Confusing Hypoxia in a 21-Year-Old Intubated Multiple Trauma Patient

A 21-year-old man was brought to the emergency department due to multiple trauma (MT) caused by a motor car accident (MCA). On arrival, the patient was intubated by prehospital emergency medical services (EMS) and had a Glasgow coma scale (GCS) score of 6 on 10 (Due to intubation, verbal score was omitted). Physical examination revealed blood pressure of 150/70 mmHg, oxygen saturation (O2sat) of 60%, and pulse rate of 110/min. Examination of the tracheal tube site revealed incorrect esophageal placement. The patient was intubated again and his O2sat improved and reached approximately 96%. His pupils were reactive and of the same size. The Doll’s eye was normal, and plantar reflex was neuter in both sides. Neither expanding hematoma nor emphysema was observed in his neck. Laceration was noted on his left ear, but otorrhagia and tympanic perforation were not found. The lung sounds were normal in both sides. Extended focused abdominal sonography for trauma (e-FAST) examination revealed the absence of free fluid in the abdomen and pericardial space. No deformity of limbs was noted and the distal pulses were palpable. The patient’s O2sat decreased during his admission to the emergency department, and further examination indicated obvious decreased sound in his right lung that could not be reversed by needle thoracostomy. On reviewing his previous chest computed tomography, an obvious questionable pathology was detected in his right side Figure 1.What is your diagnosis

Acute Physiology and Chronic Health Evaluation (APACHE) III Score Compared to Trauma-Injury Severity Score (TRISS) in Predicting Mortality of Trauma Patients

Introduction: More than 50 scoring systems have been published for classification of trauma patients in the field, emergency room, and intensive care settings, so far. The present study aimed to compare the ability of trauma injury severity score (TRISS) and acute physiology and chronic health evaluation (APACHE) III in predicting mortality of intensive care unit (ICU) admitted trauma patients. Methods: This prospective cross-sectional study included ICU admitted multiple trauma patients of Imam Hossein and Hafte-Tir Hospitals, Tehran, Iran, during 2011 and 2012. Demographic data, vital signs, mechanism of injury and required variables for calculating APACHE III score and TRISS were recorded. The accuracy of the two models in predicting mortality of trauma patients was compared using area under the ROC curve. Results: 152 multiple trauma patients with mean age of 37.09 ± 14.60 years were studied (78.94% male). 48 (31.57%) cases died. For both APACHE III and TRISS, predicted death rates significantly correlated with observed death rates (p < 0.0001). The mean age of dead patients was 37.21 ± 14.07 years compared to 37.03±14.96 years for those who survived (p = 0.4). The area under ROC curve was 0.806 (95% CI: 0.663-0.908) for TRISS and 0.797 (95% CI: 0.652-0.901) for APACHE III (p = 0.2). Conclusion: Based on the results of this study, both TRISS and APACHE models have the same accuracy in predicting mortality of ICU admitted trauma patients. Therefore, it seems that TRISS model would be more applicable in this regard because of its easier calculation, consideration of trauma characteristics, and independency of patient care quality

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.

The Prevalence of Personality Disorders among Emergency Nurses Based on MMPI-2 Questionnaire; a Cross-sectional Study

Introduction: The prevalence of behavioral disorders is substantially higher in stressful working environments such as emergency departments. The present study aimed to evaluate the prevalence of personality disorders among emergency nurses.Methods: In the present epidemiologic study, the prevalence of personality disorders among emergency nurses of three educational hospitals, Tehran, Iran, were evaluated based on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) test. After the questionnaires were filled, data were entered to a special software for MMPI-2 test and the final result was interpreted based on the opinion of a clinical psychologist. Findings were reported using descriptive statistics.Results: 102 emergency nurses with the mean age of 30.2 ± 5.6 years were enrolled (100% female; 100% with master’s degree in nursing). The mean working time and experience of studied nurses were 210.8 ± 47.9 hours/month (130-370) and 4.1 ± 3.6 years (1-20), respectively. 32 (31.4%) cases showed symptoms of personality disorders The most common personality disorder detected in this study was somatization with 8.8%, hysteria with 6.9% prevalence, and pollyannaish with 4.9%. Among the studied factors only recent history of unpleasant event has significant correlation with existence of personality disorders (p = 0.015).Conclusion: The present study showed that somatization, hysteria, and pollyannaish were the most common personality disorders among the emergency nurses. History of an unpleasant event in the past year was the only effective factor in existence of personality disorders in the studied nurses

Comparing the Quality and Complications of Tube Thoracostomy by Emergency Medicine and Surgery Residents; a Cohort Study

Introduction: Tube thoracostomy complications depend on the operator’s skill, patients’ general condition and the place in which the procedure is done. The present study aimed to compare the quality and complications of tube thoracostomy carried out by emergency medicine residents (EMRs) and surgery residents (SRs).Methods: This cohort study was conducted on 18-60 years old trauma patients in need of tube thoracostomy presenting to two academic emergency departments. Quality of tube placement and its subsequent complications until tube removal were compared between SRs and EMRs using SPSS 20.Results: 72 patients with the mean age of 37.1±14.1 years were studied (86.1% male). 23 (63.8%) cases were complicated in SRs and 22 (61.1%) cases in EMRs group (total= 62.5%). Chest drain dislodgement (22.2% in SRs vs. 22.2% EMRs; p>0.99), drainage failure (19.4% in SRs vs. 16.7% EMRs; p=0.50), and surgical site infection (11.1% in SRs vs. 19.4% EMRs; p=0.25) were among the most common observed complications. The overall odds ratio of complication development was 0.89 (95% CI: 0.35-2.25, p = 0.814) for SRs and 1.12 (95% CI: 0.28-4.53, p = 0.867) for EMRs.Conclusion: The findings of the present study showed no significant difference between SRs and EMRs regarding quality of tube thoracostomy placement and its subsequent complications for trauma patients. The rate of complications were interestingly high (>60%) for both groups

Using Cervical Collar for Multiple Trauma Patients in Pre-Hospital Settings; a Letter to Editor

چکیده: زمینه و هدف: امروزه وقوع تروما علی­الخصوص آسیب­های گردنی يکي از مشکلات اساسي تهديدکننده سلامت جامعه است. در زمینه پیشگیری از آسیب­های بیشتر، مطالعات نتایج مختلفی را در ارتباط با استفاده از کلار گردنی بیان کرده­اند. هدف از انجام مطالعه حاضر بررسی اثرگذاری کلار گردنی در پایداری ستون فقرات گردنی پس از تروما می­باشد. مواد و روش­ها: این مطالعه به صورت توصیفی آینده­نگر، در مرکز آموزشی درمانی لقمان-ایران و بر روی تمامی بیماران با آسیب در ناحیه ستون فقرات گردنی طی سال­های 17-2016 مراجعه کننده به این مرکز انجام شد. بیماران به دو دسته استفاده و عدم استفاده کلار تقسیم­بندی شدند. چک لیستی برای هر بیمار تهیه و اطلاعات بیماران وارد آن گردید. بیمار از نظر عوارض عصبی مورد بررسی قرار گرفت. در ادامه تمامی داده­های حاصل از مصاحبه و معاینه بیماران وارد برنامه آنالیز آماری SPSS v18 شده و با استفاده از تست­های آماری مرتبط با اهداف مطالعه به تحلیل داده­ها پرداختیم. نتایج: در این مطالعه که بر روی 1000 بیمار با ترومای گردن انجام شد اکثریت بیماران (3/75 درصد) مرد بوده و اکثریت نیز در بازه سنی 40-20 سالگی (6/49) بودند. شایع­ترین مکانیسم منجر به ترومای سر و گردن سقوط از ارتفاع در 5/24 درصد بیماران بود. در میان موارد شکستگی، شایع­ترین شکستگی در این بیماران شکستگی مهره 7 در 4/7 درصد بیماران بود. همچنین مشاهده شد که 79 درصد بیماران پیش از تروما از کلار استفاده کرده بودند. نتایج نشان داد که کلار در زنان بیشتر از مردان مورد استفاده واقع شده بود. فراوانی افرادی که دچار اختلال هوشیاری شدند در نتیجه استفاده از کلار گردنی بیشتر بود و نیز در افرادی که کلار گردنی استفاده کرده بودند درصد فوتی نسبت به افرادی که کلار گردنی استفاده نکرده بودند بیشتر بود. نتیجه ­گیری: نتایج این مطالعه نشان داد استفاده از کلار نتوانسته بود میزان بروز ضایعات عصبی را کاهش معنی ­داری دهد.Relative neck fixation using neck collar for all trauma patients is among the pre-hospital measures emphasized by many of the existing protocols in dealing with these patients. As emergency medicine specialists, in many cases, at the time of trauma patients’ handover from pre-hospital staff we have seen that neck collar has not been used during the transfer of patients to the emergency department. Therefore, the authors of this letter decided to study the rate of neck collar use and its consequences on these patients in the emergency department of Loghman Hakim Hospital for 1 year to document this experience. The present study was performed on 1000 patients with multiple trauma (75.3% male, 50% aged 20-40 years). The most common mechanism of trauma was falling with 245 (24.5%) patients, and level of consciousness was 13 or higher (based on Glasgow coma scale) in 715 (71.5%) cases. 466 (46.6%) cases had midline neck tenderness at the time of admission. Neck radiography findings showed that 329 (32.9%) patients had at least one fracture in their cervical vertebrae or spinous process. Among the patients with fractures in the cervical vertebra, fracture had most commonly occurred in the 7th cervical vertebrae (4.7%). Evaluation of patients in terms of neck collar usage rate showed that only 790 (79%) patients had a neck collar when entering the emergency department and 210 (21%) patients did not. The results of imaging showed cervical vertebrae or spinous process fracture in 67 (32%) of the patients who had been transferred to the hospital without a collar. Also, 262 (33.2%) of those who had a collar upon arrival, had cervical vertebrae fractures. Out of the 210 patients who had been transferred to the hospital without a collar, 72 (34.3%) developed neurological deficits or whiplash injury, 2 (1%) died, and 136 (64.8%) were discharged from the hospital without any special complications. The results of this study confirm the assertion that all patients with multiple trauma in pre-hospital conditions will benefit from wearing neck collar during their transfer to emergency department

The Effect of Emergency Department Overcrowding on Efficiency of Emergency Medicine Residents’ Education

Introduction: Creating a calm and stress-free environment affects education significantly. The effects of the emergency department overcrowding (EDO) on the training of emergency medicine residents (EMR) is a highly debated subject. Therefore, this study aimed to evaluate the effect of EDO on efficiency of EMR’s education. Methods: In this cross-sectional study, the effects of overcrowding on EMR’s education in the resuscitation room and acute care unit. Data collection was done using a questionnaire, which was filled out by the second year EMRs.  The crowding level was calculated based on the national emergency department overcrowding scale (NEDOCS). The relationship between the two studied variables was evaluated using independent sample t-test and SPSS 21 statistical software. Results: 130 questionnaires were filled out during 61 shifts. 47 (77.05%) shifts were overcrowded. The attend’s ability to teach was not affected by overcrowding in the resuscitation room (p=0.008). The similar results were seen regarding the attend’s training ability in the acute care unit. Conclusion: It seems that the emergency department overcrowding has no effect on the quality of education to the EMRs

The Effect of Intravenous Ketamine in Suicidal Ideation of Emergency Department Patients

Introduction: Suicidal ideation is an emergent problem in the Emergency Department (ED) that often complicates patient disposition and discharge. It has been shown that ketamine possesses fast acting antidepressant and anti-suicidal effects. This study was conducted to examine the effects of a single intravenous bolus of ketamine on patients with suicidal ideations in ED. Methods: Forty-nine subjects with suicidal ideations with or without an unsuccessful suicide attempt, received 0.2 mg/kg of ketamine. Scale for suicidal ideation (SSI) and Montgomery-Abserg depression rating scale (MADRS) were evaluated before and 40, 80 and 120 minutes after drug intervention. The results were compared using the paired t-test and patients were followed up 10 days after ED admission for remnant suicide ideation. Results: SSI (df: 3, 46; F=80.7; p<0.001) and MADRS (df: 3, 46; F=87.2; p<0.001) scores significantly dropped after ketamine injection; the SSI score before and after 20, 40, and 80 minutes of ketamine injection were 23.0±6.7, 16.2±5.2, 14.3±4.3, and 13.6±4.0 respectively. The MADRS scores were 38.2±9.3, 25.6±7.1, 22.7±6.3, and 22.1±5.95 at the same time intervals. 25.5% of patients were hospitalized, 63.3% received medications and 12.2% discharged. 6.2% of patients had suicidal ideations ten days after ED disposition.  Conclusion: It seems that Ketamine couldn't be a good choice for fast reduction of suicidal ideations in ED patients. Further studies are needed to determine the optimal dose of ketamine for different patients

Characteristics of Methadone Intoxicated Children Presenting to Emergency Department; a Cross Sectional Study

Introduction: Each year a large number of patients present to emergency departments (EDs) following accidental or intentional poisoning with methadone. This study was designed with the aim of demographic evaluation of methadone poisoning in children presenting to ED and proposing preventive measures to parents and the healthcare system. Methods: This cross sectional study was carried out on children under the age of 12 years presenting to ED of a poisoning referral center. Demographic characteristics of the child and parents, cause of poisoning, form of drug consumed, dose consumed, the symptoms of the child on admission, clinical examination, laboratory findings, and final outcome were recorded and reported using descriptive statistics. Results: 179 cases were studied (59.2% boys). Cause of consumption was accidental in 175 (97.8%) cases and consumed drug dose was unknown in 53 (53.6%) cases. On admission 6 cases were in deep coma, 133 (74.3%) had miotic pupils, and 52 (29.1%) were affected with respiratory apnea and cyanosis. In 132 (73.8%) cases drugs were obtained from unapproved stores and form of drug consumed was syrup in 146 (81.6%) cases. 177 (98.9%) cases were discharged after 2 or3 days and 2 (1.1%) cases died. Conclusion: Based on the results of the present study, most cases of methadone poisoning were accidental, in children residing in poor and middle-class areas, with parents who had a low level of education and had obtained the drug from unapproved stores and stored it in improper containers or at improper places. Only 64.8% of the parents were educated regarding drug storage

Predictive Factors of Poor Outcome in Road Traffic Injures; a Retrospective Cohort Study

Introduction: Road traffic injuries (RTI) are among the most important health problems worldwide as they cause more than 1.2 million deaths and 50 million injuries each year. Therefore, the present study aims to evaluate the outcome and aftermath of RTI in those who were injured and hospitalized due to a traffic accident.Methods: In the present retrospective cohort study with a one-year follow-up, data were extracted from the profiles of the RTI hospitalized patients. Outcome of the patients was evaluated at the time of discharge and 1-year later including their living state, presence of a disability or complete recovery.Results: 1471 patients were studied (mean age of 32.8±17.0; 80.3% male). 571 (38.8%) had mild disability, 684 (46.5%) moderate disability, and 85 (5.8%) had severe disability at the time of discharge. In the end, 53 (3.6%) died. In the 1-year follow-up, 194 (13.2%) had mild disability, 43 (2.9%) had moderate disability, 9 (0.6%) had severe disability, and 7 (0.5%) were in a vegetative state. Presence of an underlying disease (p=0.03), loss of consciousness for more than 24 hours (p=0.04), spinal injury (p=0.002), presence of multiple trauma (p=0.01), increased ISS (p<0.001), need for ventilator (p<0.001), and organ injuries during hospitalization (p<0.001) are independent factors that increase the risk of poor outcome in RTI patients.Conclusion: Based on the results of the present study, underlying illnesses, loss of consciousness for more than 24 hours, spinal injury, multiple trauma, increased ISS, need for ventilator, and organ injuries during hospitalization were independent factors that increased the probability of poor outcome in RTI injuries