فهرست مطالب

Advanced Journal of Emergency Medicine - Volume:2 Issue: 1, 2018
  • Volume:2 Issue: 1, 2018
  • تاریخ انتشار: 1396/12/20
  • تعداد عناوین: 12
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  • Leyla Nasehi, Reza Taslimi, Ahmadreza Dehpour, Javad Seyedhosseini Page 2
    Introduction
    Renal colic is caused by colicky spasms of ureters. As has been shown in previous experiments, glycerol trinitrate (TNG) can inhibit these muscular spasms.
    Objective
    This study was performed to assess the pain relieving effect of TNG among patients referred due to renal colic pain to the emergency department (ED).
    Methods
    This study is a randomized, placebo-controlled study on 60 patients with renal colic who were referred to the ED, who were diagnosed clinically to have renal colic, and their pain was more than 5 based on a visual analogue scale (VAS). The patient's pain was recorded at the moment of clinical diagnosis, and each one received one capsule, either 0.4 mg TNG or placebo, plus a 100 mg indomethacin suppository. The pain score was re-assessed after 5 and 30 min. The values were recorded and compared using SPSS-16 software.
    Results
    Sixty patients with a mean age of 35.75 ± 11.99 years were enrolled (73.3% male). Patients in the two groups were matched for age (p = 0.290), sex (p = 0.559), and the presence of microscopic hematuria (p = 0.292). Pain relief from the start point until the end of the intervention was statistical different in all studied patients (p
    Conclusion
    It is likely that adding TNG to an indomethacin suppository had no significant effects on better pain management of patients referred with renal colic to the ED.
    Keywords: Emergency service, hospital, Nitroglycerin, Pain management, Renal colic
  • Mehdi Momeni, Elnaz Vahidi, Javad Seyedhosseini, Alemeh Jarchi, Zeinab Naderpour, Morteza Saeedi Page 3
    Introduction
    Emergency overcrowding is defined as when the amount of care required for patients overcomes the available amount. This can cause delays in delivering critical care in situations like stroke.
    Objective
    The aim of this study was to assess the possible impact of emergency department (ED) crowding on the quality of care for acute stroke patients.
    Methods
    In this cross-sectional prospective study, all patients with symptoms of acute stroke presenting to the ED of educational hospitals were enrolled. All patients were assessed and examined by the emergency medicine (EM) residents on shift and a questionnaire was filled out for them. The amount of time that passed from the first triage to performing the required interventions and delivering health services were recorded by the triage nurse. ED crowding was measured by the occupancy rate. Then, the correlation between all of the variables and ED crowding level were calculated.
    Results
    The average daily bed occupancy rate was 184.9 ± 54.3%. The median time passed from the first triage to performing the interventions were as follows: the first EM resident visit after 34 min, the first neurologic visit after 138 min, head CT after 134 min, ECG after 104 min and ASA administration after 210 min. There was no statistically significant relationship between the ED occupancy rate and the time elapsed before different required health services in the management of stroke patients either throughout an entire day or during each 8-hour interval (p > 0.05).
    Conclusion
    In the current study, the ED occupancy rate was not significantly correlated with the time frame associated with management of admitted acute stroke patients.
    Keywords: Bed occupancy, Emergency service, hospital, Health services, Quality of health care, Stroke
  • Pauline Haroutunian, Mohammed Alsabri, FranÇois Jerome Kerdiles, Adel Ahmed Abdullah Hassan, Abdelouahab Bellou Page 4
    Introduction
    Patients’ complaints from Emergency Departments (ED) are frequent and can be used as a quality assurance indicator.
    Objective
    Factors contributing to patients’ complaints (PCs) in the emergency department were analyzed.
    Methods
    It was a retrospective cohort study, the qualitative variables of patients’ complaints visiting ED of a university hospital were compared with Chi-Square and t test tests.
    Results
    Eighty-five PC were analyzed. The factors contributing to PC were: communication (n=26), length of stay (LOS) (n=24), diagnostic errors (n=21), comfort and privacy issues (n=7), pain management (n=6), inappropriate treatment (n=6), delay of care and billing issues (n=3). PCs were more frequent when patients were managed by residents, during night shifts, weekends, Saturdays, Mondays, January and June. Moreover, the factors contributing to diagnostic errors were due to poor communication, non-adherence to guidelines and lack of systematic proofreading of X-rays. In 98% of cases, disputes were resolved by apology and explanation and three cases resulted in financial compensation.
    Conclusion
    Poor communication, LOS and medical errors are factors contributing to PCs. Improving communication, resolving issues leading to slow health care provision, adequate staffing and supervision of trainees may reduce PCs.
    Keywords: Communication, Diagnostic Errors, Emergency Department, Patient Complaint
  • Farhad Heydari, Mohammad Hosein Maghami, Mehrdad Esmailian, Majid Zamani Page 5
    Introduction
    The purpose of triage in the standard Clinical Practice Guide (CPG) for multiple trauma patients is to perform the primary and secondary evaluations in the quickest and shortest possible time with minimal errors and the best quality in the emergency department (ED).
    Objective
    In this study, a practical program for a coordinated management of multiple trauma patients in the ED has been provided by using the CPG guide. The impact of its implementation on the multiple trauma patients’ management was evaluated.
    Methods
    This is a cross-sectional study conducted in 2014 and 2015 in Isfahan’s Al-Zahra hospital ED. Administration and management of multiple trauma patients had been prepared before the implementation of the plan based on standard clinical methods of implementation in a way that used a 12-step protocol for the practical guide. This protocol was designed as a flowchart and the results before and after its implementation were evaluated.
    Results
    In this study, 100 multiple trauma patients before and after the implementation of the protocol were studied. The mean age of the patients and other baseline characteristics of studied patients in the two periods before and after implantation of the CPG were not significantly different (p > 0.05). The frequency of intubation (p = 0.016) and sent to the operating room (p
    Conclusion
    Implementation of the strategic plan of CPG lead to a significant reduction in waiting time for visits by emergency medicine services and other specialized services, increased the deployment of patients needing surgery, and reducing the time spent in the ED.
    Keywords: Clinical protocols, Emergency service, hospital, Multiple trauma, Triage
  • Sahar Mirbaha, Mohammadmehdi Forouzanfar, Mohammadmehdi Mohebi, Hamid Kariman Page 6
    Introduction
    Leaving the hospital without notice is among the problems that can inflict financial and non-financial burdens on the health care system of a country.
    Objective
    The present study was carried out with the aim of evaluating the prevalence of leaving without notice cases in the emergency department (ED) of one of the major teaching hospitals of Tehran affiliated with Shahid Beheshti University of Medical Sciences and calculating the direct costs resulting from it.
    Methods
    This study was a retrospective cross-sectional one carried out during 1 year from 2016 to 2017 in one of the teaching hospitals of Tehran affiliated with Shahid Beheshti University of Medical Sciences. Sampling was performed via census method and the study population consisted of the profiles of all the patients who had left the hospital without notice or checking out after being admitted to the hospital. To gather the required data for this study, a checklist consisting of questions regarding sex, age, insurance coverage, and the amount of money they owed the hospital was used. Statistical analysis was performed using the software IBM Statistics for Windows v22 and P-value
    Results
    Out of the total of 39946 patients visiting the ED of the studied hospital during 1 year, 1692 (4.2%) had left the hospital without checking out. Below 30 years age range was the most common age range with 46.9% (794 patients) and 72.9% of the patients leaving without notice were men. Based on the findings obtained, male patients without insurance coverage had attempted to leave the hospital without notice more than others (p
    Conclusion
    Throughout the year this study was performed, a total of 1.2% of all the visitors of the ED of a hospital affiliated with Shahid Beheshti University of Medical Sciences left the hospital without notice or checking out, which inflicted a considerable cost on the ED.
    Keywords: Absconding, Costs, cost analysis, Emergency service, hospital, Health care costs, Health expenditures
  • Ali Abdolrazaghnejad, Mohsen Banaie, Mohammad Safdari Page 7
    Context: The aim of this study is to evaluate the applications of ultrasonography (US) as a diagnostic tool in emergency settings.
    Evidence acquisition: In the present review article, search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane were searched for the applications of US in emergencies. Finally, related articles which were published between 2000 and 2017, were selected and by reviewing them an attempt was made to evaluate various applications of US for examining and facilitating decision-making in emergency department (ED).
    Results
    As a diagnostic tool, US can be of diagnostic help in emergency settings for the specialists and the treatment team regarding trauma, measuring intracranial pressure (ICP), hemothorax pneumothorax, abscess and its drainage, deep vein thrombosis (DVT), dyspnea, acute abdomen, appendicitis and biliary problems, renal colic and renal stones, shock, foreign object, bone fracture, peripheral nerve block, establishing central and peripheral venous access, lumbar puncture (LP), and confirmation of nasogastric tube (NGT) and endotracheal tube (ETT) placement.
    Conclusion
    The results of this review study showed that US can be of help to EMPs as a diagnostic tool in a wide range of diseases and clinical conditions, which in turn can result in a decrease in the time needed for diagnosis and treatment, and therefore improve both the quality and quantity of the service provided in ED.
    Keywords: Diagnosis, Emergency treatment, Emergency service, hospital, Ultrasonography
  • Seyedhossein Seyedhosseini-Davarani, Hossein Asle-Soleimani, Hooman Hossein-Nejed, Reza Jafarbaghdadi Page 8
    Introduction
    Chest pain, which can be cardiac or non-cardiac and either benign or life-threatening, needs appropriate diagnosis and treatment in emergency department (ED).
    Objective
    The aim of this study was to compare delivery time of primary care for patients with chest pain before and after applying triage system in ED.
    Methods
    Medical records were reviewed of thirty patients (group one) with chief complaint of chest pain who referred to ED between April and July 2008 (before installing triage system) and thirty-five patients (group two) with the same chief complaint who referred between August and September 2009 (after installing triage system). Time between patients’ arrival and beginning of diagnostic and therapeutic interventions including cardiac monitoring, first physician visit time, intravenous line insertion, and electrocardiogram performance were compared between the two groups.
    Results
    Based on the findings, the mean age and sex ratio of studied patients in the two groups were not significantly different (p>0.05). Door to ECG performance, Door to intravenous line insertion, and Door to cardiac monitoring were significantly shorter in post triage installing period than previously (p
    Conclusion
    It is likely that patients with chest pain who referred to ED benefit from installing triage system in terms of performing some nursing care including ECG performance, starting cardiac monitoring, and IV insertion.
  • Arpith Easo Samuel, Reshma Balembi Krishna Page 9
    Introduction
    Cardiac tamponade, a variant of cardiogenic shock, is a medical emergency. A traumatic cardiac tamponade is an expected phenomenon; however, in non-traumatic events such as malignant pathology, it is usually less dramatic and takes several days or weeks to manifest. Occurrence of tamponade physiology due to pericardial effusion in a patient with multiple myeloma is a distinctly unusual entity. The involvement of a serous cavity in multiple myeloma is rare and pericardial effusion in such a case is due to restrictive cardiomyopathy or amyloidosis, a presentation late in the course of the disease that carries a grave prognosis.
    Case Presentation
    We present to you a case of a 60-year-old patient with cardiac tamponade due to pericardial effusion secondary to an advanced multiple myeloma. Due to the early diagnosis, she underwent a successful emergency pericardiocentesis with a central venous catheter under ultrasound guidance even in a resource limited emergency department (ED) of a district in southern India. She also showed marked improvement after the procedure and was transferred to the intensive care unit for further management.
    Conclusion
    Cardiac tamponade is not an “all or none” phenomenon, but rather a continuum of findings. A high index of suspicion and timely clinical decision-making is the key for an emergency physician. Although there are several mimics for cardiac tamponade in ED, it is important for an emergency physician to be aware of such varied presentations of a disease spectrum owing to its rarity and clinical importance.
    Keywords: Cardiac tamponade, Emergency pericardiocentesis, Multiple myeloma, Resource limited setting Keywords: Cardiac tamponade, Emergency pericardiocentesis, Multiple myeloma, Resource limited setting
  • Seyed Mojtaba Aghili, Maryam Kia, Rokhsareh Aghili Page 10
    Case Presentation
    A 58-year-old man presented to the emergency department with abdominal pain, nausea and loss of appetite for the last 8 hours. He reported diffuse pain that had been localized to the right lower quadrant (RLQ). Physical examination revealed muscular defense and tenderness in the RLQ. Computed tomography (CT) of the abdomen and pelvis confirmed luminal distension with a thickened enhancing wall with an appendicolith.
    Learning points: Appendicitis may be developed by an appendicolith, a calcified deposit within the appendix. It may be an incidental finding on an abdominal radiograph, ultrasound (US) examination or CT. It appears as echogenic focus and casts an acoustic shadow on US examination and manifests as a calcified mass on plain radiograph or CT. The incidence of appendicolith is higher among patients with a retrocaecal appendix. In our patient, a clinical diagnosis of acute appendicitis was made and the patient was immediately transferred to the operating room and an appendectomy was performed.
  • Mahbube Ebrahimpur, Mahnaz Pejman-Sani, Zeinab Naderpour Page 11
    Case Presentation
    A 55–year-old diabetic woman presented to the emergency department with a complaint of nausea, vomiting, right upper abdominal pain, and fever with chills since 10 days. She revealed a 10-year history of poorly controlled diabetes on oral agent and kidney stones. On examination, the patient was found to be febrile (39 ℃) with tenderness in the right renal angle. Laboratory data has revealed the following findings: blood sugar (BS: 480 mg/dl), HbA1C: 13%, complete blood count (white blood cells (WBC): 13,900; polymorphonuclear leukocytes (PMN): 80%; lymphocytes: 18%; hemoglobin: 12 g/dl; and platelet: 118,000), blood urea nitrogen (BUN): 79 mg/dl, creatinine (Cr): 2.3 mg/dl, and erythrocyte sedimentation rate (ESR): 103 mm in 1 h. The urine analysis revealed 12–13 WBCs, 7–8 red blood cells (RBCs), and several bacteria. Urgent ultrasound indicated a heterogeneous mass in with focal echoes suggesting intraparenchymal gas, along with gross hydronephrosis and numerous stones, in the right kidney. The patient was treated with hydration, insulin, and intravenous imipenem 500 mg twice daily (adjusted with her creatinine). After 48 h, blood culture report was negative, whereas urine culture revealed presence of imipenem sensitive Citrobacter. Computed tomography (CT) scan without contrast indicated an enlarged, edematous right kidney with multiple air bubbles and air fluid levels. Based on the clinical and radiological findings, diagnosis was confirmed and right urgent nephrectomy was performed after 36 h of admission. The histopathology of the removed kidney revealed acute or chronic inflammation and necrosis, extending to the perinephric fat. The patient was discharged without any major complication after a 14-day hospital stay.
    Learning points: Emphysematous pyelonephritis (EPN) is an acute, severe, and gas producing necrotizing bacterial infection that affects the renal parenchymal and surrounding tissues. The predisposing factors include: diabetes mellitus, urinary tract obstructions, and immune incompetence. Diabetes mellitus is the most commonly associated factor and up to 90% of the patients report uncontrolled diabetes mellitus. Bilateral renal involvement and obstruction has been observed in 5% and 30% of the patients, respectively. The most common pathogen causing EPN is Escherichia coli. Other pathogens have been reported including Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa. Several factors contribute in the pathogenesis of EPN including high levels of glucose inside the tissues, gas forming bacterial infection, impaired vascular blood supply, reduced host immunity, and obstruction in the urinary system. Clinical manifestations are similar to acute pyelonephritis, including fever, nausea, vomiting, and flank pain; however, often they do not respond to the medical treatment. Laboratory investigations often reveal leukocytosis with a shift to the left, thrombocytopenia, and elevation of the serum creatinine levels. As aforementioned, urine analysis reveals WBCs, RBCs, and several bacteria. The diagnosis is confirmed by radiological imaging. A plain abdominal X-ray can be more specific than the ultrasound, indicating the presence of gas in the kidney. The gold standard is abdominal CT scan that reveals the presence of gas and obstruction in the urinary tract systems. Treatment should commence with fluid resuscitation, antibiotic therapy, and control of blood sugar and electrolytes. Percutaneous drainage or DJ-stenting is recommended in the patients with urinary tract obstruction. If the aforementioned measures fail, then emergency nephrectomy should be considered.
  • Mehran Sotoodehnia, Pooya Payandemehr Page 12
    The patient was a 58-year-old woman with a history of mitral valvuloplasty, presenting to the emergency department (ED) due to weakness and shortness of breath. Her vital signs were stable. The patient’s electrocardiogram (ECG) is presented in figure 1. What is the correct interpretation of this ECG?
    1.Sinus dysrhythmia
    2.Paroxysmal atrial tachycardia with variable AV node block
    3.Atrial flutter with variable AV node block
    4.Sinoatrial block
    5.Atrial fibrillation with normal ventricular rate
    The baseline rhythm of this ECG shows an irregularity at the first glance that is repeated without any specific pattern. After considering this irregular abnormal pattern, in the next step, the heartbeat in this ECG should be calculated, taking into account the irregular base rhythm, about six seconds of the ECG should be considered, and the number of complete QRS complexes should be counted in this period. The resulting number should be multiplied by ten in order to estimate the heart rate in a minute. In this patient, the heart rate was about 90 beats per minute. So far, we have an irregular abnormal rhythm in the ECG. Differential diagnosis of this condition in the ECG varies based on the wide or narrow QRS complexes. A narrow QRS complex is a sign of the natural ventricular depolarization, and several rhythms with a natural rate (60-100 beats per minute) can have irregular QRS intervals. In the case of irregular abnormal rhythms, normal rates, and narrow QRS complexes, there are various differential diagnoses, some of which are mentioned in the multiple choice answer to this question. In the following, after mentioning the electrocardiographic characteristics of each of the rhythms mentioned in the question and their simultaneous assessment in this ECG, we will reach the correct answer.