Journal of Emergency Practice and Trauma
Volume:9 Issue: 1, Winter-Spring 2023

Cellulitis is treated with antibiotics as routine management and based on the literature the cellulitis hospitalization can be avoided by 11% if appropriate antibiotics are used.1 Randomized clinical trials and Cochrane reviews have suggested that oral antibiotics are non-inferior to intravenous administration (1). We would like to highlight here the unrequired use of intravenous antibiotics in cellulitis. Intravenous antibiotics are recommended in patients with sepsis. This is supported by a study done on 1800 patients with cellulitis diagnosis, where one third of patients were hospitalized

Colonic injuries after blunt trauma abdomen are a rare entity which may sometimes have a delayed presentation. In the intensive care unit (ICU), various interventions like sedation, analgesia and paralysis may confoundclinical examination findings pertaining to abdominal pathology. Computed tomography (CT) provides anexcellent diagnostic modality in blunt trauma abdomen but requirement of high ventilatory support and/orvasopressors may preclude safe transfer of patients from ICU to radiology suites. Point of care ultrasound (POCUS)provides an excellent adjunct in diagnosis of hollow viscus perforation and is considered as a reliable alternative toplain radiograph for the diagnosis of pneumoperitoneum

In order to heal burn wounds, many researches have been done, including the use of biological scaffolds due to their ability to achieve the desired properties. Owing to the appropriate biological properties of chitosan such as biocompatibility and antimicrobial properties as well as the promotion of wound healing in biomedical applications, we aimed to perform a systematic review to investigate the effect of this technology on the treatment of burn hazards victims.

The present research was conducted in 2020 as a systematic review of studies related to the effect of chitosan on burns. In this study, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Critical Appraisal Skills Programme (CASP) guidelines were used to assess the articles. The key words “Chitosan,” “Chitin,” “victim,” “Injury,” “Burn,” “Heal,” “wound” “treat,” “hazard,” and “care” were used in combination with the Boolean operators OR and AND. The ISI web of science, PubMed, Scopus, Science Direct, Ovid, Pro Quest, Wiley and Google Scholar were searched.

Recently, chitosan and its derivatives have been proposed as suitable candidates for scaffolding and can be used as temporary scaffolds to modify and stimulate the growth of new tissues. Studies to demonstrate the use of chitosan in the treatment of burns have been limited to research on animal models and have been superior to conventional therapies in terms of time, pain, and efficacy.

The effect of chitosan on burns has been positive in animal models and has accelerated wound healing. Since the main ingredient of chit powder is chitosan and due to the limited studies done on humans, it cannot be said with certainty that the use of chitosan and its derivatives to treat burns is better than other ways to treat burns.

The adherence of the physicians to guidelines in resuscitation of the patientsis of great importance since it can predict the outcome. To evaluate the adherence of thephysicians of our center in hydration of traumatic patients with crystalloids regarding theAdvanced Trauma Life Support (ATLS) guidelines. We designed an algorithm obtained from ATLS guidelines using vital signsand status of bleeding of the traumatic patients to classify them. After categorizing thepatients according to the algorithm, we evaluated the adherence of the physicians to theguideline in hydration of traumatic patients with crystalloids. This is a cross-sectional study in which 998 traumatic patients who were admittedto the emergency ward of Rajaee trauma hospital were enrolled. Most of the patients weremen (89.6%) and the most common causes of traumatic injuries were traffic accidents.Proper hydration was seen in only 14.7% of the patients. Most of the patients were overhydrated (85%) regarding both our algorithm and the patients’ base excess. The present study showed that the adherence of physicians in our centerin resuscitation with crystalloid was low. Also, most of the traumatic patients wereoverhydrated with crystalloids. It is suggested that physicians retrain concerning theside effects of over hydration. In addition, we need a user friendly and more applicableguideline for hydration with crystalloids

Hand lacerations are among the most frequent causes of visiting emergencydepartments (EDs). Wound infection is one of its complications. There is still an ongoingdisagreement on the administration of oral versus intravenous (IV) antibiotics (ABs). Theobjective of this study is to compare the effectiveness of oral versus IV ABs in preventingwound infection of hand lacerations. In this double-blind, randomized clinical trial, we enrolled all patients with handlacerations (based on the inclusion criteria) during 6 months in the EDs of 2 tertiary referralcenters. Convenient sampling was done. Finally, in the first group, 382 patients receivedoral AB (two 500 mg cephalexin capsules) and the other 382 patients in the second groupreceived IV AB (1 gr IV cefazolin) before wound management. Both groups were followedand received oral cephalexin during 48 hours after suturing. Rates of wound infection anddifferent complications were compared between the two groups. T-test, Mann-Whitney Utest, Chi square and Fisher analysis were used. Both groups had the same age and gender distribution rate (79.8% of males withthe mean age of 30.8 years in the first group, and 83.5% of males with the mean age of 32.6years in the second group (P = 0.19 and 0.39, respectively). In our study, wound infectiondeveloped in 2.6% and 1.8% of patients in the first and second groups, respectively (P =0.46). Based on the results of this study, oral and IV ABs were not significantlydifferent in terms of preventing wound infection

The goal of our study was to determine the prognostic value of CURB-65,Sequential Organ Failure Assessment (SOFA), pneumonia severity index (PSI), MuLBSTA,and Acute Physiology and Chronic Health Evaluation (APACHE) II upon admission inpatients with coronavirus disease 2019 (COVID-19, as well as the prediction cut-off valuefor death regarding these parameters. This observational retrospective study was performed in COVID-19 triagein Peymaniyeh hospital in Jahrom in 2021. In order to calculate SOFA, APACHE II, PSI,MuLBSTA, and CURB-65, data were collected from patients who were selected by availablesampling method from PCR-confirmed COVID-19 patients. Thirty-day mortality wasassessed as the primary outcome. ROC analysis was conducted using the STATA software toevaluate the prognostic value of the scoring systems. DeLong test was utilized to compareAUC of scores using a web based tool.Ninety-two patients were included in this study with the mean age of 51.02±17.81years (male to female ratio was 1:1). SOFA had an AUC of 0.656 (P=0.130), but other indiceshad statistically significant values of AUC. Based on the comparison of the AUCs, SOFAwas the worst scoring system in COVID-19 as it had significantly lower AUC than PSI andAPACHE II (P<0.05); while its comparison with MULBSTA and CURB65 was not statisticallysignificant (P>0.05). It seems that APACHE II and PSI are the best prognostic factors in our studywith no statistical difference compared together (P>0.05). The sensitivity of APACHE II andPSI was 0.857 with the specificity of 0.927 and 0.976, respectively. The optimal cut-off pointwas 13 and 50 for APACHE II and PSI, respectively

In general, spinal fusion surgery causes heavy bleeding. The purpose of thisstudy was to evaluate the use of two different doses of magnesium sulfate to control thebleeding in lumbar fusion surgery. This study was carried out as a randomized double-blinded clinical trial in 2020in Al-Zahra hospital in Isfahan. The participants were 60 patients selected using inclusionand exclusion criteria and were randomly allocated into three groups. In the first group,50 mg/kg and in the second group, 40 mg/kg magnesium sulfate was infused. The thirdgroup received normal saline. From the beginning of anesthesia, heart rate, diastolic andsystolic blood pressure, respiratory rate and blood oxygen saturation percentage weremonitored and logged every 30 minutes during the operation and recovery. The volumeof bleeding during the operation was calculated by counting the number of gauzes usedand the amount of suctioned blood during the operation. Other required informationsuch as the duration of operation, duration of anesthesia, time of intubation and the timeperiod of hospitalization and recovery were determined and recorded in all patients. Weused independent t-test and repeated measure ANOVA tests to compare data betweendifferent time lines and also different groups. P value<0.05 was considered as significancethreshold. The collected data were analyzed by using SPSS software version 23. The group receiving 50 mg/kg magnesium sulfate had a significantly lower systolicblood pressure compared to other groups within 15, 30 and 45 minutes after the injections(P=0.04 for all). The pulse rate was significantly lower in the 50 mg/kg magnesium sulfategroup compared to other groups within 15, 30 and 45 minutes after the injections (P<0.05for all). Patients that received 50 mg/kg magnesium sulfate had a lower duration of surgery(P=0.007), lower duration of anesthesia (P=0.007), lower bleeding volume (P<0.001),lower fluid intake (P=0.01) and also lower transfused blood (P=0.01). The surgeons alsohad a significantly higher satisfaction with these patients (P=0.001). Injection of 50 mg/kg magnesium sulfate had a correlation with reducedblood pressure as well as bleeding volume compared to 40 mg/kg magnesium sulfate.

Cardiopulmonary arrest is a devastating outcome of some clinical situationsand requires strict implementation of cardiopulmonary resuscitation (CPR) protocols.Since ultrasound is one of the recommended tools to determine the presence of cardiacmovements and may be a predictor of the outcome, this study examined the relationshipbetween echocardiographic findings during CPR with patients’ outcomes. This cross-sectional prospective observational study was conducted on patientswith cardio-respiratory arrest in the emergency department of Shariaty hospital during2019. sampling method was random. Echocardiography was done at the patient’s bedsideduring the CPR process in accordance with the last advanced cardiac life support (ACLS)guidelines, on two points, after the end of the second and 10th minutes from the start ofCPR. The echocardiography findings (cardiac movement vs standstill) were recorded, andpatient outcomes were followed. Thirty-two patients enrolled in this study with a meanage of 56.9±15.3 years. Chi-square and Mann-Whitney U tests were used to calculate theassociation between heart contractions during resuscitation and the outcomes via SPSSV.22. Fisher’s exact test and Kruskal-Wallis test were used to evaluate the relationshipbetween heart rhythm in the second and tenth minutes with the outcomes of CPR. The presence of cardiac movement in the 10th minute of CPR, in contrast to thefindings of the second minute, had a significant correlation with the success rate of CPRand outcomes (P<0.05). Moreover, patients with ventricular tachycardia (VT)/ventricularfibrillation (VF) cardiac rhythm had a better resuscitation rate, 24-hour survival rate, andbetter outcome than patients with other cardiac rhythms and asystole (P<0.05). Echocardiographic findings in the 10th minute of the CPR process can beused as a prognostic factor for cardiac arrest

Pandemics would certainly have a negative impact on mental health. Positivemodifications as well as negative alterations have been documented in earlier viralpandemic according to previous investigations. Teenagers face a variety of challengesduring adolescence. Adolescents may become more concerned if this time coincides withother worries. This study aims to investigate the positive changes that occur in a youngadolescent’s life after COVID-19 pandemic, and to see how they relate to perceived socialsupport. This cross-sectional study was performed on adolescents who were randomlyselected from high schools in Kerman, Iran 2020 during the COVID-19. the sample sizewas 108 and for sampling wes used multi-stage random sampling at the end the data wasanalyzed by Pearson correlation test. Demographic information, the MultidimensionalScale of Perceived Social Support (MSPSS) and Posttraumatic Growth Inventory short form(PTGI-SF) were used to collect data. The data were subjected to descriptive and analyticalstatistical tests (Pearson correlation) using SPSS software version 24. Statistically a positive correlation was found between the PTG total score andyoung homeschooled adolescents, parents working remotely, income loss and COVID-19experience. Moreover, during the COVID-19 pandemic, a positive association was foundbetween perceived social support and PTG total scores in young adolescents. There werealso substantial positive connections between the MSPSS subscales and the PTGI overallscore. Based on the findings, an overall growth in all areas of PTG was observedduring the COVID-19 among young adolescents. Perceived social support scores have apositive and significant relationship with COVID-19 effects. In the crises we face throughoutlife, intimate family members and friends play a significant supporting role in adapting tothese situations

One of the most important indicators used in the evaluation of emergency centers is the chronometric analysis of patients’ workflow. The aim of this study was to provide a chronometric analysis of patients’ workflow (patients’ waiting time in the emergency department) and related factors. This hospital-based prospective cohort study was carried out in Khatam al-Anbia hospital in Shoushtar in 2020. Random sampling was used and patients referred to the emergency ward in three shifts based on the ESI 5-level triage system. The research tools were the emergency workflow chronometry form and a questionnaire of determining the factors related to the speed of emergency services and using a stopwatch. In order to analyse the data, Stata software version 16 and Weibull model of survival analysis were used. Of 468 participants, the most common cause of referral was trauma with 21.7%. The median ± interquartile range duration of giving the final result was 6.06 ± 4.48 hours, which was more than 0.54 times shorter in clients with level 3. There was a statistically significant difference in the duration of making the final decision based on the request for testing, manner of referring and the type of initial diagnosis (P < 0.05). The duration of service provision in the studied hospital is appropriate for an Iranian hospital, but it should be closer to international standards. At level 2 triage, patients stayed longer. This can be reduced by lessening the time of consultations which can help the emergency ward.

Fractures of orbital rims are common and restoration of these fractures back toits normal anatomic form is essential to maintain the function and aesthetics of the eyes.Low profile miniplates are the rigid fixation device of choice for such fractures. But in caseof sagittal and grossly displaced fractures of orbital rims it is difficult to achieve stability byusing miniplate osteosynthesis. The low profile miniplates may not be able to withstandthe forces to reduce this kind if grossly displaced fractures, another stable option needs tobe considered in these situations.

This case report presents a simple and effective technique of reductionand fixation of an oblique fracture of infraorbital rim fracture using lag screw principle.A standard titanium screw of 2 mm diameter and 10 mm length is being used in thedescribed technique for stable fixation of fractured segments.

The technique is simple, hardware’s are easily available and can be practisedin emergency circumstances where newer advanced technologies are not available

Orbital emphysema, defined as the presence of air in orbital and periorbital tissues, is a relatively uncommon clinical condition which occurs mostly following facial trauma. It can not only resolve spontaneously without any treatment, but it can also cause life threatening complications such as pneumomediastinum (PM). PM is an uncommon complication of facial fractures and is defined as the presence of air in the mediastinal space. Developing PM following blunt trauma is commonly considered as a red flag for underlying injuries, such as trachea and esophagus rupture. Therefore, other complementary diagnostic procedures, including bronchoscopy and esophagostomy, are often necessary for patients developing this condition.

A 31-year-old man with a history of facial and neck trauma was presented to the emergency room of our tertiary referral hospital with a complaint of right orbital swelling. On physical examination, vital signs were stable. There was a mild swelling of right upper eyelid, but no proptosis. An hour after admission, following sneezing and blowing his nose, the patient had further swelling of his right face with extension of swelling through the right side of his neck to the nipple. He also complained of dyspnea and acute severe progressive epigastric pain.

Orbital emphysema following orbital wall fracture is typically benign and self- limited, but physicians should be aware of serious complications such as PM. Therefore, monitoring the patient is crucial and should be considered in such ct

Purtscher’s retinopathy is the retinal damage following trauma or non-traumatic systemic disease, which may contain cotton-wool spots (CWSs), and may cause Purtscher flecken, atrophy of the optic nerve, and hemorrhage of the posterior pole of the eye.

A 28-year-old male patient fell down from a height of 10 m and was admitted with swelling and ecchymosis of the peri-orbit of the right eye. The patient’s vision was at the level of light perception. A mild subconjunctival hemorrhage and hyphema were seen in the right eye. In the fundus, the hemorrhage, edema, and CWS were seen in the posterior pole and around the optic disk. Macular thickness (MT) in Purtscher’s retinopathic eye was 353 μm. Also, the patient had a nose and mandibular fracture and was hospitalized for several days.

The findings indicate a decrease in the vision due to Purtscher’s retinopathy caused by trauma. There was no improvement spontaneously

Gastrointestinal bleeding is one of the surgical emergencies that is routinelyvisited in emergency departments. Although most of these patients are managed withendoscopic modalities, some of them are managed with surgical interventions. Most ofemergency surgical interventions are done via laparotomy. With evolution in minimalinvasive surgery, the role of laparoscopic surgeries in emergency settings is on a rise.

In this report we describe a case of lower gastrointestinal bleedingthat was presented with melena and during workups no bleeding lesion was detectedin colon, stomach or duodenum. Further investigations revealed bleeding of proximaljejunum mass that was resected with the laparoscopic approach which is rarely used inthe emergency management of patients with gastrointestinal bleedings. Also, resectionand anastomosis of proximal jejunal loop was challenging in this case.

This report is intended to describe the feasibility of laparoscopy in proximalsmall bowel lesion resection in emergency settings as well as the role of CT angiography indetecting the source of obscure gastrointestinal bleeding

To demonstrate the significance of fused cervical vertebrae in emergencymedicine practice.

Case report:

 A 35-year-old male was brought to the emergency department (ED) whoattempted suicide by hanging and was later found to have congenital fusion of cervicalvertebra C2 and C3, a condition referred to as - vertebra critica. This is the only case reportof a patient with vertebra critica admitted for near hanging. The patient was intubatedwith a Portex® North Polar endotracheal tube (ETT) through the nasal route. This proved tobe a critical decision as it helped early airway control avoiding any complication.

As the victims of near-hanging should have cervical spine restriction,judicious use of flexible portex® ETT may help in early intubation and resuscitationwithout aggravating the neurological injuries. It must be noted that nasal intubation iscontraindicated in base of skull fractures and it should be avoided in patients with obvioustraumatic injury to the neck including laryngeal trauma, tracheal disruption and vesselinjuries.

Since the identification and spread of the novel coronavirus disease 2019(COVID-19) in December 2019, respiratory presentations have been introduced as themain symptoms of this new type of viral disease; however, the extra-pulmonary featuresare raising awareness for researchers due to the vast diversity of vital organs affectedby the virus. Among the wide range of clinical manifestations, limited data are availableregarding rhabdomyolysis (RML) in COVID-19.

In this report, we present a 58-year-old woman with COVID-19presenting with RML, with extremely elevated creatinine phosphokinase (CPK) and lactatedehydrogenase (LDH) levels (3283 and 1280 U/L, respectively) as the second sign ofdisease. Since the onset of the COVID-19 pandemic, several COVID-19 induced RML caseshave been reported, and timely diagnosis and proper management are of paramountimportance.

Due to the findings that rhabdomyolysis can be a critical and missed cause ofmyalgia in COVID-19 patients, the importance of checking the serum level of CPK in patientswith myalgia and fatigue in the era of COVID-19 upon their arrival will be highlighted.

Rhabdomyolysis is an important etiology for developing acute kidney injury(AKI). Among the many varying reasons for rhabdomyolysis, electrical injury seems to bea lesser-known factor. The clinical presentation of rhabdomyolysis is usually in the formof severe and widespread pain, tenderness, weakness in the muscles and dark urine. Itis characterized by the disruption of cell integrity in myocytes as a result of widespreaddamage to skeletal muscles and the passage of intracellular components into thecirculation.

Here we presented a case report of a young man who hadrhabdomyolysis induced by electrical injury which is relatively less common among theother etiological factors with preserved renal functions. He had electrical injury relatedwounds on extremities. Urgent intravenous fluid therapy was initiated as soon as hisadmission to the emergency department (ED), without delay.

AKI is very common due to the nephrotoxic effect of myoglobinuria and theprerenal status. It is rare that AKI does not develop in patients with a severe increase increatinine kinase. It is a very important point to start effective fluid therapy in a short time.

Ultrasound assessment of inferior vena cava (IVC) collapsibility is performed todetermine the volume status of critically ill patients. We propose a new acoustic windowfor visualizing a vein in a prone patient.

A healthy volunteer took part in the study. The study protocol includestwo stages: 1) performing a magnetic resonance imaging (MRI) examination to determinethe projection of a certain IVC area on the posterior chest surface (holotopy), 2) performingan ultrasound scanning in the area of IVC projection in order to identify it and determineits dimensions.

The 11th intercostal space parallel to the paraspinal line allows to visualizethe IVC in the prone position. This gives a potential opportunity to use it to assess the IVCcollapsibility. Its potential advantage is the ability to assess the compressibility of IVC inthe antero-posterior direction