Thoracic Injury Rule out Criteria in Prediction of Traumatic Intra-thoracic Injuries; a Validation Study

Introduction: Doing Chest X Ray (CXR) for all trauma patients is not efficient and cost effective due to its low diagnostic value. The present study was designed aiming to evaluate the diagnostic accuracy of thoracic injury rule out criteria (TIRC) in prediction of traumatic intra-thoracic injuries and need for CXR. Method: The present study is a prospective cross-sectional study that has been carried out to evaluate the accuracy of TIRC model in screening blunt multiple trauma patients in need of CXR for ruling out intra-thoracic injuries. Results: 1518 patients with the mean age of 33.53 ± 15.42 years were enrolled (80.4% male). The most common mechanisms of trauma were motor car accident (78.8%) and falling (13.6%). Area under the ROC curve, sensitivity, and specificity of model in detection of traumatic thoracic injuries was 0.95 (95% CI: 0.93 – 0.97), 100 (95% CI: 87.0 – 100), and 80.1 (95% CI: 78.0 – 82.1), respectively. Brier score for TIRC was 0.02 and its scaled reliability was 0.0002. Conclusion: Findings of the present study showed that TIRC has high accuracy in prediction of traumatic intra-thoracic injuries and screening patients in need of CXR.

اورژانس های منطقه ای، استان کرمان، شهرستان بم؛ اجسام خارجی ناشی از نخل خرما

One of the most common causes of emergency department (ED) visits in Pasteur Hospital, Bam, Iran, is a foreign body from palm tree fronds entering different parts of body. This town is located in southeast Iran and has many palm tree orchards. Most of its residents are farmers or orchardists and many children play in these orchards. When palm harvest season approaches (about the end of summer), a considerable number of patients are presented to emergency department of this town with complaint of foreign bodies. These foreign bodies called “date thorns” among the locals (figure1) are wooden and can easily penetrate various body parts due to their needle-like, pointy shape. Some patients manipulate the foreign bodies before going to the ED and cause it to move deeper. Another group, delay going to the hospital and only reach ED a few days after the initiation of inflammation, redness, and evidence of infection. History and physical examination aid in finding the place of the foreign body, but sometimes they are not perceptible and diagnostic imaging is needed. Radiolucent objects such as wood cannot be detected in graphy but are visible in sonograms (1, 2). Removal of these bodies is usually performed under sterile conditions, using local anesthesia or regional nerve blockade, by making an incision and searching the region, finding and removing the foreign body, and finally suturing and bandaging. The procedure gets more difficult in children and patients who do not cooperate and occasionally, procedural sedation and analgesia is required, which leads to side effects such as nausea, vomiting, lethargy, agitation, and respiratory depression. Depending on the site of injury, patients are usually unable to use the affected organ for a few days after the procedure and need daily washing and bandage, and sometimes taking antibiotics. If tendon, joint, nerve, or vascular injuries are present, it gets more complicated and need for operation and hospitalization will be added to the afore-mentioned requirements (3-5). This can lead to temporary or permanent disability of the organs during the busiest workdays, in addition to severe pain especially in cases of the foreign body piercing a joint. The presence of these patients in the ED leads to overcrowding and sometimes decreases the time spent on patients in poor condition. This becomes troublesome on occasion as staff and equipment are limited, particularly when sonographic or radiologic guidance is needed for removal of the foreign body (6, 7). In the time between March and October 2014, 240 patients have been presented to the ED with complaint of foreign body, which makes up 10% of total ED visits as 2400 patients visit the ED each month (77.36% male). The patients’ age range was 3 to 70 years. In 190 (79.16%) cases, the foreign body was successfully removed in the ED and the other 50 (20.83%) needed surgery. The foreign body was in the lower extremities in 107 (56.31%) cases, upper extremities in 77 (40.52%) and other body parts in 6 (3.15%). These findings emphasize the importance of prioritizing prevention over treatment. It seems that by taking a few simple measures we can vastly decrease the financial and health burdens of this problem:1- Avoiding walking barefoot on the grounds beneath palm trees that are full of the dry thorns mentioned. This is especially important in case of children.2- Education for use and providing personal safety tools such as helmets, long impenetrable gloves, glasses, and proper shoes while working and harvesting dates.3- Having classes for the farmers and orchardists, held by health centers of the regions affected by this problem.4- Educating the patients on the importance of rapid referral to ED and not manipulating the foreign body to avoid further complications.5- Train the medical staff of the ED to increase their skills in removing radiolucent objects using sonographic guidance.6- Educate the families to take more care of the children especially in harvest season.7- Mechanization of the harvest process to decrease using hands with the aid of respective organizations یکی از مراجعات شایع به بخش اورژانس بیمارستان پاستور، بم، ایران، ورود جسم خارجی ناشی از لیف درخت خرما به قسمتهای مختلف بدن می باشد. این شهر در جنوب شرقی ایران واقع شده است و نخلستانهای زیادی دارد. بسیاری از ساکنین شهر بم و اطراف آن کشاورز و باغدار بوده و تعداد زیادی از کودکان هم در این باغها مشغول بازی هستند. با نزدیک شدن به فصل برداشت خرما (اواخر تابستان) بخش اورژانس این شهر محل ارجاع تعداد قابل توجهی از بیماران با شکایت جسم خارجی است. این اجسام خارجی که در اصطلاح محلی سیخ خرما نامیده می شود از جنس چوب بوده و به دلیل شکل سوزنی و انتهای تیزی که دارند به راحتی وارد قسمت های مختلف بدن میشود. برخی از بیماران قبل از مراجعه به اورژانس، اقدام به دستکاری کرده و باعث فرورفتن عمیق تر این اجسام می شوند.در ادامه این نوشتار به ارزیابی شیوه مدیریت این بیماران خواهیم پرداخت.

اورژانسهای منطقه ای، استان کرمان، شهرستان بم؛ مسمومیت با متادون

Regional emergencies, Bam, Kerman province, IranMethadone Poisoning Setareh Asgarzadeh, Mojtaba Jafari*, Bahareh Feizi Emergency Department, Pasteur Hospital, Bam University of Medical Sciences, Bam, Iran. *Corresponding Author: Mojtaba Jafari; Emergency Department, Pasteur Hospital, Baravat road, Bam, Kerman province, Iran; Tel: +989151404821; Email: [email protected]مسمومیت یکی از علل شایع مراجعه به بخش های اورژانس و دومین عامل مرگ غیرعمدی در کودکان است. مسمومیت با متادون در اطفال از مراجعات شایع به بخش اورژانس بیمارستان پاستور، شهرستان بم (جنوب شرقی ایران) می باشد. در طی سالهای اخیر استفاده از شربت متادون جهت ترک اعتیاد در این منطقه روند رو به افزایشی داشته است. عرضه و بسته بندی این دارو معمولا به شکل غیراستاندارد بوده و از بطری های نوشیدنی و یا ظرف داروهای دیگر جهت نگهداری آن استفاده می شود. این روش عرضه دارو به همراه ظاهر بی رنگ آن بارها باعث اشتباه در مصرف دارو به جای آب یا داروهای دیگر بخصوص توسط کودکان شده است. در اغلب موارد با شروع علایم، کودک توسط والدین به اورژانس آورده شده و تحت درمان قرار گرفته است؛ اما در صورت مراجعه دیرهنگام، ممکن است که درمان موثر نبوده و با مرگ و میر یا ناتوانی ناشی از هیپوکسی طولانی مدت همراه گردد. با توجه به ماهیت قابل پیشگیری مسمومیت های غیرعمدی به ویژه در کودکان، در ادامه به گزارش فراوانی این مشکل و ارائه راهکارهای جلوگیری از آن خواهیم پرداخت

Short-Term Outcome of Discharged Low-Risk Chest Pain without Provoke Ischemia Study

Introduction: Chest pain is a common problem in patients referring to emergency units. The present study was undertaken to evaluate the short-term outcome of patients presenting with a low risk chest pain and discharging without provoke ischemia study during emergency department admission. Methods: In the present prospective cohort study, patients with low-risk chest pain, referring to the emergency department of Imam Hossein Hospital, Tehran, during the first half of 2012, were evaluated. All the patients underwent electrocardiogram (ECG) and cardiac enzyme tests, including cardiac isoenzymes creatine kinase MB and troponin I. One week after referring to the emergency department, the patients underwent an exercise test and were followed for a month. Data were analyzed with chi-squared test at a significant level of P<0.05. Results: A total of 252 patients were included. The mean and standard deviation of patient ages was 56±7.7 years (47.5% male). The results of exercise tests for 47 (26.3%) subjects were positive [32 (28.8%) patients in the 41-60 year age group and 15 (22.7%) over 60 years of age].The angiography examination results of 5 patients (2.8%) were abnormal. There were no significant relationships between the age and gender and the results of exercise test and angiography (P>0.05). During the one-month follow-up no cases of mortality, cardiac problems, or referring again to the hospital were recorded. Conclusion: Based on the results of the present study, prevalence of cardiac etiology in patients with low risk chest pain was 2.8% and one-month follow-up did not reveal any complications or serious problems in such cases

Early vs Late Coronary Angiography and Intervention Following Thrombolytic Therapy; a Cohort Study

Introduction: The precise time of using percutaneous coronary intervention (PCI) after fibrinolytic therapy for maximum efficiency and minimum side effects is still undetermined. Therefore, the present study was designed to compare the outcome of myocardial infarction (MI) patients who underwent surgical intervention (angiography and PCI) within 48 hours of thrombolytic therapy or after that.Methods: The present study is a prospective cohort study aiming to compare the occurrence of no-reflow phenomenon, unstable angina, bleeding during intervention, and one month major adverse cardiac outcomes (recurrent MI, need for repeating surgical intervention, and mortality) between MI patents undergoing surgical intervention within the first 48 hours of or after 48 hours of thrombolytic therapy.Results: 90 patients with the mean age of 54.97 ± 10.54 were studied (86.67% male). 50 (56%) patients underwent surgical intervention within 48 hours and 40 (44%) after that. The 2 groups were not significantly different regarding baseline characteristics. No-reflow phenomenon in the < 48 hours group was about twice the > 48 hours group (OR = 0.35; 95% confidence interval: 0.14 – 0.92; p = 0.03), other outcomes were not significantly different. No case of mortality was seen in the 1 month follow up.Conclusion: Based on the results of the present study, it seems that no-reflow phenomenon rate is significantly lower in patients undergoing surgical intervention after 48 hours of fibrinolytic therapy. The difference between the two groups regarding prevalence of major adverse cardiac outcomes was not statistically significant

National Early Warning Score in Predicting Adverse Outcomes for Patients Admitted to Emergency Department; a Prognostic Accuracy Study

Introduction: Overcrowding in emergency departments (ED) is a global concern, emphasizing the need for effective resource allocation. Triage plays a crucial role in prioritizing patients based on medical needs. This study aimed to evaluate the accuracy of National Early Warning Score (NEWS) in predicting the ED patients’ outcomes. Methods: A cross-sectional study was conducted in two tertiary hospitals in Tehran, Iran, from June to July 2023. Adult patients presenting to ED were included. Data for calculating the NEWs and emergency severity index (ESI), as well as outcomes were recorded by trained nurses, and then the accuracy of each score in predicting the outcomes was evaluated. Results: A total of 2,085 patients were analyzed. The majority were male (57%) with a mean age of 54.4 years. The primary outcome, cardiopulmonary resuscitation (CPR) within 24 hours of admission, occurred in 1.9% of patients, while the need for intensive care unit (ICU) care and/or mechanical ventilation happened in 3.4%, and CPR or need for ICU care and/or mechanical ventilation was observed in 4.3% of studied cases. Each one-point increase in NEWS was associated with a 52% higher likelihood of CPR (95% confidence interval (CI): 1.41 to 1.65, p<0.001). Receiver operating characteristic curve analyses for the NEWS yielded the optimum cut-off value to be 6 for all three outcomes, with an overall area under the curve (AUC) of 0.856 (95% CI: 0.840 to 0.871), 0.834 (95% CI: 0.817 to 0.850), and 0.854 (95% CI: 0.838 to 0.869) for the primary, secondary, and tertiary outcomes, respectively. Conclusion: NEWS ≥ 6 was associated with a higher incidence of adverse outcomes, including ICU admission and need for CPR. The good predictive validity of NEWS highlights its value in identifying patients at higher risk of adverse outcomes

گزش؛ علتی ناشایع اما محتمل برای ناپایداری همودینامیک

Scorpion bites are common in south-east Iran, especially in the rural areas. Most scorpion bite cases are benign and cause no systemic side effects. Local erythema and edema, and mild allergic effects are the most common complications of scorpion bites. Yet, rarely dangerous outcomes such as myocarditis, cardiac failure, pulmonary edema, and shock have been reported. The present case report, introduces a case of scorpion bite in a 6 year old child, presented as dyspnea and pulmonary edema. عقرب گزیدگی در جنوب شرق کشور ایران و به خصوص در مناطق روستایی به صورت متداول رخ می دهد. بیشتر موارد عقرب گزیدگی بدون بروز عوارض سیستمیک، سیر بالینی خوش خیمی را طی می کنند. اریتم و تورم موضعی و عوارض حساسیتی خفیف شایعترین آثار ناشی از گزش این موجودات محسوب می شوند. ولی به ندرت عوارض خطرناکی نظیر میوکاردیت، نارسایی قلبی، ادم پولمونر و شوک نیز گزارش شده است. گزارش موردی حاضر یک مورد عقرب گزیدگی با تظاهر تنگی نفس و ادم ریه در یک کودک شش ساله را معرفی نموده است

Bite; a Rare but Probable Cause for Hemodynamic Instability

Scorpion bites are common in south-east Iran, especially in the rural areas. Most scorpion bite cases are benign and cause no systemic side effects. Local erythema and edema, and mild allergic effects are the most common complications of scorpion bites. Yet, rarely dangerous outcomes such as myocarditis, cardiac failure, pulmonary edema, and shock have been reported. The present case report, introduces a case of scorpion bite in a 6 year old child, presented as dyspnea and pulmonary edema

کله سیستیت بدون سنگ بدنبال ترومای متعدد؛ گزارش یک مورد

Acalculous cholecystitis, is a rare disease with a high morbidity and mortality, which is developed due to various reasons, including trauma and burn. Its diagnosis is based on clinical suspicion and physical examination. Ultrasonography and computed tomography scan can help in this regard. This report presents a case of post-traumatic acalculous cholecystitis in a 75-year-old patient expressing its method of diagnosis, treatment and outcome. کوله سیستیت بدون سنگ عارضه ای با مرگ و میر بالا و ناشایع است که به عنوان یک بیماری ثانویه در شرایطی نظیر ترومای شدید و سوختگی وسیع رخ می دهد. تشخیص این بیماری مشکل بوده و احتمال آن براساس شک بالینی و معاینات فیزیکی مطرح شده و به کمک سونوگرافی و سی تی اسکن به تایید می رسد. گزارش حاضر یک مورد کوله سیستیت بدون سنگ به دنبال تروما در یک بیمار 75 ساله را مطرح می کند

Post-traumatic Acalculous Cholecystitis; a Case Report

Acalculous cholecystitis, is a rare disease with a high morbidity and mortality, which is developed due to various reasons, including trauma and burn. Its diagnosis is based on clinical suspicion and physical examination. Ultrasonography and computed tomography scan can help in this regard. This report presents a case of post-traumatic acalculous cholecystitis in a 75-year-old patient expressing its method of diagnosis, treatment and outcome