Frontiers in Emergency Medicine
Volume:2 Issue: 3, Summer 2018

The Ottawa Subarachnoid Hemorrhage rule (OSR) is a clinical decision tool identified for ruling out subarachnoid hemorrhage (SAH) in those patient above 15 years of age who present to the emergency department (ED) with acute onset atraumatic headache.
The primary objective of this study was to externally validate the OSR in a single national health service (NHS) setting in the UK and secondly, to compare it with our current practice without using a decision rule.
A retrospective review of computerized medical records was done for all patients registered with headaches from January to December 2016. The data were manually charted on a data sheet from individual patient records. Patients fulfilling the preset inclusion and exclusion criteria as per the OSR were enrolled in the analysis. According to the OSR, if patient had any of the 6 criteria enlisted (age > 40 years, neck stiffness/pain, witnessed loss of consciousness, onset during exertion, thunderclap headache, limited neck flexion on examination), further diagnostic decision was required. All patients were followed up for 6 months on the computer system as it gets highlighted if the patient is represented again to the ED or is deceased.
A total of 737 ED visits with acute headache were reviewed for potential eligibility. Out of these, 649 were estimated to be eligible. On excluding 485 patients that could not meet the predetermined inclusion criteria and 19 patients as per the exclusion criteria, 145 (19.7%) patients were included in the analysis. There were 5 cases of SAH, yielding an incidence of 3.4 % (95% CI 1.3 % – 8.3 %). The sensitivity for SAH was 100% (95% CI, 46.3 % - 100 %); specificity of 44.2 % (95% CI, 36 % - 53 %); positive predictive value of 6.02 % (95% CI 2.2 % - 14.1 %); and negative predictive value of 100% (95% CI, 92.7 % - 100%).
Although being poorly specific, the OSR is a highly sensitive, simple tool for ruling out SAH in alert patients with a headache in ED settings.

Most of the patients hospitalized in the emergency department (ED) are in need of transfer to other hospital wards or paraclinic units. This process is called intrahospital transfer (IHT) that may lead to a wide range of complications known as unexpected events (UE).

In the present study we decided to evaluate the effect of using a pre-designed protocol on decrease of UEs and safety improvement of IHT among patients hospitalized in ED.

The present cross-sectional study was carried out in 2016 in the ED of Imam Khomeini Hospital, Tehran, Iran. All patients with triage levels of 1 and 2 who were in need of temporary or permanent transfer to other departments of the studied treatment center based on clinical indication as decided by the in-charge physician were enrolled in the study. This study was conducted in 3 phases of pre-intervention, intervention and post-intervention. Any UE was recorded in first phase. During intervention phase ED-IHT protocol was prepared and implemented. the checklist of complications and UEs during transfer was filled again and pre- and post-intervention results were compared.

In this study, 207 patients with the mean age of 58.9 ± 20.6 years were evaluated (61.4% male). Demographic data and baseline characteristics of the studied patients in the phases before and after implementation of the protocol has no significant difference. Overall, before implementation of the protocol out of the 105 studied patients, a total of 35 patients (33.3%) were affected by UE during transfer, but after implementation of the protocol this rate decreased to 11 patients (10.8%) out of the 103 studied patients and this decrease was statistically significant (p

Based on the results obtained from this study, it seems that performing the IHT protocol specialized for ED patients has been effective in decreasing UE cases.

pain management is an important and challenging issue in emergency medicine. Despite the conduct of several studies on this topic, pain is still handled improperly in many cases.
This study investigated the effectiveness of low-dose IN ketamine administration in reducing the need for opiates in patients in acute pain resulting from limb injury.
This randomized, double-blind, placebo-controlled trial was conducted to assess the possible effect of low-dose intranasal (IN) ketamine administration in decreasing patient's narcotic need. Patients in emergency department suffering from acute isolated limb trauma were included. One group of patients received 0.5 mg/kg intravenous morphine sulfate and 0.02 ml/kg IN ketamine. The other group received the same dose of morphine sulfate and 0.02 ml/kg IN distilled water. Pain severity was measured using the 11 points numerical rating scale at 0, 10, 30, 60, 120, and 180 minutes.
Ninety-one patients with mean age of 31.62 ± 9.13 years were enrolled (54.9% male). The number of requests for supplemental medication was significantly lower in patients who received ketamine (12 patients (30%)) than those who received placebo (27 patients (67.5%)) (p = 0.001).
It is likely that low-dose IN ketamine is effective in reducing the narcotic need of patients suffering from acute limb trauma.

Focused assessment with sonography for trauma (FAST) has been shown to be useful to detect intraperitoneal free fluid in patients with blunt abdominal trauma (BAT).
We compared the diagnostic accuracy of FAST performed by emergency medicine residents (EMRs) and radiology residents (RRs) in pediatric patients with BAT.
In this prospective study, pediatric patients with BAT and high energy trauma who were referred to the emergency department (ED) at Al-Zahra and Kashani hospitals in Isfahan, Iran, were evaluated using FAST, first by EMRs and subsequently by RRs. The reports provided by the two resident groups were compared with the final outcome based on the results of the abdominal computed tomography (CT), operative exploration, and clinical observation.
A total of 101 patients with a median age of 6.75 ± 3.2 years were enrolled in the study between January 2013 and May 2014. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. A good diagnostic agreement was noted between the results of the FAST scans performed by EMRs and RRs (κ = 0.865, P In this study, FAST performed by EMRs had acceptable diagnostic value, similar to that performed by RRs, in patients with BAT.

Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients’ flow in the ED is termed triage.
This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%.
This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients’ charts, an expert panel evaluated the validity of the triage level.
During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel’s evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen’s weighted kappa being 0.966 (CI 0.985–0.946, p The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses.

Presentation of neck injuries in ER can be with or without neurological deficit. Trauma victims with multiple injuries should be examined for neck injuries as these injuries are potentially life threatening. Further neck movement should be restricted by applying the cervical collar until further radiological investigations rule out the spine injury. Early identification and treatment of neck injuries whether spine, vascular, or muscular injury improve the morbidity and mortality in polytrauma patients.
In a series of case presentations of neck injuries through various modes, the first case of neck injury was related to road traffic accident presented with neck pain and paraplegia. In the second case, neck injury was due to suicidal hanging presented with ligature mark over the neck. Third case was related to Indian traditional sport-related neck injury presented with severe neck pain stiffness. In the fourth case, neck injury was due to gunshot and presented with bullet entry wound and quadriparesis.
Neck injury in the absence of associated injuries is rarely seen after blunt and penetrating trauma, but can result in devastating outcomes if left unrecognized. A high index of suspicion and early intervention are critical.

Facial lesions usually have a benign self-limited prognosis, but in rare cases they have a poor outcome. Extranodal natural killer/T-cell lymphoma (ENK/TCL) is a rare aggressive lesion presenting with a midline facial lesion that can easily be misdiagnosed. Diagnosis is often difficult and requires a thorough clinical examination and the use of immunohistochemistry for analysis of biopsies. Such malignancies affecting the head and neck area provide an interesting but difficult diagnosis. The purpose of this article is to report a severe case of ENK/TCL-nasal type in a boy with a previous history of nasal trauma.
An 11-year-old boy was referred to the maxillofacial unit of Sulaimany Teaching Hospital, Iraq, with midline facial destruction. The patient stated that about 6 months prior he had fallen down and suffered nasal trauma; 3 months after the trauma, an asymptomatic ulcer appeared and gradually increased in size. Two biopsies were performed with no conclusive results. In the third biopsy, histology showed atypical lymphoid tissue surrounded by intense necrosis. The diagnosis was confirmed by immunohistochemistry. The treatment of choice was chemotherapy followed by radiotherapy. The patient had a satisfactory response but 2 months later during chemotherapy the patient unfortunately died from a pulmonary embolism.
Suspicious midline ulcerative lesions in the head and neck region must have ENK/TCL considered in the differential diagnosis and repeated biopsies may be necessary to confirm the diagnosis.

Gender-based violence (GBV) against women has been identified as a global health and development issue. We reported a case of GBV causing sever, multiple injuries in a middle-aged female.
Case report: A 47-year-old woman presented to emergency room with disturbed level of consciousness, shortness of breath and multiple patches of skin discoloration. On examination, the patient was semi-conscious, with multiple ecchymosis and bilateral decreased air entry. Computed tomography scan of the neck and chest showed six rib fractures on the left side, and eight rib fractures on the right side, sternal fracture, manubriosternal dislocation, bilateral hemothorax, fracture of body of eleventh thoracic vertebra, and fracture of cervical spine of fifth and seventh vertebrae. The patient was intubated and admitted to intensive care unit. She was discharged with good health condition after 23 days of hospital admission.
GBV is still a cause of severe trauma that puts the patient’s life at risk.

Traumatic diaphragmatic hernia (TDH) is one of the critical complications resulting from penetrating chest trauma. The rate of undiagnosed TDH equivocates 12-60%. The significant part of complications happens 1-4 years after the primary damage. Here, we report a case of delayed TDH presented with upper gastrointestinal bleeding (GIB) as an excuse to discuss this issue.
The patient was a 35-year-old man, admitted with objection of abdominal pain. A nasogastric tube was inserted and fixed that resulted in drainage of about 500cc dark blood. He was candidate for emergent endoscopy due to upper GIB. During resuscitation measures, he suddenly developed respiratory distress that could not be justified by upper GIB alone. Therefore, bedside sonography discovered some soft tissue apart from lung tissue in the left hemithorax. After performing diagnostic measures, with diagnosis of diaphragmatic herniation and strangulation he underwent emergent surgery.
Small diaphragmatic lesions, which usually result from stab wounds, may develop into larger injuries if left untreated and they might lead to a diaphragmatic hernia with a potential risk of early or late complications and mortality. One of the rare complications is GIB, which should be considered in a patient with past history of trauma and presentation of GIB.

A 46-year-old man was admitted to the emergency department with complaints of fever and skin lesions in the right leg since 3 days before. Moreover, he revealed a history of 5 years of poorly controlled diabetes mellitus despite being on oral medication. On physical examination, he was oriented and the following vital signs were observed: blood pressure: 80/60 mmHg; pulse rate: 90 beats/min; respiratory rate: 18 breaths/min; and oral temperature: 38 °C. Two large erythematous lesions with central necrosis in the upper segment of the right leg were noticed. Further examination revealed crepitation of the same right leg segment. Laboratory findings revealed the following: white blood cell (WBC) count, 17,000/mm3; hemoglobin, 15 g/dl; sodium, 125 meq/l; potassium, 3.8 meq/l; blood glucose, 400 mg/dl; blood urea nitrogen, 45 mg/dl; creatinine, 2.4 mg/dl; and bicarbonate,13 meq/l. Plain X-ray of right leg revealed gas formation in the soft tissues, which was a diagnostic criterion for necrotizing fasciitis (Figure 1). The patient was treated immediately with intravenous fluid, broad spectrum empiric antibiotics (meropenem plus vancomycin), and insulin infusion; moreover, urgent surgical consultation was requested. He underwent emergency debridement within few hours of hospitalization.

A healthy 24-year-old female presented at the emergency department (ED) after a car accident with ambulance while injured severely after the bus got run over her lower limb. As the trauma team was activated, her primary survey was started: Ac (Airway and cervical collar): She was awake and could talk. Cervical collar was fixed, oxygenation with face mask was started. B (Breathing): Her chest rising was symmetrical without any laceration or abrasion. Chest auscultation was clear and there was no tenderness or crepitation on palpation. No tracheal shift was found. She had normal respiratory rate and O2 saturation of 94% at ambient air. C (Circulation): Two large bore IV lines were inserted and blood samples were obtained. Her vital signs were BP = 60/40 mmHg, PR = 130/min, RR = 12. E-FAST was performed which was negative for free fluid in abdomen, pelvis and thorax, tamponade, and hemopneumothorax. Her pelvis was unstable on examination and pelvic wrapping was performed with sheath. IV fluid therapy with normal saline was started followed by 3 units of packed RBC transfusion. More pack cells and FFP were also requested. D (Disability): She had Glasgow coma scale of 15/15 with normal size and reactive pupil. No neurologic deficit was found except disability of lower extremities due to crush injury. E (Exposure): She had no midline spinal tenderness with normal sphincter anal tone, but there was a laceration in the perineum which extended to the vagina. Portable chest and pelvic x-ray as an adjutant to primary survey were performed which showed type C pelvic fracture. On her secondary survey, she had abrasion on her scalp, 1.5 cm laceration on her right tibia, deformity of her right thigh, and laceration in her genitalia with some vaginal bleeding. Direct pressure was applied and all lacerations were packed. According to negative e-FAST and pelvic fracture and shock, since the angiography was not available, it was decided to fix the pelvis with external fixator in the operation room. After the fixation, and because shock persisted, operative pelvic packing was undertaken. Unfortunately, she suffered cardiorespiratory arrest in the operating room and died.