Bulletin of Emergency And Trauma
Volume:7 Issue: 3, Jul 2019

To identify prevalent domains related to the concept of assessing preparedness of non-hospital centers to provide primary emergency care in order to develop a comprehensive framework. Five databases including PubMed, Scopus, Web of science, Barakat Knowledge Network Systems (BKNS) and Scientific Information Database (SID) were searched in English and/or Persian languages with no time limit until March, 2018. Manual search and grey literature were also done. According to the eligibility criteria, all the studies were independently tracked by two researchers. Studies were appraised using the Mixed Methods Appraisal Tool (MMAT). The findings were synthesized through directed content analysis method. Out of 3014 studies, 15 studies were included for data synthesis. The synthesis of literature resulted in the emergence of 13 domains and 25 sub-domains. Then, they were categorized based on Donabedian’s triple model and a conceptual framework was developed. In this framework, 6 domains were put in input, 6 in processes, and 1 domain in outcome. Of the 15 included studies, 1 study considered 10 domains and 14 other studies considered 4 to 8 domains out of 13 synthesized domains. The most prevalent synthesized domains were “medical supplies and equipment” and “human resources”, which were considered in 15 studies. In this study, a conceptual framework was constructed that identifies elements that significantly affect the preparedness of these centers. This framework may assist managers to take a comprehensive approach to assess these centers.

To compare the stewardship of road traffic accidents (RTIs) prevention in three pioneer countries and three similar ones to Iran. In this descriptive comparative study, the United States of America, Sweden, and Brazil as the pioneer countries in RTIs prevention were compared to the India, Pakistan, and Turkey as the countries socioeconomically similar to Iran. Embase, PubMed, Scopus, IranDoc, IranMedex, SID, and MagIran were searched. Also a hand search conducted on websites and search engines using related keywords. In the pioneer countries in RTIs prevention there was a delegation to a particular organization. In the other three countries a part of the Ministry of Transportation had the overall responsibility of RTIs. In Iran there was uncertainty in the stewardship of RTIs prevention. There was little evidence on the role and activities of health systems in RTIs prevention. It seems necessary to define a lead agency organization on RTIs prevention in Iran with sufficient authority and resources. This study also recommends conducting reliable studies to investigate the possible roles that the health system of a country can assume regarding the RTIs prevention.

To evaluate the Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in comparison with other risk factors for mortality including osteopenia as an indicator for frailty in geriatric patients subjected to emergency laparotomy.  All geriatric patients (≥65 years) undergoing emergency laparotomy at a single university hospital between 1/2015 and 12/2016 were included in this cohort study. Demographics and outcomes were retrospectively collected from medical records. Association between prognostic markers and 30-day mortality was assessed using Poisson and backward stepwise regression models. Prognostic value was assessed using receiver operating characteristic (ROC) curves. 209 patients were included with a mean age of 76 ± 7.3 years. American Society of Anesthesiologists (ASA) classification, age, indication and type of surgery, hypotension, transfusion requirement and current malignancy proved to be statistically significant predictors of 30-day mortality. P-POSSUM mortality was statistically significant in the backward stepwise regression (incidence rate ratio=1.58, 95% CI: 1.16–2.15, p=0.004) while osteopenia was not. P-POSSUM had poor prognostic value for 30-day mortality with an area under the ROC curve (AUC) of 0.59. The prognostic value of P-POSSUM improved significantly when adjusting for patient covariates (AUC=0.83). P-POSSUM and osteopenia alone hardly predict 30-day mortality in geriatric patients following emergency laparotomy. P-POSSUM adjusted for other patient covariates improves the prediction.

To investigate the prognostic value of clinical and laboratory tests in prediction of outcome in patients at day 30 post presentation to hospital with shock and to determine the prognostic value of mid regional pro-adrenomedullin (MR-proADM) on mortality prediction at 30 days in the same patient cohort. This prospective multicenter cohort study analyzed data from patients who had presenting with shock to the emergency departments of eleven urban, tertiary-care University hospitals in Spain between March, 2011 and May, 2011. Recruitment of patients was via convenience sampling. Inclusion criteria included age between 14 and 100 years with clinical diagnostic criteria of shock on admission. Various patient parameters were analysed, such as age, sex, past medical history. Other clinical variables were measured on arrival to hospital, including sequential organ failure assessment score (score SOFA), blood pressure, oxygen saturations, capillary refill time and shock index (SI). Laboratory variables investigated included base excess, MR-proADM, lactate, C-Reactive Protein (CRP) and procalcitonin (PCT). There were 212 patients included in the study from the eleven hospitals involved. The mean age was 72.2 years old and 60.4% of the patients were men. In the discriminant analysis only age, MR-proADM and PCT remained in the final discriminant equation. The separate analysis of MR-proADM showed that, in the non-survivors group, MR-proADM levels are significantly higher than those found in the group of survivors (p<0.001). Age, PCT and MR-proADM were useful to predict short-term mortality in patients presenting to the emergency department shock. This suggests that PCT and MR-proADM in combination with the most common prediction models will improve prognostic value.

To compare the anesthetic effects of topical amitriptyline 2% with lidocaine 2% in isolated limb wound repair with suturing. In a randomized clinical trial, 90 patients with a complaint of isolated ulcer and require a preliminary repair by suturing were selected from patients referred to emergency department of Beast Hospital in Hamadan.  First, the scars were washed and anesthetized with lidocaine 2%. If after the peak period effect of lidocaine, the pain score of patients did not decrease, they randomly assigned to two groups, Lidocaine or Amitriptyline gel. After the intervention and during the suturing, the patient's pain score was measured at the intervals specified time by the visual analogous scale (VAS) and results recorded on the checklist. Finally, the collected data were analyzed by SPSS software version 20 at 95% confidence level In the lidocaine and amitriptyline group, the mean age of the patients was 29.08 and 27.34 years, and male gender frequency was 71.1% and 80% respectively. Both groups were matched for age and sex. Mean score of pain in both groups decreased from the score of 10 before the intervention to 7.33 in the lidocaine group and 0.53 in amitriptyline group. Based on the results of the ANOVA repeated measure test, there was a statistically significant difference between the mean score of pain in the two groups (p<0.001). In patients with isolated limbs ulcers, requiring initial repair with suturing, numbness and analgesia effect of amitriptyline 2% gel, with dose 2 mg/kg is better than lidocaine 2%.

To evaluate the effects of dexmedetomidine in caudal epidural on controlling pain, erythrocyte sedimentation rate (ESR) and quality of life in patients with failed back surgery syndrome (FBSS). The study was a single-blind clinical trial. From the total of 70 patients suffering from low back pain caused by a failed back surgery syndrome were referred to Akhtar and Imam Hossein Hospitals between the ages of 25 to 75 years with a history of back pain more than 12 weeks and a visual analogue scale (VAS) score of higher than 3, and 50 people were randomly selected and divided into two groups of dexmedetomidine and control. The control group received an epidural dose of 10 cc containing triamcinolone and bupivacaine, and the dexmedetomidine group received an epidural dose of 10 cc, containing dexmedetomidine, triamcinolones and bupivacaine with diluted normal saline. Epidural caudal injections were performed in the abdomen in a laid down position. Before starting the study and at the end of the fourth week, the two test groups were measured for visual analogue scale (VAS) and ESR and were asked to complete the quality of life questionnaire. Overall, 50 patients with FBSS were enrolled. The mean age was 53.88 ± 8.9 years (range 25–75); 54% (27/50) were men. The results showed that the injection of dexmedetomidine in epidural caudal was associated with decreased pain (p=0.001) and improved quality of life (p=0.022), while showed no significant effect on ESR (p=0.110). Administration of dexmedetomidine in the epidural caudal is effective in controlling pain and quality of life in patients with failed back surgery syndrome.

To investigate the success rate (technical precision) of ultrasound-guided lumbar transforaminal epidural steroid injection, which was validated by conventional fluoroscopic technique. A total of 20 patients with unilateral single-level lumbar foraminal disc protrusion causing radiculopathy were enrolled. Using transforming route, the needle location was determined by an axial (transvers) view of the ultrasound with fluoroscopic confirmation. We determined the needle placement accuracy of ultrasound- guided lumbar transforaminal injections approach.  The accuracy of ultrasound-guided interventions was 90% as confirmed by fluoroscopy. There were 2 failed cases at the L4-L5 level in the US-guided. The success rate in L5-S1 level was 100%, in L4-L5 level was 80% and in L3-L4 level was 100%. No complications were noted. Ultrasound-guided lumbar transforaminal epidural injections are accurate and feasible in clinical setting with an accuracy of 90% and no complications.

To determine the mortality, morbidity, types of intracranial hemorrhages, and factors associated with length of stay (LOS) associated with accidental traumatic brain injury (TBI) at a pediatric intensive care unit (PICU) of a regional trauma center in an Asian city. This study is a retrospective review of types of head injury, mortality and morbidity demographics of patients admitted to a PICU with TBI. All patients with accidental TBI were included, namely road traffic injury (RTI) and fall, and their demographics compared. Non-accidental injuries (NAI) were excluded. 95 children (78% males) were admitted to a PICU with RTI or falls from 2002 to 2017. They accounted for 3.7% of PICU admissions. Comparing with falls, victims of RTI were older (p<0.001) and more likely to suffer from skull fracture (p=0.017). There were 4 deaths with falls (6.8%) but none with RTI. Subarachnoid hemorrhages, extradural hemorrhages, the use of mechanical ventilation, inotropes and neurological supports were associated with longer LOS in PICU in these injuries (p<0.001). A longer PICU LOS is associated with extradural and subarachnoid hemorrhages, usage of inotropes, mechanical ventilation and neurological supports in falls and RTI. Three-quarters of victims are males. Preventive health education should be especially directed to boys to reduce severe TBI in this Asian city.

To evaluate the accuracy of internal jugular vein waveform to detect early stage of hemorrhagic shock Forty-three volunteers enrolled in our study between November and December 2018. After blood donation of 450cc, the blood donors in the case group underwent color Doppler sonography of internal Jugular Vein. Besides, the clinical and laboratory indicators of shock were evaluated. The same clinical, laboratory and sonographic data was also obtained from the volunteers in the control group, then Chi-square and Student t-test were applied to make   comparison between mentioned groups. After excluding five volunteers, eighteen subjects were included in the blood donor group (mean of age: 35.81±8.05) and 20 healthy volunteers enrolled in the control group (mean of age: 34.95± 6.86). The Jugular pulsatility index was significantly smaller in the case group (0.47 ± 0.27 vs. 0.77 ± 0.52). The jugular pulsatility index above 0.91 excluded blood loss (sensitivity=100%). The combination of clinical, laboratory and sonographic data were also represented as two other indices; Jugular Pulsatility-Shock index and Jugular Pulsatility-Shock-Base Deficit index (JPSBDI). These indices were also accurate enough to detect early blood loss (p=0.011 and <0.001, respectively). JPSBDI below 0.38 was highly accurate to rule out blood loss. (Area under the curve: 0.868, sensitivity=95% and specificity=76.47%). The internal Jugular vein waveform is accurate to detect early stages of shock. The combination of clinical, laboratory and sonographic data is more promising than each of them, separately.

To investigate the risk factors that can be proper indications for performing brain computerized tomography (CT)-scan in patients with mild and moderate traumatic brain injury (TBI) in order to avoid unnecessary exposure to radiation, saving on costs as well as time wasted in emergency wards. Data of patients with mild traumatic brain injury (TBI) referring to Emergency Department with age ≥2 years and primary GCS of 13-15 were examined including focal neurological deficit, anisocoria, skull fracture, multiple trauma, superior injury of clavicle, decreased consciousness, and amnesia. Brain CT-scan was performed in all the patients. Kappa Coefficient was used to determine the ratio of agreement of the CT indications (+ and ⎼) and multiple logistic regression to determine the relative odds of positive CTs. Overall we included 610 patients. One-hundred and one patients (16.5%) had positive and 509 (83.5%) had negative CT findings. Of positive CTs, the highest percentage was dedicated to high-energy mechanism of trauma. High-energy trauma mechanism (OR=1.056, 95% CI, OR, 1.03-1.04, P<0.001), superior injury of clavicle (OR=1.07, 95% CI, OR, 1.03-1.1, P<0.001) and moderate to severe headache (OR=1.04, 95% CI, OR, 1.02-1.05, P<0.001) were positive predictors of CT findings. The combined mean of positive symptoms equaled 0.29 ± 0.64 in negative CTs, but 5.13 ± 2.4 in positive CTs, showing a significant difference. (P<0.001) Abnormal positive brain CT in victims with mild TBI is predictable if one or several risk factors are taken into account such as moderate to severe headache, decreased consciousness, skull fracture, high-energy trauma mechanism, superior injury of clavicle and GCS of 13-14. The more the symptoms, the more likely the positive CT results would be.

To evaluate the diagnostic accuracy of ultrasonography in pediatric acute appendicitis. In this cross-sectional study, 230 children aged 5-15 years with the diagnosis of acute appendicitis were studied. This study included the evaluation of demographic indices, ultrasound findings at diagnosis, and then comparing the results with the description of the patient's procedure and the pathology report of these patients. Patients who did not undergo ultrasound before surgery or their ultrasound did not include the evaluation of appendicitis or their pathologic report was not available were excluded. Overall, we have included a total number of 230 children with clinical diagnosis of acute appendicitis among whom there were 121 (52.6%) girls and 109 (47.4%) boys with mean age of 11.44 ± 2.90 years. Preoperative ultrasound report showed that 51.3% were normal and 48.7% had acute appendicitis. 34.8% had normal appendix and 65.2% had a pathological diagnosis of acute appendicitis. The sensitivity and specificity of ultrasound in these children were 58% and 68%, respectively. Positive and negative predictive values were 77% and 46%, respectively. The area under curve (AUC) was 0.853 (CI 95% 0.788-0.917) indicating a test with moderate accuracy.    According to the obtained results, abdominal ultrasonography is of acceptable diagnostic accuracy in pediatric patients with acute appendicitis. The use of auxiliary techniques in ultrasound would increase the sensitivity and specificity in the diagnosis of acute appendicitis in children.

The present study was aimed at assessment of effect of application of Chitosan/Nano Selenium biofilm on infected wound healing in rats Sixty-eight male Wistar rats were randomized into four groups of 17 animals each. In group I (Normal) the wounds were created with no infection. In group II (MRSA), the wounds were infected with methicillin resistant Staphylococcus aureus (MRSA). In group III (MRSA/CHIT), animals with infected wounds were dressed with chitosan biofilm only. In group IV (MRSA/CHIT/NS), animals with infected wounds were dressed with Chitosan/Nano Selenium biofilm. There were significant differences in comparisons of group IV and other groups, particularly in terms of cellular infiltration and neovascularization. During the study period, scores for neovascularization was significantly higher in group IV rats than other groups (P<0.05). Polymorphonuclear (PMN) and mononuclear (MNC) cell count and fibroblast cell proliferation in group IV were significantly higher than those of other experimental groups (P<0.05) Chitosan/Nano Selenium biofilm resulted in significant improvement in histopathological indices in full thickness infected wound healing.

To compare the effects of curcumin and nanocurcumin oral supplementation on the muscle healing rate of an animal model of surgical muscle laceration.

Thirty-two male adult rats were randomly divided into sham, control, curcumin, and nanocurcumin groups. Partial transection of the gastrocnemius muscle was made in the right limb of the control and treatment groups. The sham and control groups received normal saline, curcumin group received 500 mg/kg of curcumin and nanocurcumin group received 100 mg curcumin-loaded nanomicelles orally every day. They euthanized two weeks later and the specimens were stained by hematoxylin-eosin (H&E) and Masson’s trichrome methods. Aspartate transaminase (AST) and creatine phosphokinase (CPK) were measured in blood samples.

The percentage of collagen fibers in the nanocurcumin group was significantly lesser than the control and curcumin groups (p<0.001). Muscle fiber regeneration in the treatment groups was significantly higher than the control group (p<0.001). The blood vessels of the nanocurcumin group were significantly more than other groups (p<0.001). Plasma AST had a significant difference in the control group compared to the sham and nanocurcumin groups (p=0.026). The plasma CPK level of the control group was also significantly higher than other groups (p<0.001).

In conclusion, although oral curcumin supplementation has little effects because of its poor bioavailability, embedding it in nanoparticles could enhance its systemic effects in promoting the muscle healing process.

To develop a national model for hospitals’ Emergency Department (ED) preparedness when facing radiation and nuclear incidents as well as nuclear terrorism in Iran. This analytical study was carried out in 2019 via Delphi technique in two rounds and prioritization using a pairwise questionnaire. Using classic Delphi technique and pairwise comparison, the components were given to 32 specialists in emergency medicine, nuclear medicine, medical physics, nuclear physics, radiobiology and radiation protection, health in disaster and emergency, and passive defense. Finally, the national model was developed by holding two focus group sessions. The results from the two rounds of Delphi technique showed that 31 factors of preparedness were classified into three main classes, namely staff, stuff, and structure (system). Only three factors were excluded and the rest were agreed upon by the specialists. Given the weight of each class, it was found that staff preparedness and stuff preparedness had the highest and lowest priorities, respectively. Comprehensive preparedness requires enhancing and promoting cultural, social, economic, and political levels. Indeed, all preparedness levels should be promoted in alignment with each other. Hence, governments should align their policies to manage such incidents.

To determine the effects of the implementation of the telephone cardiopulmonary resuscitation (T-CPR) program on the outcomes of out-of-hospital cardiac arrest (OHCA). In this prospective study, Emergency Medical Service (EMS) dispatchers and all bystanders attending to patients with OHCA were included. The consensus sampling was carried out based on inclusion and exclusion criteria. The data collection tool was consisted of a demographic questionnaire for patients and bystanders accompanied by a checklist for CPR outcomes. Data were collected 6 months before and after the implementation of the T-CPR program and analyzed using SPSS version 18. The results revealed that the percentages of successful and unsuccessful CPR cases before the implementation of the T-CPR program were 28.1% and 71.9%, respectively. However, in total, 32% and 67.8% of the CPR cases were successful and unsuccessful, respectively, after the implementation of the mentioned program. The survival rate increased from 56.5% in the pre-intervention phase to 72.4% in the post-intervention one. In terms of the outcomes, brain complications decreased from 40% in the pre-intervention phase to 32.1% in the post-intervention one; however, the Chi-square test showed no significant difference in terms of CPR outcomes in the two time periods (p=0.797). According to the results, it is recommended that T-CPR programs be developed and dispatchers be trained in the area of this research. The results could be regarded as a guide to EMS managers, healthcare professionals, and the basis for further studies on this subject.

To evaluate the efficacy and preparedness of Emergency Medical Services (EMS) in Islamic Republic of Iran to face Ebola. The present study is cross-sectional and somehow descriptive. We used a standard questionnaire that was designed by “center for disease control and prevention”. This questionnaire was captioned “Emergency Medical Services (EMS) checklist for Ebola preparedness”. We collected a lot of data by studying that questionnaire and every manager in every province of Iran were informed about that info in 2016. This data was analyzed by using SSPP software version 16. Findings have showed the average score related to preparation level of EMS in facing Ebola in Iran was 63.73±12.77 percent. There was no significant difference between the country regions regarding the preparedness of to detect (p=0.975), protect (p=0.275) and respond (p=0.344) to ebola outbreaks.The highest score had been achieved by region number 5 and the lowest score belonged to region number 7. Although the acquired average score in this study is higher than standards, considering the increased threat of breaking out biologic threats especially Ebola infection, using and practicing some measures in order to enhance preparation level of Emergency Medical Services counter this infection and similar infectious diseases is inevitable.

Ileus is a very rare complication of methamphetamine (MET) intoxication. We herein report a 15-year-old non-addict girl who ingested about 5 gr of MET. She suffered from bowel obstruction manifestations. She was treated by intravenous metoclopramide and erythromycin. On next morning, she became restlessness with tachycardia and sweeting that was treated by intravenous diazepam. Abdominal-pelvic computerized tomography (CT) scan confirmed generalize dilatation in small intestine and more prominent in colon with no ischemia or mechanical obstruction. It also showed some hyperdense collections in ascending colon, sigmoid and rectum. MET was detected in her urine. On the third day, the bowel obstruction signs resolved. On fourth day, the prokinetic drugs were discontinued and whole bowel irrigation by polyethylene-glycol was performed. She passed the drug packages, and was discharged in well condition on fifth day. MET intoxication can induce ileus, specially, in the higher doses of MET and physicians should mention this rare MET presentation.

New onset seizures in pregnancy or the postpartum period can be of great importance and denote various underlying pathologies. Eclampsia and cerebrovascular accidents are common, and brain tumors are uncommon causes of postpartum seizures among others. Acute presentation of brain tumors in pregnancy or the postpartum period is extremely rare. Meningiomas are the most common benign intracranial tumors. Although 1.3 to 2.4% of these benign tumors may bleed, acute presentation of them with hemorrhage is quite rare. Herein, we report a rare case of a 36-year-old lady who presented with severe headache, seizure, and loss of consciousness in the postpartum period, five days after delivery of a full-term baby. Primary emergency evaluation revealed an extra-axial lesion with subdural hemorrhage. A Decompressive craniectomy was performed, hematoma was evacuated, and the tumor was totally resected. Histopathologic evaluation was consistent with a fibroblastic meningioma (WHO grade I). She was discharged in good general condition. Our case highlights the significance of complete evaluation of patients with new-onset seizures in pregnancy or the postpartum period. Although uncommon, brain tumors in pregnancy can have potentially devastating outcomes which may necessitate prompt surgical intervention.

Bonsai is a synthetic cannabinoid (SC) substance which can cause lung toxicity with chronic use. However,there are few case reports in literature related to bonsai-induced intracerebral hemorrhage in literature. A 25-year-old man presented at the Emergency Room (ER) with dyspnea,hemoptysis,agitation subsequent to bonsai use. He became unconscious in ER,was then intubated,admitted to the intensive care unit (ICU). The cranial computed tomography (CT) scan was non-specific,a thoracic CT scan revealed consolidation,the appearance of “ground-glass” in the lung,and therefore,development of diffuse alveolar hemorrhage was considered. The patient recovered consciousness on the second day of hospitalization,was extubated. During follow-up,he lost consciousness once again,on the cranial CT images,hemorrhage areas located in the left frontal,right posterior parietal regions were observed. Nevertheless,no surgical intervention was considered. The patient recovered consciousness three weeks after the second intubation,was transferred to the psychiatry clinic. In patients with synthetic cannabinoid substance abuse,life-threatening intracranial complications in the early and,or late phase should be kept in mind in addition to respiratory,systemic complications in the acute phase.