-SAH in a patient with methanol poisoning
- Abstract: Objective: Methanol poisoning is a dangerous life-threatening event, manifested withvarious symptoms, sometimes very rare ones, that all should be addressed to preventmisdiagnosis of the methanol-poisoned patients.Case Presentation: A 21-year-old young man was brought to the emergency department(ED) with a generalized tonic-clonic (GTC) seizure and he was diagnosed with methanolintoxication. A non-contrast computed tomography (NCCT) of the brain demonstratedfindings similar to subarachnoid hemorrhage (SAH). After the brain CT, he had a GlasgowComa Score (GCS) of 3 and all brainstem reflexes were absent. Neurology consultantagreed with the diagnosis of pseudo-SAH. Brain death was confirmed by a positive apneatest within 24 hours of presentation.Conclusion: It is suggested that compression of dural sinuses due to severe brain edema,reduces the venous drainage and leads to venous engorgement, which appears highattenuated in the background of low-density edematous brain matter.
Pulmonary necrosis and bronchopleural fistula in a patient infected with
COVID-19: A case report
- Abstract: Objective: Bronchopleural fistula (BPF) is a pathological communication between thebronchial tree and pleural space. BPFs are commonly seen after lung surgery, and are lesscommon in trauma, lung abscess, and radiation therapy. In this study, we describe theclinical course and surgery of a case of pulmonary necrosis and BPF in a patient infectedwith coronavirus disease 2019 (COVID-19).Case Presentation: The patient was a 54-year-old man with multiple myeloma and endstagerenal disease from the last 8 years. He had a history of coronary artery bypass graftingfrom the last 3 years. He also suffered from progressive shortness of breath and dry coughsince March 2019.Conclusion: The results of this study showed that BPF is one of the most severecomplications after thorax surgery, and there is no effective prevention methodparticularly in this patient who had COVID-19 pneumonia. Therefore, early intervention,especially when diagnosed at an early stage, by strengthening the stump inside the thoraxor thoracotomy in the open window may eventually accelerate the closure of the BPF andimprove the survival.
Underlying causes of pulled elbow in children: Could there be a
physiopathology similar to transient synovitis of the hip'
- Abstract: Objective: Partial dislocation of radius head (pulled elbow) is the most common trauma observed in out-patient orthopedic treatment of children. The typical mechanism of this trauma includes exertion of longitudinal force along the forearm in a pronation position, causing partial dislocation of the radius head.Methods: This Retrospective descriptive and cross-sectional study was undertaken on patients referring to the emergency ward of Imam Reza hospital of Mashhad with typical history of partial dislocation of radius head (pulled elbow). The present study was conducted between March 20, 2018 and March 20, 2019. Based on the number of patients at the emergency ward, the sample size was determined to be 80. Descriptive statistics such as mean and standard deviation were used to describe the collected data.Results: From among 80 children diagnosed with partial radius bone dislocation, 66.23% were girls and 33.77% were boys. The age range of patients was 28.08 months for girls and 31.04 months for boys. Findings also showed that 32 patients had a history of recent respiratory infection within 1 week before the pulled elbow incident.Conclusion: Findings revealed that, similar to previous studies, the pulled elbow injury was more common in girls than in boys. Successful reduction in first and second attempts, notwithstanding the maneuvers used indicated that the success rate of first attempts at reduction was 93%. The history of recent respiratory infections during 1 week before the injury was taken into account, where 40% of the children had some history of such respiratory infections.
Final triage methods to decide on home-isolation versus hospitalization in
COVID-19 pandemic: a challenge for clinicians
- Abstract: Objective: Final patient triage determines which patients can be home-isolated andwhich patients require hospitalization on the basis to predict the patient’s prognosismost accurately. Final triage is an important link in the clinical management chain of thecoronavirus disease 2019 (COVID-19) pandemic, and a comprehensive review of variouspatient triage methods is very important to guide decision making and triage efficiency.Decision by clinicians about hospitalization or home-discharge is one of the main challengesin places with limited hospital facilities compared to the high volume of COVID-19 patients.This review was designed to guide clinicians on how to address this challenge.Methods: In this mini review we searched scientific databases to obtain the final triagemethods of COVID-19 patients and the important criteria in each method. In order toconducted searches a period from December 2019 to July 2020 was considered. All searcheswere done in electronic databases and search engines.Results: Findings revealed four current methods for final triage (decision-making regardinghome-isolation or hospitalization of COVID-19 patients). These methods included 1)demographic and background information, 2) clinical information, 3) laboratory indicatorsand 4) initial chest CT-scan. Each of the aforementioned methods encompassed significantcriteria according to which decisions on the patient’s prognosis and final triage were made.Finally, by evaluating each final triage method, we found that each method had somelimitations.Conclusion: An effective and quick final triage requires simultaneous complementary useof all four methods to compensate for each other’s weaknesses and add to each other’sstrengths. It is therefore suggested to assure that clinicians are trained in all four COVID-19patient’s triage methods and their useful criteria in order to achieve evidence-basedperformance for better triage (decision between home-isolation versus hospitalization).
The proposed scoring system for hospitalization or discharge of patients
with COVID-19
- Abstract: Objective: Since the outbreak of coronavirus disease 2019 (COVID-19), the triage ofpatients diagnosed with corona virus has been a very important issue. The aim of thisstudy was to introduce a triage scoring system according to the clinical and para-clinicalfindings of patients in order to be admitted or discharged with COVID-19.Methods: After confirming the positive polymerase chain reaction (PCR) test for patients,we used a scoring system which included: the age of patient (less than 40 years and >40years), early vital signs at the time of admission, lab tests including C-reactive protein (CRP),white blood count (WBC), lactate dehydrogenase (LDH), D-dimer, chest imaging findings,comorbidity and shortness of breath.Results: The clinical score obtained for each variable in this scoring system was a numberbetween 0 and 3. The total score was a minimum of 0 and a maximum of 17. A higher scoreindicated an increase in the intensity and the need for intensive care. These scores wereclassified into 3 groups: 0-4, 5-10 and above 10. In the next stage, patients were dividedinto three groups: mild, moderate and severe. In this regard, patients with mild symptomswere suggested to receive home quarantine and home treatment, patients with moderatesymptoms were recommended hospitalization and medical care, and finally patients withsevere symptoms were inclined to intensive care.Conclusion: In order to treat and manage patients with COVID-19, it is necessary to payparticular attention to clinical and para-clinical findings and prioritize these findings basedon the severity and the condition of patients.