Frontiers in Emergency Medicine
Volume:3 Issue: 4, Autumn 2019

Although the ideal treatment route for management of patients with ST-segment elevation myocardial infarction (STEMI) is rapid diagnosis and direct transfer to the catheterization unit and undergoing primary angioplasty, using thrombolytic still has its place in cases that the equipment are not available or there is not enough time for performing angioplasty. Of course these drugs are associated with specific side effects such as probability of gastrointestinal (GI) and cerebral bleeding, allergic reactions and etc. Therefore, finding drugs with fewer side effects and limitations for use has always been interesting in this regard. The drug which has been used all around the world since 1970 and is also traditionally used in Iran for managing patients with STEMI is streptokinase. This drug is a protein extracted from beta hemolytic streptococci, which combines with plasminogen and facilitates transformation of plasminogen to plasmin. However, recently fibrin specific drugs or recombinant tissue plasminogen activators (rtPA) such as alteplase, urokinase, tenecteplase, reteplase and etc. have become available to emergency medicine physicians and cardiologists. Having longer half-lives, fewer side effects, and easier method of use, these drugs have opened a new door for physicians regarding use of thrombolytic drugs in treatment of STEMI and brain stroke. Studies regarding comparison of safety and effectiveness of these drugs are ongoing. In a systematic review and meta-analysis, Tourani et al. showed that the safety and effectiveness of streptokinase and tenecteplase were in the same level. Reteplase is an rtPA peptide, which converts endogenous plasminogen to plasmin. Plasmin causes destruction of the fibrin present in the clot and the clot disappears. In a prospective case-control study in Amiralmomenin Hospital, Tehran, Iran, we divided 152 patients with STEMI and the mean age of 56.41 ± 10.40 (27 – 85) years who were candidates for receiving thrombolytic therapy into 2 groups receiving either streptokinase (from CSL Behring GmbH Co, Germany) or reteplase (from Reliance Life Sciences Co, India) (83.6% male). Then we compared outcomes such as GI bleeding, mortality, hypotension, arrhythmia, and etc. between the 2 groups. The 2 groups were in a similar condition regarding sex (p = 0.331) and age distribution (p = 0.393), blood pressure on admission (p = 0.378), and the rate of positive troponin on admission (p = 0.113). Overall, 61 (40.1%) patients showed at least one of the outcomes that we studied (13 cases in the streptokinase group and 48 cases in the reteplase group; p < 0.0001). In this study, all 20 cases of GI bleeding observed following thrombolytic prescription were in the reteplase group. Additionally, out of the 19 cases of death observed, 14 were in reteplase group and 5 had received streptokinase. One case of arrhythmia and 2 cases of hypotension were seen in streptokinase group. Based on the findings of this study, it seems that despite factors such as longer serum half-life and ease of use, the rate of side effects of this drug should be carefully considered before use. Based on some existing studies, it seems that in the most optimistic scenario, these 2 groups have similar side effects and effectiveness. For a more accurate assessment at least regarding the Iranian race, more accurate studies with larger sample size are required. This topic might have received less attention in developed countries as considering availability of equipment in those countries, treatment protocols are mostly based on angioplasty and not using thrombolytic drugs there. This subject becomes more important when we are aware of the higher treatment costs of these new drugs for patients since insurance does not cover them. Performing cost/benefit studies and evaluating the safety of treatment are suggested for future studies.

Patients with bronchial asthma usually land up for surgery and pose a significant challenge as far as their anesthetic management is concerned. Most of these patients either take medicines or else are in a comparatively controlled state. Different protocols have been suggested for such cases such as corticosteroids, long-term β2 agonists, leukotriene receptor antagonists and theophylline sustained-release preparations.

The emergency department (ED) at Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH) is a medium size department which sees around 260-300 patients per day. As a result of sustained demand, we continue to struggle to meet the four hour waiting target and face similar challenges of those of ED’s nationally. Working in a busy ED is challenging and demanding. specific challenges around communication and risks arise directly from the unique contextual demands of the ED environment.

Aim being to improve the productivity of the ED team and find a mechanism to create a more supportive and enjoyable working environment within the department.

Our clinical leadership started looking for answer to improve communication among team members and to create a platform where there was no hierarchy and all team members could be directly involved in problem solving. With the support of the quality improvement (QI) team, ED assembly was born. The assembly is a simple method of regularly bringing together staff to facilitate improvement and better team working. It is a platform for effective communication and innovation, in which there is no hierarchy and everyone is encouraged to contribute.

The assembly runs to a routine; every other Wednesday at 11am, the team come together for just half an hour. The agenda is set by the team in advance and everyone is encouraged to contribute their ideas and items they wish to contribute to others. Here are some examples of the quality improvement initiatives that have been born out of ED assembly: ED board rounds, coding information, overdose proforma, timely completion of standard investigations, access to fracture clinic appointments, nil-by-mouth communication, safety huddles, patient safety and sepsis, inclusive improvement, adoption of the ED assembly model by other teams and etc.

ED assembly has supported many small but effective QI initiatives and regular communications support timely feedback on progress and update on plan-do-study-act (PDSA) cycles, resulting in changes in the everyday practice and improved pathways of patient care.

Although pain management in EDs has been fully addressed in clinical trials, prehospital settings have rarely been investigated.

The present study was conducted to compare the effectiveness of intravenous acetaminophen with that of ketorolac in pre-hospital pain control.

This randomized clinical trial (RCT) was performed at a prehospital setting during EMS missions in Tehran, Iran. The eligible candidates comprised all patients over the age of 7 years with a complaint of moderate to severe pain. The patients were randomly assigned to two groups, one receiving 30 mg of intravenous (IV) ketorolac and the other 1 g of IV acetaminophen. The pain intensity was measured using a visual analog scale (VAS) before administering the analgesic and upon admission to the ED.

The present study was conducted on 150 patients aged 8-81 years with a mean age of 40.4 ± 17.7, including 84 (56%) males. The mean reduction in the pain score was 14.9±8.6 in the acetaminophen group and 16.0±8.8 in the ketorolac group. Univariate analyses suggested no statistically significant differences between the two groups in terms of delta pain score (pain reduction) (P=0.429).

Based on the obtained findings, both ketorolac and acetaminophen could be administered for pain management in prehospital settings in both traumatic and non-traumatic patients in case their contraindications are considered.

Patients’ relatives commonly play the role of interpreters in medical interviews. These non-professional interpreters are prone to potentially-dangerous translation errors.

The present study was conducted to evaluate these errors in the emergency department (ED).

Twenty interviews with Azeri patients were recorded. They were unable of speaking Persian and therefore accompanied by a relative as a Persian interpreter. These records were presented to two physicians as native Azeri speakers to determine the clinical importance of the interpreters' errors according to their medical expertise.

The total omission and addition errors observed in Azeri to Persian translation were significantly more than in Persian to Azeri translation, while mistranslation errors were almost the same. The relatives with higher levels of education made fewer errors, and those living with the patients made significantly more addition errors.

Non-professional interpreters cannot effectively facilitate patient-physician communication, as their translation is error-prone, especially in terms of translating their native language into official languages. These errors can have important clinical ramifications.

The observation period was recently challenged by some studies; and it has been suggested that a 1-hour observation period may be sufficient to allow safe discharge in asymptomatic patients with penetrating thoracic injury (PTI) and normal initial Chest X-Ray (CXR).

The current study was performed to investigate if in asymptomatic and hemodynamically stable patients with PTIs who has an initial normal evaluation, 1-hour observation interval is safe to detect clinically significant injuries and is it possible to discharge these patients safely after a negative Extended – Focused Assessment with Sonography in Trauma (E-FAST) at hour1 instead of hour 3.

This cross-sectional study was performed on asymptomatic patients with penetrating thoracic injury, referred to emergency department (ED) and normal initial CXR and the Extended Focused Assessment with Sonography in Trauma (E-FAST). The second E-FAST was done 1 hour after the first one and the third repeat E-FAST and control CXR then performed 3 hours post-injury. 24 hours follow up by phone call was done for each patient after discharge.

Finally, 117 patients with the average ages of 25.9 ± 7.8 years were enrolled of whom 92.5% were male. Eight patients developed PTX or HTX during first hour of observation that were diagnosed by E-FAST or CT scan requested by the in-charge physician. One hundred-nine patient completed E-FAST and radiograph studies at times zero, 1 h, and 3 h. One patient had a normal initial evaluation but demonstrated a PTX on the 3-h managed without intervention. The rate of delayed abnormality after an initially normal study was 7.7 % (9/117). No discharged patients returned to our ED with delayed manifestations of either PTX or HTX.

The results of our study have shown that asymptomatic patients with PTI with negative initial evaluation and no deterioration at intervals, about 1 hour may be sufficient for detection of clinically significant pathology, considered for safe and early discharge.

Knowledge of epidemiological aspects can be a useful guide in determining the resources for better prevention and management of injuries. There are some performed studies on this topic in Iran, based on the limited hospital database. However, to the best of our knowledge, there is not any survey based on the pre-hospital database.

The purpose of this study was to assess baseline characteristics of the traumatic patients according to the records of Tehran Emergency Medical Service (EMS) Center to present descriptive statistics of their epidemiological features.

This cross-sectional study was conducted retrospectively, using Tehran EMS center data registry. All traumatic patients examined by EMS in Tehran, Iran following call to emergency medical dispatcher were included. By reviewing the EMS technicians’ mission forms, required data were extracted. The mission form contains information such as age, sex, injured location, damage mechanism, accident location (home, workplace, street), time of call, the outcome of the patient's ambulance mission and the results of the assessment of the technician, etc.

Totally, 56612 injured cases with the mean age of 33.1±15.6 years were examined by EMS during one-year study period of whom 80.4% were male. Crude Incidence Rate was 10.5 and 2.5 per 1000 in male and female, respectively. Traffic accident and then fall were the two most prevalent mechanism of injuries. All types of injuries were significantly more prevalent in males (P<0.001). Most injuries were in winter season with 15570 cases (27.5%). Car accident was prevalent in winter and other injuries were significantly prevalent in spring (P<0.001). The most frequent places of injuries occurred on main roads and streets (55.7%). All of the road-related injuries was prevalent in winter, whereas injuries in other places were prevalent in spring (P<0.001). Most of the cases (78.3%) were transferred to the health centers, but 20.7% did not consent to treatment and transmission. Only 222 cases (0.4%) died, that 95% was due to traffic accident. there was a significant relationship between the number of injured organs and the death; So that the highest death rate occurred for those with more than 5 injured organs (P <0.001).

Based on the findings, traffic accident was the most frequent cause of trauma that led to visiting a traumatic patient by an EMS technician in Tehran, Iran. Injuries in all age groups were more prevalent in males, and the involvement of 5 or more injured organ had a significant relationship with mortality.

Emergency medical technicians (EMTs) should be always prepared to deal with the stressful condition of treating patients with serious physical and emotional injuries. Given that EMTs consider safety the first priority, they must pay adequate attention to their own physical well-being and fitness to practice.

The present study was conducted to analyze the fitness of Jordanian EMTs.

The present prospective study was conducted to evaluate the well-being of Jordanian paramedics. The survey was designed using Google forms, which were completed by the participants. The data collection tools comprised an already-designed checklist, including items such as age, gender as well as height and weight, which are used for calculating body mass index (BMI). In addition, the presence of chronic diseases such as hypertension, diabetes mellitus, renal failure and cardiorespiratory diseases as well as the history of surgeries and disabilities were investigated. The participants were also asked about their smoking status and other health-related habits.

Out of 115 surveys conducted, 7 were discarded owing to loss of information or making completion mistakes. Out of the remaining 108 respondents, 82 (75.9%) were male and below 10% were over the age of 30 years. BMI was over 25 in 40.7% of the respondents, and only 4 (3.7%) had chronic diseases. Moreover, 46 (42.6%) respondents were smokers, and only 30 (27.8%) performed regular exercise.

The present findings suggest health problems in a small percentage of the EMTs, potentially due to the appropriate support provided by the employers or university authorities in this regard. The major health problem was overweight and unhealthy lifestyle, including smoking and not doing regular exercise.

Context: Nurses are the largest group of health service providers with a vital role in assisting victims during disasters. They must be therefore appropriately prepared to respond to health requirements in these situations. Evidence acquisition: Three articles were ultimately extracted from a comprehensive search conducted in the present systematic review and meta-analysis in Google Scholar, SID, Magiran, Scopus, PubMed and Web of Science using English keywords and their Persian equivalents. The I2 index was used to evaluate the heterogeneity between the studies, and the analyses were performed in STATA 14.

This review was conducted on 586 nurses working in hospitals. The final meta-analysis included three articles. The matched mean scores of knowledge, attitude and performance concerning disaster preparedness were respectively found to be 43.49 (95% CI: 37.67-49.31, P=0.581, I2=0.0%), 68.81 (95% CI: 63.04-70.58, p=0.913, I2=0.0%) and 56.19 (95% CI: 53.95-58.42, P=0.001, I2=86.2%).

The present findings suggested moderate levels of knowledge and performance and good attitudes associated with preparedness in disasters in the Iranian nurses. These parameters can be therefore improved to desirable levels and the overall preparedness for coping with disasters boosted in nurses by training nurses and performing hospital drills.

Acute abdominal pain is a common clinical problem in emergency and non-emergency cases accounting for 5 to 10% of all referrals to the emergency department. Studies have indicated that these widely differentiated diagnoses are common to these complaints. Considering the high prevalence of this complaint in the patients and the wide range of its differential diagnosis, this review study was designed and evaluated aiming at investigating the causes of acute abdominal pain with a focus on assessing the position of ultrasound as a diagnostic tool in the emergency department. Evidence acquisition: This article was conducted as a narrative review of 106 articles from 2005 through 2019. By comparing them, a comprehensive review of ultrasonographic status was conducted in patients with acute abdominal pain referring to the emergency department.

In this review study, we attempted to use the articles of the clinical approach, the required laboratory tests, the disadvantages and advantages of each imaging technique, the differential diagnosis for acute abdominal pain according to the location of the pain, and the position of ultrasound as a diagnostic aid tool. Eventually, the proposed protrusion will be considered in dealing with a patient with acute abdominal pain.

Regarding the wide range of causes providing multiple differential diagnosis, as well as the limited time of the health team in the emergency department for diagnostic and therapeutic measures, particularly in time-sensitive clinical conditions, ultrasound offered by emergency medicine specialists as a diagnostic aid is considered to improve the overall diagnosis and treatment of patients, thereby reducing complications.

Recently, the use of metal and plastic containers instead of clay containers in producing this type of cheese has provided the anaerobic condition for growing the bacterium and producing the botulinum toxin. In this case report was to introduce "clay cheese dug in the ground" as a source of botulinum toxin for the first time. Case Report: A 34-year-old man with dizziness, asthma, and inability to swallow for four days referred to the hospital emergency department. He had diplopia and ptosis for two days. During admission to the emergency, the patient was conscious without fever, but with dysarthria and bilateral ptosis, an impaired gag reflex, slow right papillary reaction to light, a decreased eye movement, and a decreased power of facial muscles and limbs. The patient reported the use of clay cheese in a week before referring to the emergency. Hematological, biochemical, electrocardiogram, magnetic resonance imaging, and chest X-ray assays were normal. According to the Centers for Disease Control and Prevention classification, these symptoms were related to botulism. The evaluation of serum samples, emission, and gastric juice confirmed botulism by type A toxin.

Considering the clinical results of this case study, clay cheese, which is produced in the west of Iran, can be introduced as a new source of the botulinum toxin.

Lipomas are the most common benign neoplasms, occurring in any part of the body where fat is present. Their occurrence in the head and neck is not common. Here, we report a large laryngeal lipoma with extra laryngeal component, mimicking mixed form of laryngocele.

A 47-year-old man presented with a 3-year history of hoarseness, intermittent dyspnea and mass sensation in the neck. The patient was submitted to indirect laryngoscopy; a large submucosal mass obliterating the left side of the supraglottic larynx and partially obstructing the airway was found. Enhanced computed tomography (CT) scan demonstrated non-enhancing homogeneous hypodense fat density mass lesion measured 55*45*32 mm, extending through the thyroid membrane to parapharyngeal space and showing extra laryngeal component with an intact laryngeal mucosa lesion. Open surgery of the submucosal mass was performed. Pathology examination confirmed the diagnosis of lipoma.

Neck lipomas are also typically asymptomatic, but can compress nearby structures, causing symptoms such as hoarseness, dyspnea and dysphagia. When symptomatic, they should be removed via surgery.

Diagnosing an osteoid osteoma as a benign tumor can be challenging owing to its different presentation patterns, ambiguous radiological findings and unusual sites of involvement. The present case report involves a 30-year-old female patient with a large osteoid osteoma of the thoracic vertebrae as an uncommon site of its presentation.

The patient presented with a one-year history of progressive right-sided upper back and interscapular pains. She was identified as a candidate for surgery using the whole body bone scan and a multiple detector computed tomography (MDCT) scan. A large 25-mm osteoid osteoma of the lamina of the third thoracic vertebra (T3) was also diagnosed through histopathology.

As a potential cause of persistent back pain in young adults, an osteoid osteoma may be easily missed by routine radiographs. The CT scan is an effective tool in the investigation of the size and location of this tumor. Surgical excision can also be used for treating spinal lesions.

A 62-year-old male came to emergency department (ED) with a complaint of “separation of foot” during sleep at night. He noticed he lost his foot while getting up from bed to go to toilet at midnight. Upon arrival in ED, his blood pressure was 218/96 mmHg and random blood sugar 556mg/dl. The patient had large ketone bodies in urine. He was a known case of diabetes and hypertension for many years. He was on homeopathic medications for his diabetes, hypertension and diabetic foot. He refused any form of invasive treatment and hospitalization. The patient was adamant on not getting admitted and wanted to continue his homeopathic medications as before. He only wanted his leg stump covered with a dressing after which he was discharged.

The patient was a 62-year-old man presenting to the emergency department 6 hours after the onset of dizziness, nausea and vomiting. The patient complained of numbness of the right side of her body and reported swallowing problems. The initial examination showed the patient was alert and stable. The left side of her face was sweating while the right side was completely dry. The neurological examination revealed the patient was alert, and the right pupil was about 2 mm smaller than the left eye pupil, and both pupils responded to light. A paresis was observed in the right side of the face, tongue and uvula. Uvula was slightly deviated to the right. Other signs included hoarseness and swallowing impairment. The muscle strength of all four limbs was 5/5. Babinski reflex was downward on both sides. The patient could not sit by herself, and leaned to the right. The patient had a history of primary coronary intervention (PCI) and stent placement four years ago. She had smoked a pack of cigarettes for 40 years. She used nitrocontin, pearl, lisinopril, carvedilol and furosemide. Laboratory tests were normal. The first CT scan in the emergency department was normal. As a brain stem infarction was suspected, MRI was performed and revealed an infarct (Figure 1). The patient received neurology consultation and was discharged with stable vital signs and the daily order of aspirin and atorvastatin after five days. The patient was asked to have weekly follow-up visits.

In the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion, for an independent cohort study, for an independent case-control study, and for a diagnostic test accuracy study. In this article, we explain how to calculate the sample size for a superiority clinical trial.

This multi-centric, prospective, observational study is commissioned by the Indian Council of Medical Research (ICMR) as a National Task Force Project. This study is being conducted in five sites, viz., Anand, Bengaluru, Delhi, Lucknow and Thrissur located across India. Each centre will have a level I, two level II and three level III trauma hospitals. The study will be carried out in four phases namely: i) preparatory phase, ii) trauma registry establishment and pre-intervention data collection, iii) intervention and iv) impact evaluation. The preparatory phase, which lasts for four months includes the situational analysis pertaining to managing RTIs. Trauma registry will be initiated from the fifth month. Pre-intervention data will be collected for six months. The intervention will be conducted for six months in the form of prehospital notification, training for trauma care providers and trauma care quality improvement. Post-intervention data collection will continue for 12 months and the impact of the intervention will be assessed. The primary outcome measure will be early preventable mortality, defined as death at 24 hours after admission for patients with a calculated probability of survival >50% based on their injury severity score.