Frontiers in Emergency Medicine
Volume:4 Issue: 3, Summer 2020

Foreign body ingestion is a common presenting complaint in the emergency department. While ingestion of small foreign bodies like coins and button batteries is not uncommon, ingestion of long and rigid foreign bodies like toothbrush is very rare. 

We describe a 36-year-old man who presented to us after accidental ingestion of a toothbrush. The patient underwent urgent endoscopic removal; Psychiatric evaluation revealed an acute and transient psychotic disorder in him. 

Ingestion of long and rigid foreign bodies like a toothbrush is an uncommon entity. Such foreign bodies when ingested find it difficult to maneuver through the GI tract, which makes their spontaneous passage almost impossible. Their ingestion is associated with increased risk of impaction, perforation and, bleeding. Therefore, early removal of the ingested toothbrush is recommended before complications develop.

Superior vena cava (SVC) syndrome which is defined as the obstruction of blood flow through the SVC vein, often affecting patients with malignancy especially small cell lung cancer (SCLC) and is potentially an emergent condition needing prompt management. It is an ominous sign with poor prognosis and a mean of 8-10 months survival rate. 

Here we present a middle-aged man who presented with fascial swelling and dyspnea with final diagnosis of advanced SCLC. Combination of multiple chemotherapy regimen, prophylactic brain radiation with administration of anticoagulant drugs were performed for him leading toward extension of his survival to 28 months. 

These therapeutic approaches may lead to extending the survival in patients with SVC syndrome and SCLC.

New computerized system, including health information technologies (HITs), plays an important role in the efficacy of management and nursing care services. 

This study was aimed to determine the use of HIT in patient care management, in a case study in Iran. 

This mixed method study was conducted in 2018 at the Kowsar Hospital of Semnan, Iran. Data collection was performed, using an observational checklist, and a questionnaire, including two main parts, one demographic and other assessment of information technology (IT) application in the care management of inpatients. The researcher prepared the questionnaire and its validity was verified. The data were organized and analyzed in the form of a descriptive analytic report. In the process of data collection 10 participants, including nurses, head nurses, physicians, radiology experts and IT managers were interviewed, and data analysis was performed, using conventional content analysis. 

Nurses were satisfied with the computerized system and believed it can expedite the job. From the nurse’s viewpoint, the most common use of the HIT was to have access (observation) to patient admission and discharge information (100%), providing medicine and equipment, and transfer of patients (92.3%). The least use of IT was the retrieval of evidence in the care process (0%), and judgment and analysis related to radiological diagnostic procedures (0%). The potential of electronic record is still not applicable. 

Use of modern information and communication technology in hospitals facilitates access and transfer of information, and also accelerates patient’s admission and discharge process, relation between hospital units, simplifying the administration of current affairs and providing the necessary medical supplies and diagnostic procedures. However, modifying organizational policies improves the infrastructure, and enhances nurses' motivation in documentation of nursing reports, which can be effective in increasing the impact of IT in care management processes, especially in electronic record and nurse’s clinical judgment and evidence-based care.

Trauma scoring systems help physicians and nurses to be informed of injuries to a patient and assist their decision making in the cases of trauma and importantly prediction of their outcome and prognosis. 

This study aimed to compare the accuracy of GAP and MGAP scoring systems as predictors of mortality in trauma patients. 

This diagnostic accuracy study was conducted amongst 1861 trauma patients admitted to Rajaee Hospital in Shiraz, Iran, during 2017. The data on demographic features were extracted from the patients’ records. Then, trauma scoring systems including injury severity score (ISS), GAP, MGAP, and Glasgow coma scale (GCS) were compared to evaluate their accuracy in predicting mortality. Area under the receiver operating characteristic (ROC) curve was used to evaluate the accuracy of different trauma scoring systems and detect the sensitivity and specificity in order to predict status of discharge after 24 hours. 

Based on the results, the area under the ROC curve was 0.8 for GCS. Moreover, Area Under Curve (AUC) of GAP was 0.91 and amongst different values, GAP value of ≤18 was selected as the cut-off point, since it exhibited the best sensitivity and specificity (72.99 and 95.52, respectively). In addition, the area under the ROC curve was 0.9 for MGAP, and value of ≤23 was selected as the cut-off point because it showed the best sensitivity and specificity (81.04 and 87.70, respectively). Additionally, AUC of ISS was 0.88. 

Both GAP and MGAP methods were able to appropriately predict mortality and were not significantly different; hence, both can be used for the right triage of patients and to predict the severity of injuries and subsequent mortality. Moreover, GAP and ISS had the best specificity and sensitivity, respectively.

Different methods have been well addressed in literature in terms of treating superior vena cava (SVC) syndrome; nevertheless, the patency of endovascular treatment has rarely been investigated in patients with SVC syndrome in patients with central venous access. 

The present study was performed to assess the patency rate of endovascular procedure in patients with SVC syndrome caused by intravenous catheterization. 

The present case series and longitudinal study was conducted on patients with SVC syndrome in presence of central venous catheter who underwent venoplasty. Computed tomography (CT) venography was performed 1, 6 and 12 months after venoplasty. Facial swelling, facial discomfort, extremity edema, arteriovenous fistula (AVF) dysfunction, impairment in dialysis and SVC stenosis were measured at baseline and 1, 6 and 12 months after venoplasty. 

Out of 20 investigated patients, 11 (55%) were male. Significantly decreases were observed in the median grades of facial swelling and extremity edema in the follow-up (P<0.001). The decrease in facial discomfort was statistically insignificant (P=0.129), and the median grade of SVC stenosis significantly decreased from 1.5 to zero in the follow-up (P<0.001). A statistically-significant decrease was observed in AVF dysfunction (P=0.007), and impairment in dialysis significantly decreased after the intervention during the follow-up (P<0.001). 

Findings of the present study revealed the appropriate patency rate of endovascular treatment in patients with SVC syndrome in presence of central venous catheter.

Acute appendicitis is one of the most common emergencies of general surgery. Contrary to simple appendicitis, the complicated cases are associated with higher morbidity and mortality. Except for pathology, no accurate diagnostic test has been found to identify complicated cases. 

Here in, we aim to evaluate the serum C-Reactive Protein (CRP) level in both acute simple and complicated appendicitis. 

In this diagnostic accuracy study, 199 patients with acute appendicitis were enrolled. The serum CRP level was evaluated in patients. Post-operatively, the patients were divided into simple and complicated appendicitis based on histopathological examination. Eventually, analysis of the CRP level and type of appendicitis was performed. 

Fifty-three patients were categorized into complicated appendicitis and 146 patients into simple appendicitis. The median of CRP was significantly higher in the complicated group. Additionally, the optimal cutoff point was as follows: [65.0 (25.0) vs 25.0 (51.0); P-value< 0.001]. The optimal cutoff point for CRP was more than 42 with 81.1% sensitivity (95% CI: 68.0 to 90.6), and 67.8% specificity (95% CI: 59.6 to 75.3). The positive (PPV) and negative predictive values (NPV), based on the prevalence of complicated appendicitis (26.6%) for optimal cutoff point, were 47.8% (95% CI: 37.1 to 58.6) and 90.8% (95% CI: 83.8 to 95.5). 

Our study revealed that evaluation of serum CRP levels could be useful and beneficial in the diagnosis of acute complicated appendicitis.

Recently, radiological imaging could be help to diagnose injury in the patients with multiple trauma in the emergency department (ED). 

In this study, we aimed to compare the radiation exposure within 48 hours, in patients with multiple trauma in level 2 and 3 triage admitted to ED. 

This cross-sectional study was conducted on patients with multiple trauma of Level 2 and 3 triage who were referred during 2014-2015 to the EDs of Imam Khomeini Hospital of Tehran and Alzahra hospital of Isfahan, Iran. Radiation exposure of radiographies and computed tomography (CT) scans in patients were calculated during the first 48 hours of admission. 

In this study, 220 patients with the mean age of 35.41±15.04 years were studied of whom 120 patients (54.5%) were male. The mean radiation exposure was 3.43±3.12 mSv. The mean radiation exposure of CT-scan in level 2 was significantly higher than level 3 (p<0.001). On the other hand, the mean radiation exposure of radiography in level 3 was significantly higher than level 2 (p=0.022). Also, the mean radiation exposure of total radiation in level 2 was significantly higher than level 3 (p<0.001). 

In 48 hours admitting to emergency department, patients with multiple trauma in Level 2 had more radiation exposure than Level 3.

It is crucial to find ways to improve the durability of learning in clinical units. One of these methods is team-based learning (TBL). This learning method is active and students must study the subject before the session. 

This study examined TBL and compared it with conventional lecture method (LM) in an educational approach to tachycardia and bradycardia in adult patients. 

In this quasi-experimental study, medical students (interns) were randomly divided into two groups of TBL and LM. Two faculty members of emergency medicine were responsible for teaching in both LM and TBL groups. Data collection tool was a checklist including demographic information and a researcher-made questionnaire for assessing knowledge about tachycardia and bradycardia in adult patients. Two sets of questions with the same difficulty were designed to be used for pre-test and post-test. Both groups completed pre-test and post-test, which were finally compared. 

Totally 65 medical interns with the mean age of 28.75±2.26 years were participated of whom 37 persons (56.9%) were female. There was no significant difference in terms of the mean age of the participants in the two groups (p=0.914). The two groups were also matched in terms of male/female ratio (p=0.416). There was no significant difference between TBL and LM groups regarding pre-test score (p=0.935). However, they were significantly different in post-test (p=0.001) when TBL group scored higher than the LM group. 

Based on the research findings, it seems that TBL was more effective than LM on students' understanding of approach to tachycardia and bradycardia in adult patients.

Exactly recognizing the effect of health reform plan (HRP) in emergency departments (EDs) is crucial given the large portion of budget assigned to this plan and the effect of introducing this plan on inducing demand and the associated potentially-unbearable costs. 

The present study was conducted to assess the demand induced after implementing the HRP in the selected EDs of Isfahan University of Medical Sciences, Isfahan, Iran. 

The present quantitative and descriptive study collected data related to certain emergency services, performance indicators and working hours of emergency staff using a researcher-made checklist and based on hospital records and information in the years before and after implementing the HRP in Iran, i.e. 2013 and 2015. The data collected were analyzed in SPSS-21. 

The obtained results suggested significant increases in emergency admissions (69.97%), radiographic images (65%), clinical tests (27.27%) and specialist visits (69.95%). Significantly increases observed in the performance indicators in the ED included the mean hospitalization duration by 61.14%, the bed occupancy rate by 15.71% and the working hours of the nursing staff by 11.43% and those of emergency medicine specialists by 44.72% in the first year after implementing the HRP compared to in the year before the implementation. 

Although implementing the HRP in Iran significantly changed the performance indicators in the ED, certain infrastructure such as human resource management and the increased demand are considered the main time-consuming and costly challenges in EDs.

The current outbreak of the novel coronavirus SARS‐CoV‐2 (COVID-19) has rapidly spread worldwide, which greatly endangers the global health and economy. Due to vast limitations in hospital resources, some countries have encountered serious problems for fair access to hospital beds. An interesting letter in this journal recommended 6-minute walk test (6MWT) as a proper clinical test to determine the necessity for going to the hospital in patients with suspected COVID-19. 6MWT is a field exercise test in which, patient should walk for 6 minutes as far as possible. It is usually used to compare pre- and post-treatment conditions in many pulmonary and cardiac disorders or to estimate functional status of individuals with some pulmonary and cardiovascular diseases. This test may be applied as a predictor of morbidity and mortality in these patients. Although the idea of finding an applicable and feasible clinical test to do at home is valuable by itself, but in our opinion, there are great concerns to use 6MWT for this purpose. Here, we will discuss about some serious concerns about the practical, judicious and scientifically justified use of this test in patients with suspected COVID-19.

Nursing staff’s professional resilience plays an important role in overcoming the stressful and adverse situations common to the trauma emergency department and helps to achieve positive outcomes. 

This study intended to explore the concept of resiliency among Iranian trauma emergency department nurses. 

Data were collected using semi-structured interviews with 21 trauma emergency department nurses and analysed through a deductive content analysis based on the general conceptual model of resilience derived from King and Rothstein’s study. 

All codes were nested into the four main categories of the above-mentioned model including: 1) Personal characteristics; 2) Opportunities, supports and resources; 3) Self-regulatory processes; 4) Positive outcomes. Some new sub-categories including Professional abilities (sub-category of Personal characteristics) and Cooperation with colleagues and Volunteers’ declaration of readiness (sub-categories of opportunities, supports and resources) were developed in this study. In the positive outcomes category, three sub-categories including Improved professional abilities, Personal growth, and Job retention were developed. 

Our results demonstrated that Iranian trauma emergency department nurses could achieve positive outcomes using specific affective, cognitive, and behavioural personality traits, professional abilities and effective external supports from different resources during self-regulatory processes. It is suggested that nurses should be selected for work in the emergency department based on appropriate characteristics and skills.

Dear editor:A shoulder dislocation is a common diagnosis at the emergency department, showing an incidence of 23.9 per 100,000 person-years. In the current diagnostic work-up, a radiograph is often used to confirm the dislocation. As radiographs are associated with radiation exposure, the ultrasound has been proposed as an alternative. Therefore, the study by Entezari et al is of great importance in evaluating the applicability of the ultrasound. However, the authors suggest that the ultrasound can be used as an alternative to the radiograph. In our opinion, an important advantage of the radiograph has not been discussed and we question some decisions that were made in terms of methodology. Therefore, we think that this study has to be seen in the light of these remarks.

Spontaneous rupture of the urinary bladder (SRUB) is rare condition. It is often difficult to diagnose particularly in busy emergency department (ED). SRUB is usually secondary to an underlying pathology, but in extremely rare condition, it can be idiopathic. Significant morbidity and mortality can result from a missed or delayed diagnosis. 

We report a case of idiopathic SRUB in a young male presented with inability to pass urine and abdominal pain in the absence of prior trauma or alcohol intoxication. A bedside ultrasound was performed by the emergency physician (EP) to confirm his suspicion, which demonstrated free intra-peritoneal fluid. This expedited further workup and management. Emergency consultation to urologist on call was initiated, the diagnosis was confirmed by CT scan and the patient was taken to the theatre. 

We report this case as it is unique in presentation, very rare in occurrence and bedside US had expedited further workup and management.

Treatment of myocardial infarction (MI) has been successfully developed, especially after introducing primary percutaneous coronary intervention (PPCI) as it nowadays is the recommended treatment for ST-segment elevation myocardial infarction (STEMI). 

This study aimed to evaluate the in-hospital mortality of STEMI patients treated with PPCI according to gender and other likely risk factors. 

This cross-sectional study presents a part of the results of a single-center registry in Imam Ali cardiovascular center affiliated to Kermanshah University of medical science (KUMS). From June 2016 to December 2017, 731 consecutive patients undergoing PPCI registered. Data were collected using a case report form developed by European Observational Registry Program (EORP). The relationship between in-hospital mortality and predicting variables was assessed using the Chi-square test, t-test, and univariate and multivariate logistic regression models (Forward LR). 

Totally, 155 patients (approximately 21%) were female. The mean age of women and men was 65.2 and 57.5, respectively (p=0.001). There were differences between women and men in hypertension (58.1% vs. 30.4%, respectively, p=0.001), diabetes mellitus (26.5% vs. 14.9%; p=0.001), hypercholesterolemia (37.4% vs. 18.6%; p=0.001), and history of prior congestive heart failure (5.2% vs. 2.0%; p=0.016). Although more men were current smokers (58.7% (men) vs. 15.5% (women); p=0.001). Women had a significantly greater incidence of multi-vessel disease, thrombolysis in myocardial infarction (TIMI) flow grade of 0/1 before PPCI, and longer symptom-to-balloon time. In-hospital mortality was higher in women than in men (5.2% vs. 1.9%; p=0.024). Multivariate analysis identified age ≥ 60 years, Killip class≥ II, and post-procedural TIMI flow grade < 3, but not female sex, as independent predictors of in-hospital mortality. 

In-hospital mortality after PPCI in women was higher than men, though this difference was likely due to the severe clinical profile in women. Also, female gender was not identified as an independent predictor of death.

The first unprovoked seizure (FUS) in children is a convulsive seizure with an unknown cause, which may be due to an underlying neurological disease or a manifestation of epilepsy. 

The aim of this study was to evaluate the findings of brain magnetic resonance imaging (MRI) in pediatric patients with FUS, presenting to the emergency department (ED). 

In this cross-sectional study, all children with FUS (age: >1month and<14 years), who were referred to the ED of Qaem Hospital, Mashhad, Iran from 2016 to 2019, were investigated. Medical records, brain MRI findings, electroencephalography (EEG) results, and developmental status of children were reviewed retrospectively. 

The brain MRI findings of 56 children with FUS were reviewed. The mean age of children was 3.92±6.05 years, and the sex distribution was equal. Seventeen (30.4%) patients had abnormal EEG findings, while 13 (23.2%) patients’ had non-specific EEG findings. Neurological examination of 4 (7.1%) children was abnormal. Overall, 6 (10.7%) patients had non-specific abnormal brain MRI findings for seizure, while 3 (5.4%) patients had specific abnormal findings. A significant relationship was observed between the developmental status of children and abnormal MRI findings (P=0.04). However, MRI findings had no significant relationship with EEG or neurological findings (P>0.05). 

It may be useful to perform brain MRI for children with FUS presenting to ED, especially those who are suspected of developmental disorders.