Worsened Dysrhythmia after Chemical Cardioversion with Digoxin; a Case of Malpractice

The patient was a 23-year-old man referred to the emergency department (ED) with the chief complaint of palpitation. The patient experienced dizziness, cold sweating, and lightheadedness after getting up which started spontaneously. He had four episodes of the same problems in seven months ago that felt better after taking 10 mg propranolol. But, in the current episode his problem was not solved by the same medication. He had no history of smoking, substance abuse, medication use, congenital heart disease, syncope, previous surgery, chest trauma, or any other known medical problems. As well, he had no any positive history of the same problems in his family. The patients’ on-arrival vital signs were as follow: systolic blood pressure (SBP): 90 mmHg, pulse rate (PR): 150/minute, respiratory rate (RR): 14/minute, oral temperature: 37◦C, oxygen saturation 96% with nasal cannula and 100% oxygen, Glasgow coma scale (GCS) 15/15. He was not experienced any other concomitant problems such as ischemic chest discomfort, shortness of breathing, or sign of circulatory shock such as paleness, mottling, etc. On general physical examination the patients’ lung and heart sounds, four limbs pulses, and capillary refile were normal. As well, focused neurological and abdominal examinations did not have any positive finding. The patient underwent close cardiac, vital sign monitoring and electrocardiography (ECG). Figure 1 shows the on-arrival patients’ ECG. Atrial fibrillation (AF) was diagnosed by the corresponding physician and digoxin (!?) prescribed that led to severe lethargy, weakness, sweating, and bradycardia. Figure 2 shows the post mediation ECG of patient

Evaluation of intoxication in patients with acute impaired consciousness using rapid urine test tape; a diagnostic accuracy study

Objective: Determining the exact underlying etiology of loss of consciousness (LOC) can become a real challenge for physicians due to the broadness of differential diagnoses. The current study aimed to assess the accuracy of a commercially available strip for urine drug screening, in patients presenting with LOC. Methods: One hundred fifty patients with LOC were enrolled in the current cross-sectional study. The diagnostic accuracy of a multidrug urinary strip rapid test was evaluated in comparison to blood analysis as the reference test, and the screening performance characteristics of the rapid test for each substance were estimated. Results: The average age of patients was 46.21±18.59 years (72.67% male). The most frequent false positive results of the test were related to Benzodiazepine (21.5%), Methamphetamine (7.5%), and Tramadol (5.4%), respectively. The screening performance characteristics of the test tape were the best in detection of Amitriptyline with 100.0% (95% CI: 30.99 – 100.0) sensitivity, Cocaine with 100.0% (95% CI: 5.46 – 100.0) sensitivity, and Methadone with 91.54% (95% CI: 81.88 – 96.51) sensitivity, respectively. Conclusion: The current study reveals that employing a urinary strip test for detecting drug intoxication in the setting of emergency department can lead to significant false positive and negative results. Accordingly, relying on a urine drug screen to determine the underlying etiology of LOC should be done with caution

Deep Vein Thrombosis despite Receiving Anticoagulant Prophylaxis; a Cross-sectional Study

مقدمه: آمارهای مختلفی از بروز ترومبوز ورید عمقی و عوارض متعاقب آن حتی پس از درمان ضدانعقادی پیشگیرانه در بیماران با آسیب اندام تحتانی وجود دارد. با توجه به وجود این اختلاف نظرها، مطالعه حاضر با هدف ارزیابی شیوع وقایع ترومبوآمبولیک در بیماران مبتلا به شکستگی اندام تحتانی که تحت درمان ضد انعقادی پیشگیرانه قرار گرفته اند طراحی شده است. روش کار: مطالعه مقطعي گذشته نگر حاضر با هدف ارزیابی میزان شیوع عوارض ترومبوآمبولیک متعاقب شکستگی اندام تحتانی در بیماران مراجعه کننده به بخش اورژانس طی یک سال طراحی شد. بیماران بالای 18 سال با ترومای اندام تحتانی پایین تر از زانو که نیازمند ثابت سازی با آتل یا گچ برای بیش از 2 هفته بودند مورد بررسی قرار گرفتند. یافته ها با استفاده از آماره های توصیفی و نرم افزار آماری SPSS نسخه 21 گزارش شدند. يافته ها: 130 بیمار با میانگین سنی 5/18± 05/40 (92-15) سال مورد مطالعه قرار گرفتند (5/61 درصد مرد). 18 (8/13 درصد) بیمار سابقه سوء مصرف مواد داشتند، 1 (8/0 درصد) بیمار مبتلا به دیابت، 8 (2/6 درصد) بیمار مبتلا به پرفشاری خون، 1 (8/0 درصد) مبتلا به آسم، 1 (8/0 درصد) بیمار مبتلا به سکته مغزی بودند. مکانیسم تروما در 44 (8/33 درصد) مورد سقوط از ارتفاع، 50 (5/38 درصد) مورد سوانح جاده ای و در 36 (7/27 درصد) مورد ترومای مستقیم بود. در نهایت 3 (3/2 درصد) بیمار علی رغم دریافت داروی ضد انعقاد مبتلا به ترومبوز ورید عمقی شدند. متوسط زمان بین ترخیص تا وقوع علائم 6/3 ± 6 روز بود. نتيجه گيری: یافته های مطالعه حاضر حاکی از شیوع  3/2 درصدی حوادث ترومبوآمبولیک در بیماران نیازمند به ثابت سازی اندام تحتانی تحت درمان با هپارین با وزن مولکولی پایین بود. هر سه مورد ترومبوز ورید عمقی در مطالعه حاضر در دو هفته اول بعد از ثابت سازی اتفاق افتاده بودند.Introduction: Contradicting statistics exist regarding the prevalence of deep vein thrombosis (DVT) following lower limb trauma despite administration of anti-thrombotic agents. The present study aimed to evaluate the prevalence of DVT in patients with lower limb trauma despite receiving anticoagulant prophylaxis. Methods: The present cross-sectional study was carried out to evaluate the prevalence of traumatic lower limbs DVT despite anti-thrombotic therapy, in patients presenting to emergency department. Patients over 18 years old with traumas in the areas lower than knees in need for fixation with cast or splint for > 2 weeks were enrolled. Data were analyzed using SPSS version 21 and descriptive statistics. Results: 130 patients with the mean age of 40.05 ± 18.5 (15-92) were studied (61.5% male). 18 (13.8%) cases had history of drug abuse, 1 (0.8%) had diabetes mellitus, 8 (6.2%) had hypertension, 1 (0.8%) had asthma, and 1 (0.8%) had history of cranial vascular thrombosis. Mechanism of trauma was falling down in 44 (33.8%) cases, road traffic collisions in 50 (38.5%), and direct trauma in 36 (27.7%). 3 (2.3%) patients developed DVT despite receiving prophylactic anti-thrombotic agents. The mean time interval between discharge and development of DVT was 6 ± 3.6 days. Conclusion: Based on the results of the present study, the prevalence of DVT, despite receiving anti-thrombotic agents, in patients with lower limb trauma in need for fixation for > 2 weeks was 2.3%. All three cases of DVT in this study were developed in the first 2 weeks of fixation.

Knowledge of Emergency Medicine Residents in Relation to Prevention of Tetanus

Introduction: Knowledge of emergency medicine residents about the management of patients suspected of having tetanus favoring wounds is very important due to their responsibility for the treatment of such patients. The aim of the present study was to evaluate this knowledge and making sure of the adequacy of instructions they have received in relation to prevention of tetanus.  Methods: A reliable and reproducible questionnaire was used to evaluate knowledge of all the emergency medicine residents in Imam Hussein Hospital in Tehran, Iran, about conditions favoring tetanus (9 questions) and proper interventions in such conditions (12 questions). The questionnaires were completed and scored as poor and good. The Mann-Whitney U test was used to analyze data. Statistical significance was set at P<0.05. Results: In the present study, 73 emergency medicine residents were evaluated (45.2% male). Knowledge of 31 (42.5%) residents in relation to conditions favoring tetanus and 41 (56.2%) residents in correct therapeutic interventions was in good level. The most frequent incorrect answer was related to diabetic ulcers and wounds in patients with sepsis. There was an increase in scores of conditions favoring tetanus (P<0.001) and correct therapeutic interventions (P=0.001) with an increase in educational years. However, age (P=0.64), gender (P=0.31), job experience (P=0.38) and participation in educational courses (P=0.67) had no effect on the knowledge level of emergency medicine residents. Conclusion: According to the findings of the present study, the knowledge of emergency medicine residents about correct management of patients suspected of tetanus was low, which emphasizes the necessity of providing further instructions on prevention of tetanus in wound management.

An Audit of Emergency Department Accreditation Based on Joint Commission International Standards (JCI)

Introduction: Despite thousands of years from creation of medical knowledge, it not much passes from founding the health care systems. Accreditation is an effective mechanism for performance evaluation, quality enhancement, and the safety of health care systems. This study was conducted to assess the results of emergency department (ED) accreditation in Shohadaye Tajrish Hospital, Tehran, Iran, 2013 in terms of domesticated standards of joint commission international (JCI) standards. Methods: This is a cohort study with a four months follow up which was conducted in the ED of Shohadaye Tajrish hospital in December 2013. The standard evaluation check list of Iran hospitals (based on JCI standards) included 24 heading and 337 subheading was used for this purpose. The effective possible causes of weak spots were found and their solutions considered. After correction, assessment of accreditation were repeated again. Finally, the achieved results of two periods were analyzed using SPSS version 20. Results: Quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities had the score of below 50%. The mean of total score for accreditation in ED in the first period was 60.4±30.15 percent and in the second period 68.9±22.9 (p=0.005). Strategic plans, head of department, head nurse, resident physician, responsible nurse for the shift, and personnel file achieved the score of 100%. Of total headings below 50% in the first period just in two cases, collection and analysis of data with growth of 40% as well as competency and capability test for staffs with growth of 17%, were reached to more than 50%. Conclusion: Based on findings of the present study, the ED of Shohadaye Tajrish hospital reached the score of below 50% in six heading of quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities. While, the given score in strategic plans, head of department, head nurse, resident physician, responsible nurse for the shifts, and personnel file was 100%

Re-admission Rate of Patients with Ureteral Stone: A Descriptive Study

Introduction: Patients with acute renal colic need to choose between undergoing medical treatments and receiving interventions. The Aim of this study is to evaluate the outcomes of patients who are discharged from emergency departments with ureteral stones lesser than 6 millimeters. In doing so, the effect of diagnostic treatment approaches on clinical outcomes and referral rate is to be assessed.Patients and Methods: This study was performed on patients with ureteral stones referred to emergency department of Shohadaye Tajrish Hospital between May2015 to June 2018. A checklist was filled out for each patient and it included their complete medical history, physical examination results and paraclinical data. Patients were then studied for 4 weeks to determine referral times to hospital and clinical outcomes.Results: 105 patients include 81 men (77.14%) with average age of 37.1±12.4 years were studied. The mean stone diameter was 4.2±2.1 mm.  Most of ureteral stones were seen in the right-hand side (60 percent). 71 patients (67.6%) did not have any history of nephrolithiasis and 73 (69.5%) did not have positive family history for nephrolithiasis. Ureteral stones were still observed in 42 patients (40%) after two weeks of studies and only one patient (1.1%) had stone in Ultrasound Imaging after 4 weeks of observations.Conclusion: Most Patients (95%) with stones smaller than 6 mm responded to Medical Expulsive Therapy (MET) after 4 weeks and passed spontaneously ureteral calculi

Associated Factors of In-hospital Outcomes in Emergency Department's Cardiopulmonary Resuscitation; a Cross-Sectional Study

Introduction: Even though the basic principles of cardiopulmonary resuscitation (CPR) are simple, the patients' outcome remains inconsistent. This study aimed to investigate the CPR outcomes and associated factors in the emergency department. Method: This cross-sectional study was conducted on patients who underwent in-hospital CPR following a cardiac arrest in the emergency department for one year. The patient's baseline characteristics and CPR outcomes were recorded from patients' profiles, and the association of patient-related and CPR-related variables with the outcomes was assessed. Results: 220 patients with a mean age of 71.5 ± 16.9 (range: 20-100) years were included (60.5% male). 193 cases of cardiac arrests had occurred in the hospital. Presenting cardiac rhythm in 198 cases (90.0 %) was asystole (not requiring defibrillation). The mean duration of conducted CPR was 43.2 ± 15.6 (5-120) minutes. Only 7 patients (3.2%) achieved the return of spontaneous circulation (ROSC) and were discharged from the hospital, with one suffering from neurological impairment due to CPR. There was a significant association between age (p = 0.047), consciousness status at admission (p = 0.003), presenting cardiac rhythm at CPR initiation (p = 0.0001), and establishment of ROSC under 45 minutes (p = 0.043) with patients' outcomes. Presenting cardiac rhythm at CPR initiation (p = 0.001), ROSC under 45 minutes (p = 0.012), and consciousness status at admission (p = 0.027) were independent predictive factors of survival. The area under the ROC curve for presenting cardiac rhythm and ROSC under 45 minutes was 0.817 (95% CI: 0.617-1.000) and 0.805 (95% CI: 0.606-1.000), respectively. Conclusion: Based on the present study's findings, the survival rate of patients after CPR in ED was 3.2%. Presenting cardiac rhythm, ROSC under 45 minutes, and consciousness status at admission was among the independent predictors of mortality

Validation of CRASH Model in Prediction of 14-day Mortality and 6-month Unfavorable Outcome of Head Trauma Patients

Introduction: To date, many prognostic models have been proposed to predict the outcome of patients withtraumatic brain injuries. External validation of these models in different populations is of great importancefor their generalization. The present study was designed, aiming to determine the value of CRASH prognosticmodel in prediction of 14-day mortality (14-DM) and 6-month unfavorable outcome (6-MUO) of patients withtraumatic brain injury. Methods: In the present prospective diagnostic test study, calibration and discriminationof CRASH model were evaluated in head trauma patients referred to the emergency department. Variablesrequired for calculating CRASH expected risks (ER), and observed 14-DM and 6-MUO were gathered. Then ERof 14-DM and 6-MUO were calculated. The patients were followed for 6 months and their 14-DM and 6-MUOwere recorded. Finally, the correlation of CRASH ER and the observed outcome of the patients was evaluated.The data were analyzed using STATA version 11.0. Results: In this study, 323 patients with the mean age of 34.0´s 19.4 years were evaluated (87.3% male). Calibration of the basic and CT models in prediction of 14-day and6-month outcome were in the desirable range (P Ç 0.05). Area under the curve in the basic model for predictionof 14-DM and 6-MUO were 0.92 (95% CI: 0.89–0.96) and 0.92 (95% CI: 0.90–0.95), respectively. In addition,area under the curve in the CT model for prediction of 14-DM and 6-MUO were 0.93 (95% CI: 0.91–0.97) and0.93 (95% CI: 0.91–0.96), respectively. There was no significant difference between the discriminations of thetwo models in prediction of 14-DM (p Æ 0.11) and 6-MUO (p Æ 0.1). Conclusion: The results of the presentstudy showed that CRASH prediction model has proper discrimination and calibration in predicting 14-DMand6-MUO of head trauma patients. Since there was no difference between the values of the basic and CT models,using the basic model is recommended to simplify the risk calculations

Emergency Department Performance Indexes Before and After Establishment of Emergency Medicine

Introduction: Emergency department performance index (EPI) greatly influences the function of other hospital’s units and also patient satisfaction. Recently, the Iranian Ministry of Health has defined specific national EPI containing five indexes. In the present study, the performance indexes of emergency department (ED) in one educational hospital has been assessed before and after establishment of emergency medicine. Methods: In the present cross-sectional study the ED of Shohadaye Tajrish Hospital, Tehran, Iran has been assessed during one-year period from March 2012 to February 2013. The study was divided into two six-month periods, before and after establishment of emergency medicine. Five performance indexes including: the percentage of patients were disposed during 6-hour, leaved the ED in a 12-hour, had unsuccessful cardiopulmonary resuscitations (CPR), discharged against medical advice, and the mean time of triage were calculated using data of department of medical records on daily patients’ files. Then, Mann-Whitney U test was used to make comparisons at P<0.05. Results: The average triage time decreased from 6.04 minutes in the first six months to 1.5 minutes in the second six months (P=0.06). The percentage of patients leaving the ED in a 12-hour decreased from 97.3% to 90.4% (P=0.004). However, the percentage of disposed patients during 6-hour (P=0.2), unsuccessful CPR (P=0.34) and discharged against medical advice (P=0.42) did not differ between the two periods. Conclusion: It seems that establishment of emergency medicine could be able to improve ED performance indexes such as time to triage and leave in a 12-hour period.