Emergency Medicine International http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Direct-Acting Oral Anticoagulants: Practical Considerations for Emergency Medicine Physicians Mon, 16 May 2016 12:37:12 +0000 http://www.hindawi.com/journals/emi/2016/1781684/ Nonvalvular atrial fibrillation- (NVAF-) related stroke and venous thromboembolism (VTE) are cardiovascular diseases associated with significant morbidity and economic burden. The historical standard treatment of VTE has been the administration of parenteral heparinoid until oral warfarin therapy attains a therapeutic international normalized ratio. Warfarin has been the most common medication for stroke prevention in NVAF. Warfarin use is complicated by a narrow therapeutic window, unpredictable dose response, numerous food and drug interactions, and requirements for frequent monitoring. To overcome these disadvantages, direct-acting oral anticoagulants (DOACs)—dabigatran, rivaroxaban, apixaban, and edoxaban—have been developed for the prevention of stroke or systemic embolic events (SEE) in patients with NVAF and for the treatment of VTE. Advantages of DOACs include predictable pharmacokinetics, few drug-drug interactions, and low monitoring requirements. In clinical studies, DOACs are noninferior to warfarin for the prevention of NVAF-related stroke and the treatment and prevention of VTE as well as postoperative knee and hip surgery VTE prophylaxis, with decreased bleeding risks. This review addresses the practical considerations for the emergency physician in DOAC use, including dosing recommendations, laboratory monitoring, anticoagulation reversal, and cost-effectiveness. The challenges of DOACs, such as the lack of specific laboratory measurements and antidotes, are also discussed. W. Frank Peacock, Zubaid Rafique, and Adam J. Singer Copyright © 2016 W. Frank Peacock et al. All rights reserved. Coca: The History and Medical Significance of an Ancient Andean Tradition Thu, 07 Apr 2016 14:06:18 +0000 http://www.hindawi.com/journals/emi/2016/4048764/ Coca leaf products are an integral part of the lives of the Andean peoples from both a cultural and traditional medicine perspective. Coca is also the whole plant from which cocaine is derived. Coca products are thought to be a panacea for health troubles in regions of South America. This review will examine the toxicology of whole coca and will also look at medicinal applications of this plant, past, present, and future. Amy Sue Biondich and Jeremy David Joslin Copyright © 2016 Amy Sue Biondich and Jeremy David Joslin. All rights reserved. Trainers’ Attitudes towards Cardiopulmonary Resuscitation, Current Care Guidelines, and Training Wed, 06 Apr 2016 11:36:39 +0000 http://www.hindawi.com/journals/emi/2016/3701468/ Objectives. Studies have shown that healthcare personnel hesitate to perform defibrillation due to individual or organisational attitudes. We aimed to assess trainers’ attitudes towards cardiopulmonary resuscitation and defibrillation (CPR-D), Current Care Guidelines, and associated training. Methods. A questionnaire was distributed to CPR trainers attending seminars in Finland () focusing on the updated national Current Care Guidelines 2011. The questions were answered using Likert scale (1 = totally disagree, 7 = totally agree). Factor loading of the questionnaire was made using maximum likelihood analysis and varimax rotation. Seven scales were constructed (Hesitation, Nurse’s Role, Nontechnical Skill, Usefulness, Restrictions, Personal, and Organisation). Cronbach’s alphas were 0.92–0.51. Statistics were Student’s -test, ANOVA, stepwise regression analysis, and Pearson Correlation. Results. The questionnaire was returned by 124/185, 67% CPR trainers, of whom two-thirds felt that their undergraduate training in CPR-D had not been adequate. Satisfaction with undergraduate defibrillation training correlated with the Nontechnical Skills scale (). Participants scoring high on Hesitation scale () were less confident about their Nurse’s Role () and Nontechnical Skills (). Conclusion. Quality of undergraduate education affects the work of CPR trainers and some feel uncertain of defibrillation. The train-the-trainers courses and undergraduate medical education should focus more on practical scenarios with defibrillators and nontechnical skills. M. Mäkinen, M. Castrén, J. Nurmi, and L. Niemi-Murola Copyright © 2016 M. Mäkinen et al. All rights reserved. Use of the Vocera Communications Badge Improves Public Safety Response Times Mon, 04 Apr 2016 11:33:11 +0000 http://www.hindawi.com/journals/emi/2016/7158268/ Objectives. Violence in the Emergency Department (ED) has been a long-standing issue complicated by deficiencies in staff training, ease of weapons access, and response availability of public safety officers. The Vocera Badge is being used by our staff to request public safety assistance in lieu of a formal phone call to the University Police Communications Center. We sought to learn if use of this technology improved officer response times to the ED. Methods. Mean response times were reviewed and descriptive statistics analyzed to determine if the use of the Vocera Badge improved public safety officer response times to the ED. Results. Average response times improved from an average of 3.2 minutes (SD = 0.456) in the 6 months before the use of the communication badges to an average of 1.02 minutes (SD = 0.319) in the 6 months after use began. Conclusions. The use of the Vocera Badge seemed to decrease response times of public safety officers to our ED compared with the traditional method of calling a dispatch center to request assistance. Jeremy D. Joslin, David Goldberger, Loretta Johnson, and D. Paul Waltz Copyright © 2016 Jeremy D. Joslin et al. All rights reserved. Reducing Time to First on Scene: An Ambulance-Community First Responder Scheme Mon, 28 Mar 2016 14:04:29 +0000 http://www.hindawi.com/journals/emi/2016/1915895/ The importance of early access to prehospital care has been demonstrated in many medical emergencies. This work aims to describe the potential time benefit of implementing a student Community First Responder scheme to support ambulance services in an inner-city setting in the United Kingdom. Twenty final and penultimate year medical students in the UK were trained in the “First Person on Scene” Business and Technology Education Council (BTEC) qualification. Over 12 months, they attended 89 emergency calls in an inner-city setting as Community First Responders (CFRs), alongside the West Midlands Ambulance Service, UK. At the end of this period, a qualitative survey investigated the perceived educational value of the scheme. The mean CFR response time across all calls was an average of 3 minutes and 8 seconds less than ambulance crew response times. The largest difference was to calls relating to falls (12 min). The difference varied throughout the day, peaking between 16:00 and 18:00. All questionnaire respondents stated that they felt more prepared in assessing and treating acutely unwell patients. In this paper, the authors present a symbiotic solution which has both reduced time to first on scene and provided training and experience in medical emergencies for senior medical students. Alan Campbell and Matt Ellington Copyright © 2016 Alan Campbell and Matt Ellington. All rights reserved. Paramedic Recognition of Sepsis in the Prehospital Setting: A Prospective Observational Study Wed, 09 Mar 2016 13:39:03 +0000 http://www.hindawi.com/journals/emi/2016/6717261/ Background. Patients with sepsis benefit from early diagnosis and treatment. Accurate paramedic recognition of sepsis is important to initiate care promptly for patients who arrive by Emergency Medical Services. Methods. Prospective observational study of adult patients (age ≥ 16 years) transported by paramedics to the emergency department (ED) of a Canadian tertiary hospital. Paramedic identification of sepsis was assessed using a novel prehospital sepsis screening tool developed by the study team and compared to blind, independent documentation of ED diagnoses by attending emergency physicians (EPs). Specificity, sensitivity, accuracy, positive and negative predictive value, and likelihood ratios were calculated with 95% confidence intervals. Results. Overall, 629 patients were included in the analysis. Sepsis was identified by paramedics in 170 (27.0%) patients and by EPs in 71 (11.3%) patients. Sensitivity of paramedic sepsis identification compared to EP diagnosis was 73.2% (95% CI 61.4–83.0), while specificity was 78.8% (95% CI 75.2–82.2). The accuracy of paramedic identification of sepsis was 78.2% (492/629, 52 true positive, 440 true negative). Positive and negative predictive values were 30.6% (95% CI 23.8–38.1) and 95.9% (95% CI 93.6–97.5), respectively. Conclusion. Using a novel prehospital sepsis screening tool, paramedic recognition of sepsis had greater specificity than sensitivity with reasonable accuracy. Robert S. Green, Andrew H. Travers, Edward Cain, Samuel G. Campbell, Jan L. Jensen, David A. Petrie, Mete Erdogan, Gredi Patrick, and Ward Patrick Copyright © 2016 Robert S. Green et al. All rights reserved. Routine Head Computed Tomography for Patients in the Emergency Room with Trauma Requires Both Thick- and Thin-Slice Images Thu, 11 Feb 2016 09:51:56 +0000 http://www.hindawi.com/journals/emi/2016/5781790/ Background. Images of head CT for the supratentorial compartment are sometimes recommended to be reconstructed with a thickness of 8–10 mm to achieve lesion conspicuity. However, additional images of a thin slice may not be routinely provided for patients with trauma in the emergency room (ER). We investigated the diagnostic sensitivity of a head CT, where axial images were 10 mm thick slices, in cases of linear skull fractures. Methods. Two trauma surgeons retrospectively reviewed head CT with 10 mm slices and skull X-rays of patients admitted to the ER that were diagnosed with a linear skull fracture. All patients had undergone both head CT and skull X-rays (). Result. The diagnostic sensitivity of head CT with a thickness of sequential 10 mm was 89% for all linear skull fractures but only 56% for horizontal fractures. This CT technique with 10 mm slices missed 6% of patients with linear skull fractures. False-negative diagnoses were significantly more frequent for older (≥55 years) than for young (<15 years) individuals (). Conclusions. A routine head CT of the supratentorial region for patients in the ER with head injuries requires both thick-slice images to visualize cerebral hemispheres and thin-slice images to detect skull fractures of the cranial vault. Kazuhide Maetani, Jun Namiki, Shokei Matsumoto, Katsutoshi Matsunami, Atsushi Narumi, Toshimi Tsuneyoshi, and Masanobu Kishikawa Copyright © 2016 Kazuhide Maetani et al. All rights reserved. Using Fresh Frozen Plasma for Acute Airway Angioedema to Prevent Intubation in the Emergency Department: A Retrospective Cohort Study Wed, 03 Feb 2016 12:18:28 +0000 http://www.hindawi.com/journals/emi/2016/6091510/ Background. Angioedema (AE) is a common condition which can be complicated by laryngeal edema, having up to 40% mortality. Although sporadic case reports attest to the benefits of fresh frozen plasma (FFP) in treating severe acute bouts of AE, little evidence-based support for this practice is available at present. Study Objectives. To compare the frequency, duration of intubation, and length of intensive care unit (ICU) stay in patients with acute airway AE, with and without the use of FFP. Methods. A retrospective cohort study was conducted, investigating adults admitted to large community hospital ICU with a diagnosis of AE during the years of 2007–2012. Altogether, 128 charts were reviewed for demographics, comorbidities, hospital courses, and outcomes. A total of 20 patients received FFP (108 did not). Results. Demographics and comorbidities did not differ by treatment group. However, nontreated controls did worse in terms of intubation frequency (60% versus 35%; ) and ICU stay (3.5 days versus 1.5 days; ). Group outcomes were otherwise similar. Conclusion. In an emergency department setting, the use of FFP should be considered in managing acute airway nonhereditary AE (refractory to steroid, antihistamine, and epinephrine). Larger prospective, better controlled studies are needed to devise appropriate treatment guidelines. Aya Saeb, Karen H. Hagglund, and Christine T. Cigolle Copyright © 2016 Aya Saeb et al. All rights reserved. New Insights into the Role of Metformin Effects on Serum Omentin-1 Levels in Acute Myocardial Infarction: Cross-Sectional Study Mon, 23 Nov 2015 13:31:20 +0000 http://www.hindawi.com/journals/emi/2015/283021/ Background. Serum omentin-1 level was low in the most types of ischemic heart disease compared to normal subjects; it also dependently correlated with coronary heart disease; thus, omentin-1 is regarded as a novel biomarker in IHD. Objective. The aim of the present study was to establish the links between omentin-1 and acute myocardial infarction in metformin patients. Subjects and Methods. A cross-sectional study was performed on eighty-five patients with type II DM and acute MI. They are divided as follows: Group I, 62 patients with type II DM who received metformin prior to onset of acute MI; Group II, 23 patients with type II DM who did not receive metformin prior to onset of acute MI; and Group III, 30 normal healthy controls. Venous blood was drawn from each participant for determination of lipid profile, plasma omentin-1, cardiac troponin-I (cTn-I) and other routine tests. Results. Patients that presented with acute MI that received metformin show a significant difference in all biochemical parameters (); metformin increases serum omentin-1 level and decreases serum cardiac troponin-I level compared with control subjects and nonmetformin treated patients. Conclusion. Metformin pharmacotherapy increases omentin-1 serum levels and may be regarded as a potential agent in the prevention of the occurrences of acute MI in diabetic patients. Hayder M. Alkuraishy and Ali I. Al-Gareeb Copyright © 2015 Hayder M. Alkuraishy and Ali I. Al-Gareeb. All rights reserved. Validation of EGSYS Score in Prediction of Cardiogenic Syncope Mon, 16 Nov 2015 09:48:44 +0000 http://www.hindawi.com/journals/emi/2015/515370/ Introduction. Evaluation of Guidelines in Syncope Study (EGSYS) is designed to differentiate between cardiac and noncardiac causes of syncope. The present study aimed to evaluate the accuracy of this predictive model. Methods. In this prospective cross-sectional study, screening performance characteristics of EGSYS-U (univariate) and EGSYS-M (multivariate) in prediction of cardiac syncope were calculated for syncope patients who were referred to the emergency department (ED). Results. 198 patients with mean age of 59.26 ± 19.5 years were evaluated (62.3% male). 115 (58.4%) patients were diagnosed with cardiac syncope. Area under the ROC curve was 0.818 (95% CI: 0.75–0.87) for EGSYS-U and 0.805 (CI 95%: 0.74–0.86) for EGSYS-M (). Best cut-off point for both models was 3. Sensitivity and specificity were 86.08% (95% CI: 78.09–91.59) and 68.29% (95% CI: 56.97–77.86) for EGSYS-U and 91.30% (95% CI: 84.20–95.52) and 57.32% (95% CI: 45.92–68.02) for EGSYS-M, respectively. Conclusion. The results of this study demonstrated the acceptable accuracy of EGSYS score in predicting cardiogenic causes of syncope at the 3 cut-off point. It seems that using this model in daily practice can help physicians select at risk patients and properly triage them. Hamid Kariman, Sepideh Harati, Saeed Safari, Alireza Baratloo, and Mehdi Pishgahi Copyright © 2015 Hamid Kariman et al. All rights reserved. Medical History of Elderly Patients in the Emergency Setting: Not an Easy Point-of-Care Diagnostic Marker Thu, 03 Sep 2015 13:26:27 +0000 http://www.hindawi.com/journals/emi/2015/490947/ Background. Medical histories are a crucially important diagnostic tool. Elderly patients represent a large and increasing group of emergency patients. Due to cognitive deficits, taking a reliable medical history in this patient group can be difficult. We sought to evaluate the medical history-taking in emergency patients above 75 years of age with respect to duration and completeness. Methods. Anonymous data of consecutive patients were recorded. Times for the defined basic medical history-taking were documented, as were the availability of other sources and times to assess these. Results. Data of 104 patients were included in the analysis. In a quarter of patients (25%, ) no complete basic medical history could be obtained. In the group of patients where complete data could be gathered, only 16 patients were able to provide all necessary information on their own. Including other sources like relatives or GPs prolonged the time until complete medical history from 7.3 minutes (patient only) to 26.4 (+relatives) and 56.3 (+GP) minutes. Conclusions. Medical histories are important diagnostic tools in the emergency setting and are prolonged in the elderly, especially if additional documentation and third parties need to be involved. New technologies like emergency medical cards might help to improve the availability of important patient data but implementation of these technologies is costly and faces data protection issues. Tobias Lindner, Anna Slagman, Arthur Senkin, Martin Möckel, and Julia Searle Copyright © 2015 Tobias Lindner et al. All rights reserved. Ultrasound Guided Intravenous Access by Nursing versus Resident Staff in a Community Based Teaching Hospital: A “Noninferiority” Trial Sun, 30 Aug 2015 06:15:21 +0000 http://www.hindawi.com/journals/emi/2015/563139/ Objectives. Ultrasound (US) guidance is a safe and effective method for peripheral intravenous (IV) catheter placement. However, no studies have directly compared the success rate of emergency medicine (EM) residents and nurses at using this technique especially in community hospital settings. This prospective “noninferiority” study sought to demonstrate that nursing staff are at least as successful as EM residents at placing US guided IVs. Methods. A group of 5 EM residents and 11 nurse volunteers with at least two years’ experience underwent training sessions in hands-on practice and didactic instruction with prospective follow-up. Two failed attempts on a patient using standard approach by an emergency department (ED) nurse were deemed to be “difficult sticks” and randomly assigned to either a nurse or resident, based on the day they presented. Results. A total of 90 attempts, consisting of trials on 90 patients, were recorded with a success rate of 85% and 86% for residents and nurses, respectively. With a value of .305, there was no statistically significant difference in the success rate between the residents and nurses. Conclusion. Properly trained nursing staff can be as equally successful as EM residents in placing US guided intravenous lines. Thomas Carter, Chris Conrad, J. Link Wilson, and Godwin Dogbey Copyright © 2015 Thomas Carter et al. All rights reserved. Morbidity and Mortality following Traditional Uvulectomy among Children Presenting to the Muhimbili National Hospital Emergency Department in Dar es Salaam, Tanzania Tue, 16 Jun 2015 12:16:07 +0000 http://www.hindawi.com/journals/emi/2015/108247/ Background. Traditional uvulectomy is performed as a cultural ritual or purported medical remedy. We describe the associated emergency department (ED) presentations and outcomes. Methods. This was a subgroup analysis of a retrospective review of all pediatric visits to our ED in 2012. Trained abstracters recorded demographics, clinical presentations, and outcomes. Results. Complete data were available for 5540/5774 (96%) visits and 56 (1.0%, 95% CI: 0.7–1.3%) were related to recent uvulectomy, median age 1.3 years (interquartile range: 7 months–2 years) and 30 (54%) were male. Presenting complaints included cough (82%), fever (46%), and hematemesis (38%). Clinical findings included fever (54%), tachypnea (30%), and tachycardia (25%). 35 patients (63%, 95% CI: 49–75%) received intravenous antibiotics, 11 (20%, 95% CI: 10–32%) required blood transfusion, and 3 (5%, 95% CI: 1–15%) had surgical intervention. All were admitted to the hospital and 12 (21%, 95% CI: 12–34%) died. By comparison, 498 (9.1%, 95% CI: 8–10%) of the 5484 children presenting for reasons unrelated to uvulectomy died (). Conclusion. In our cohort, traditional uvulectomy was associated with significant morbidity and mortality. Emergency care providers should advocate for legal and public health interventions to eliminate this dangerous practice. H. R. Sawe, J. A. Mfinanga, F. H. Ringo, V. Mwafongo, T. A. Reynolds, and M. S. Runyon Copyright © 2015 H. R. Sawe et al. All rights reserved. Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study Mon, 08 Jun 2015 12:10:32 +0000 http://www.hindawi.com/journals/emi/2015/401757/ Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes. Methods. A novel scoring tool (SONET: Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool) was developed and validated in two EDs with both annual volumes exceeding 100,000. Patient care outcomes including the number of left without being seen (LWBS) patients, average length of ED stay, ED 72-hour returns, and mortality were compared under the different crowding statuses. Results. The total number of ED patients, the number of mechanically ventilated patients, and patient acuity levels were independent risk factors affecting ED overcrowding. SONET was derived and found to better differentiate severely overcrowded, overcrowded, and not overcrowded statuses with similar results validated externally. In addition, SONET scores correlated with increased length of ED stay, number of LWBS patients, and ED 72-hour returns. Conclusions. SONET might be a better fit to determine high volume ED overcrowding. ED overcrowding negatively impacts patient care operations and often produces poor patient perceptions of standardized care delivery. Hao Wang, Richard D. Robinson, John S. Garrett, Kellie Bunch, Charles A. Huggins, Katherine Watson, Joni Daniels, Brett Banks, James P. D’Etienne, and Nestor R. Zenarosa Copyright © 2015 Hao Wang et al. All rights reserved. The Burden of Hand Injuries at a Tertiary Hospital in Sub-Saharan Africa Mon, 01 Jun 2015 09:46:29 +0000 http://www.hindawi.com/journals/emi/2015/838572/ Background. Hand injuries are common worldwide and lead to heavy financial losses in terms of treatment, job loss, and time off duty. There is paucity of data on hand injuries in sub-Saharan Africa. The aim of this study was to determine the burden and early outcomes of hand injuries at a tertiary hospital. Method. A descriptive prospective study. Eligible patients were recruited over 5 months and followed up for four weeks. Pain, nerve function, and gross functions of the hand were assessed. Results. In total 138 patients were enrolled out of 2940 trauma patients. Of these, 122 patients returned for follow-up. The majority of the patients were males (83%). Mean age was 26.7 years (SD 12.8). The commonest places of injury occurrence were the workplace (36%), home (28%), and on the road (traffic crushes) (23%). Machines (21.3%) were the commonest agent of injuries; others were knives (10%) and broken glass (10%). Sixty-three (51%) patients still had pain at one month. Conclusions. Hand injuries accounted for 4.7% of all trauma patients. Road traffic crushes and machines were the commonest causes of hand injuries. Men in their 20s were mostly involved. Sensitization for prevention strategies at the workplace may be helpful. P. Makobore, M. Galukande, E. Kalanzi, and S. C. Kijjambu Copyright © 2015 P. Makobore et al. All rights reserved. Peritoneal Breach as an Indication for Exploratory Laparotomy in Penetrating Abdominal Stab Injury: Operative Findings in Haemodynamically Stable Patients Tue, 12 May 2015 13:42:17 +0000 http://www.hindawi.com/journals/emi/2015/407173/ Introduction. Management of haemodynamically stable patients with penetrating abdominal injuries varies from nonoperative to operative management. The aim was to investigate whether peritoneal breach when used as an indication for exploratory laparotomy appropriately identified patients with intra-abdominal visceral injury. Methods. We conducted retrospective cohort study of all patients presenting with PAI at a major trauma centre from January 2007 to December 2011. We measured the incidence of peritoneal breach and correlated this with intra-abdominal visceral injury diagnosed at surgery. Results. 252 patients were identified with PAI. Of the included patients, 71 were managed nonoperatively and 118 operatively. The operative diagnoses included nonperitoneal-breaching injuries, intraperitoneal penetration without organ damage, or intraperitoneal injury with organ damage. The presenting trauma CT scan was reported as normal in 63%, 34%, and 2% of these groups, respectively. The total negative laparotomy/laparoscopy rate for all patients presented with PAI was 21%, almost half of whom had a normal CT scan. Conclusion. We found that peritoneal breach on its own does not necessarily always equate to intra-abdominal visceral injury. Observation with sequential examination for PAI patients with a normal CT scan may be more important than exclusion of peritoneal breach via laparoscopy. Jasmina Kevric, Victor Aguirre, Kate Martin, Dinesh Varma, Mark Fitzgerald, and Charles Pilgrim Copyright © 2015 Jasmina Kevric et al. All rights reserved. Isolated T Wave Inversion in Lead aVL: An ECG Survey and a Case Report Thu, 09 Apr 2015 11:52:31 +0000 http://www.hindawi.com/journals/emi/2015/250614/ Background. Computerized electrocardiogram (ECG) analysis has been of tremendous help for noncardiologists, but can we rely on it? The importance of ST depression and T wave inversions in lead aVL has not been emphasized and not well recognized across all specialties. Objective. This study’s goal was to analyze if there is a discrepancy of interpretation by physicians from different specialties and a computer-generated ECG reading in regard to a TWI in lead aVL. Methods. In this multidisciplinary prospective study, a single ECG with isolated TWI in lead aVL that was interpreted by the computer as normal was given to all participants to interpret in writing. The readings by all physicians were compared by level of education and by specialty to one another and to the computer interpretation. Results. A total of 191 physicians participated in the study. Of the 191 physicians 48 (25.1%) identified and 143 (74.9%) did not identify the isolated TWI in lead aVL. Conclusion. Our study demonstrated that 74.9% did not recognize the abnormality. New and subtle ECG findings should be emphasized in their training so as not to miss significant findings that could cause morbidity and mortality. Getaw Worku Hassen, Ana Costea, Claire Carrazco, Tsion Frew, Anand Swaminathan, Jason Feliberti, Roger Chirurgi, Tennyson Smith, Alice Chen, Sarah Thompson, Neola Gushway-Henry, Bonnie Simmons, George Fernaine, Hossein Kalantari, and Soheila Talebi Copyright © 2015 Getaw Worku Hassen et al. All rights reserved. An Online Tool for Nurse Triage to Evaluate Risk for Acute Coronary Syndrome at Emergency Department Thu, 02 Apr 2015 10:48:26 +0000 http://www.hindawi.com/journals/emi/2015/413047/ Background. To differentiate acute coronary syndrome (ACS) from other causes in patients presenting with chest pain at the emergency department (ED) is crucial and can be performed by the nurse triage. We evaluated the effectiveness of the ED nurse triage for ACS of the tertiary care hospital. Methods. We retrospectively enrolled consecutive patients who were identified as ACS at risk patients by the ED nurse triage. Patients were categorized as ACS and non-ACS group by the final diagnosis. Multivariate logistic analysis was used to predict factors associated with ACS. An online model predictive of ACS for the ED nurse triage was constructed. Results. There were 175 patients who met the study criteria. Of those, 28 patients (16.0%) were diagnosed with ACS. Patients with diabetes, patients with previous history of CAD, and those who had at least one character of ACS chest pain were independently associated with having ACS by multivariate logistic regression. The adjusted odds ratios (95% confidence interval) were 4.220 (1.445, 12.327), 3.333 (1.040, 10.684), and 12.539 (3.876, 40.567), respectively. Conclusions. The effectiveness of the ED nurse triage for ACS was 16%. The online tool is available for the ED triage nurse to evaluate risk of ACS in individuals. Yuwares Sittichanbuncha, Patchaya Sanpha-asa, Theerayut Thongkrau, Chaiyapon Keeratikasikorn, Noppadol Aekphachaisawat, and Kittisak Sawanyawisuth Copyright © 2015 Yuwares Sittichanbuncha et al. All rights reserved. If Hunters End Up in the Emergency Room: A Retrospective Analysis of Hunting Injuries in a Swiss Emergency Department Thu, 05 Mar 2015 10:38:44 +0000 http://www.hindawi.com/journals/emi/2015/284908/ Aim. to characterize the mechanisms, patterns, and outcomes of nonfatal hunting-related injuries in patients presenting to Bern University Hospital, Switzerland, and compare these to reports of hunting injuries worldwide. Methods. patients presenting with hunting-related injuries to the Emergency Department at Bern University hospital from 2000 to 2014 were identified by retrospectively searching the department database using the keyword “hunt.” Each case was analyzed in terms of the patient age and gender, the mechanism and pattern of injury, and management and patient follow-up. Results. 19 patients were identified. 16 were male with a mean age of 50 years (range: 16–74). Mechanisms of injury included firearm-related injuries, falls, and knife wounds. The most common patterns of injury were head injuries (7), followed by injuries to the upper (5) or lower limb (5) and trunk (2). Over half of the patients were admitted, and nine required emergency surgery. Conclusion. Nonfatal hunting accidents in Bern, Switzerland, are largely caused by firearms and falls and tend to occur in male hunters with a mean age of 50 years. The most common patterns of injury are orthopedic and head injuries, often requiring surgery. These findings are consistent with international studies of nonfatal hunting accidents. Valentina Bestetti, Emma E. Fisher, David S. Srivastava, Meret E. Ricklin, and Aristomenis K. Exadaktylos Copyright © 2015 Valentina Bestetti et al. All rights reserved. Knowledge and Confidence of a Convenience Sample of Australasian Emergency Doctors in Managing Dental Emergencies: Results of a Survey Wed, 04 Mar 2015 09:20:35 +0000 http://www.hindawi.com/journals/emi/2015/148384/ Background. We aimed to determine Australasian Specialist Emergency Physicians’ and Emergency Physicians in Training (Trainees’) level of knowledge of common dental emergencies. We also explored confidence in managing dental emergencies; predictors of confidence and knowledge; and preferences for further dental education. Methods. A questionnaire was distributed electronically (September 2011) and directly (November 2011) to Fellows and Trainees of the Australasian College for Emergency Medicine. It explored demographics, confidence, knowledge of dental emergencies, and educational preferences. Results. Response rate was 13.6% (464/3405) and college members were proportionally represented by region. Fewer than half (186/446; 42%) had received dental training. Sixty-two percent (244/391, 95% CI 57.5–67.1) passed (>50%) a knowledge test. More than 60% incorrectly answered questions on dental fracture, periodontal abscess, tooth eruption dates, and ulcerative gingivitis. Forty percent (166/416) incorrectly answered a question about Ludwig’s Angina. Eighty-three percent (360/433) were confident in the pharmacological management of toothache but only 26% (112/434) confident in recognizing periodontal disease. Knowledge was correlated with confidence (). Interactive workshops were preferred by most (386/415, 93%). Conclusions. The knowledge and confidence of Australasian Emergency Physicians and Trainees in managing dental emergencies are varied, yet correlated. Interactive training sessions in dental emergencies are warranted. Hossein Samaei, Tracey Joy Weiland, Stuart Dilley, and George Alexander Jelinek Copyright © 2015 Hossein Samaei et al. All rights reserved. Outcome of Concurrent Occult Hemothorax and Pneumothorax in Trauma Patients Who Required Assisted Ventilation Mon, 16 Feb 2015 08:26:43 +0000 http://www.hindawi.com/journals/emi/2015/859130/ Background. The management and outcomes of occult hemopneumothorax in blunt trauma patients who required mechanical ventilation are not well studied. We aimed to study patients with occult hemopneumothorax on mechanical ventilation who could be carefully managed without tube thoracostomy. Methods. Chest trauma patients with occult hemopneumothorax who were on mechanical ventilation were prospectively evaluated. The presence of hemopneumothorax was confirmed by CT scanning. Hospital length of stay, complications, and outcome were recorded. Results. A total of 56 chest trauma patients with occult hemopneumothorax who were on ventilatory support were included with a mean age of 36 ± 13 years. Hemopneumothorax was managed conservatively in 72% cases and 28% underwent tube thoracostomy as indicated. 29% of patients developed pneumonia, 16% had Acute Respiratory Distress Syndrome (ARDS), and 7% died. Thickness of hemothorax, duration of mechanical ventilation, and development of ARDS were significantly associated with tube thoracostomy in comparison to no-chest tube group. Conclusions. The majority of occult hemopneumothorax can be carefully managed without tube thoracostomy in patients who required positive pressure ventilation. Tube thoracotomy could be restricted to those who had evidence of increase in the size of the hemothorax or pneumothorax on follow-up chest radiographs or developed respiratory compromise. Ismail Mahmood, Zainab Tawfeek, Ayman El-Menyar, Ahmad Zarour, Ibrahim Afifi, Suresh Kumar, Ruben Peralta, Rifat Latifi, and Hassan Al-Thani Copyright © 2015 Ismail Mahmood et al. All rights reserved. Factors Affecting the Occurrence of Out-of-Hospital Sudden Cardiac Arrest Tue, 03 Feb 2015 07:58:41 +0000 http://www.hindawi.com/journals/emi/2015/281364/ Objective. This paper aims to discover the risk factors for sudden cardiac arrest (out-of-hospital sudden cardiac arrest (OHSCA)) which significantly affect the decision about prioritizing emergency interventions before dispatching medical emergency teams, risk of deterioration of the patient’s condition at the scene, and emergency procedures. Methods. A retrospective study taking into account the international classification of diseases ICD-10 based on an analysis of medical records of Emergency Medical Service in Wroclaw (Poland). Results. The main risk factor of OHSCA is coexistence of external cause leading to illness or death (ICD Group V-10) as well as the occurrence of diseases from the group of endocrine disorders (group E), in particular diabetes. The increase in the risk of OHSCA incidence is affected by nervous system diseases (group G), especially epilepsy of various etiologies, respiratory diseases (group J), mainly COPD, and bronchial asthma or mental and behavioral disorders (group F), with particular emphasis on the drugs issue. The procedure for receiving calls for Emergency Notification Centre does not take into account clinical risk factors for sudden cardiac arrest (SCA). Conclusion. Having knowledge of OHSCA risk factors can increase the efficiency of rescue operations from rapid assessment and provision of appropriate medical team, through effective performance of medical emergency treatment and prevention of SCA or finally reducing the costs. Izabella Uchmanowicz, Wiesław Bartkiewicz, Jarosław Sowizdraniuk, and Joanna Rosińczuk Copyright © 2015 Izabella Uchmanowicz et al. All rights reserved. Factors Associated with Overcrowded Emergency Rooms in Thailand: A Medical School Setting Mon, 29 Sep 2014 00:00:00 +0000 http://www.hindawi.com/journals/emi/2014/576259/ Background. Overcrowding in the emergency department (ED) is a significant public health problem in the US, Europe, and Asia. Factors associated with prolonged length of stay in Thailand are still limited. Methods. This study was conducted at the ED, Ramathibodi Hospital, Mahidol University, Thailand, during July 2011. We selected 300 patients (5.77%) from a total of 5,202 who visited the ED during the study period by simple random sampling. Charts were retrospectively reviewed baseline characteristics, clinical factors, and duration of ED stay. Multivariate logistic regression analyses were performed to identify independent factors for an ED stay more than or equal to 8 hours. Results. We excluded 33 patients (11%) due to incomplete data or stroke fast track enrollment. In total, 267 patients were in the analysis and 53 patients (19.85%) had an ED visit time more than or equal to 8 hours. The number of rounds of blood testing and the type of insurance were associated with prolonged ED stay of more than or equal to 8 hours. Conclusion. ED physicians may need to consider appropriate investigations to shorten the length of stay in the ED. Arrug Wibulpolprasert, Yuwares Sittichanbuncha, Pungkava Sricharoen, Somporn Borwornsrisuk, and Kittisak Sawanyawisuth Copyright © 2014 Arrug Wibulpolprasert et al. All rights reserved. Physiological-Social Scores in Predicting Outcomes of Prehospital Internal Patients Sun, 14 Sep 2014 08:45:32 +0000 http://www.hindawi.com/journals/emi/2014/312189/ The physiological-social modified early warning score system is a newly developed instrument for the identification of patients at risk. The aim of this study was to investigate the feasibility of using the physiological-social modified early warning score system for the identification of patients that needed prehospital emergency care. This prospective cohort study was conducted with 2157 patients. This instrument was used as a measure to detect critical illness in patients hospitalised in internal wards. Judgment by an emergency medicine specialist was used as a measure of standard. Data were analyzed by using receiver operating characteristics curves and the area under the curve with 95% confidence interval. The mean score of the physiological-social modified early warning score system was 2.71 ± 3.55. Moreover, 97.6% patients with the score ≥ 4 needed prehospital emergency services. The area under receiver operating characteristic curve was 0.738 (95% CI = 0.708–0.767). Emergency medical staffs can use PMEWS ≥ 4 to identify those patients hospitalised in the internal ward as at risk patients. The physiological-social modified early warning score system is suggested to be used for decision-making of emergency staff about internal patients’ wards in EMS situations. Abbasali Ebrahimian, Hesam Seyedin, Roohangiz Jamshidi-Orak, and Gholamreza Masoumi Copyright © 2014 Abbasali Ebrahimian et al. All rights reserved. Blood Transfusion Practice before and after Implementation of Type and Screen Protocol in Emergency Department of a University Affiliated Hospital in Iran Tue, 02 Sep 2014 00:00:00 +0000 http://www.hindawi.com/journals/emi/2014/316463/ Background. Blood transfusion is the cornerstone of therapy for many serious and common diseases. This study was performed to assess blood transfusion practice before and after implementation of type and screen protocol in emergency department of a university affiliated hospital in Iran, 2012-2013. Methods. An audit was studied before and after the implementation of type and screen protocol. The number of blood transfusions, time interval between blood order and transfusion, cross-match to transfusion ratio (C/T ratio), and transfusion index (TI) were checked. C/T ratio was used as a measure of the efficiency of blood ordering practice. We compared our results before and after implementation of type and screen protocol. Results. In present study after implementation of type and screen protocol, the time interval between requesting blood transfusion and transfusion of blood has decreased significantly (). The number of blood transfusions required by actual patients increased significantly from 1/2 to 2 (). The average cross-match to transfusion (C/T) ratio got near 1.13 from 1.41 and TI got near 0.91 from 0.58 (). Conclusion. The implementation of T&S protocol has been proven to be safe, efficient, and beneficial to the transfusion practice of our hospital from the current study. Mostafa Alavi-Moghaddam, Mahmoud Bardeh, Hossein Alimohammadi, Habib Emami, and Seyed-Mostafa Hosseini-Zijoud Copyright © 2014 Mostafa Alavi-Moghaddam et al. All rights reserved. Comparison of Clinical Efficacy of Intravenous Acetaminophen with Intravenous Morphine in Acute Renal Colic: A Randomized, Double-Blind, Controlled Trial Wed, 13 Aug 2014 07:29:20 +0000 http://www.hindawi.com/journals/emi/2014/571326/ The aim of this study was to compare the clinical efficacy of intravenous acetaminophen with intravenous morphine in acute renal colic pain management. In this double-blind controlled trial, patients aged 18–55 years, diagnosed with acute renal colic, who met the inclusion and exclusion criteria, were randomized into two groups. First, using the visual analogue scale (VAS), intensity of pain was assessed in both groups. Then, one gram of intravenous acetaminophen or 0.1 mg/kg morphine was infused in 100 mL normal saline to either acetaminophen or morphine group. Intensity of pain was reassessed in 15, 30, 45, and 60 minutes according to VAS criteria. Finally, data from 108 patients were analyzed, 54 patients in each group. No significant difference was observed between the two groups in regard to sex (), mean age (), and baseline visual analogue score (). A repeated measure analysis of variance revealed that the difference between the two treatments was significant (). The VAS reduction at primary endpoint (30 min after drug administration) was significantly higher in the acetaminophen group than in the morphine group (). This study demonstrated that intravenous acetaminophen could be more effective than intravenous morphine in acute renal colic patients’ pain relief. Kambiz Masoumi, Arash Forouzan, Ali Asgari Darian, Maryam Feli, Hassan Barzegari, and Ali Khavanin Copyright © 2014 Kambiz Masoumi et al. All rights reserved. Incidence of Road Traffic Injury and Associated Factors among Patients Visiting the Emergency Department of Tikur Anbessa Specialized Teaching Hospital, Addis Ababa, Ethiopia Thu, 07 Aug 2014 00:00:00 +0000 http://www.hindawi.com/journals/emi/2014/439818/ Background. Road traffic injuries are a major public health issue. The problem is increasing in Africa. Objective. To assess the incidence of road traffic injury and associated factors among patients visiting the emergency department of Tikur Anbessa Specialized Teaching Hospital, Addis Ababa, Ethiopia. Methods. Institutional based cross-sectional study design was conducted. A total of 356 systematically selected study subjects were included in the study. Bivariate and multivariate logistic regressions were performed to identify associated factors with road traffic injury. Odds ratios with 95% confidence interval were computed to determine the level of significance. Results. The incidence of road traffic injury in the emergency department of Tikur Anbessa Specialized Teaching Hospital was 36.8%. Being a farmer (AOR = 3.3; 95% CI = 1.06–10.13), conflict with family members (AOR = 7.7; 95% CI = 3.49–8.84), financial problem (AOR = 9.91; 95% CI = 4.79–6.48), psychological problem (AOR = 17.58; 95% CI = 7.70–12.14), and alcohol use (AOR = 2.98; 95% CI = 1.61–5.27) were independently associated with road traffic injury. Conclusion and Recommendation. In this study the incidence of road traffic injury was high. Alcohol is one of the most significant factors associated with Road Traffic Injury. Thus urgent education on the effect of alcohol is recommended. Bewket Tadesse Tiruneh, Berihun Assefa Dachew, and Berhanu Boru Bifftu Copyright © 2014 Bewket Tadesse Tiruneh et al. All rights reserved. Acute Stroke Care and Thrombolytic Therapy Use in a Tertiary Care Center in Lebanon Wed, 16 Jul 2014 12:59:53 +0000 http://www.hindawi.com/journals/emi/2014/438737/ Background. Thrombolytic therapy (rt-PA) is approved for ischemic stroke presenting within 4.5 hours of symptoms onset. The rate of utilization of rt-PA is not well described in developing countries. Objectives. Our study examined patient characteristics and outcomes in addition to barriers to rt-PA utilization in a tertiary care center in Beirut, Lebanon. Methods. A retrospective chart review of all adult patients admitted to the emergency department during a one-year period (June 1st, 2009, to June 1st, 2010) with a final discharge diagnosis of ischemic stroke was completed. Descriptive analysis was done followed by a comparison of two groups (IV rt-PA and no IV rt-PA). Results. During the study period, 87 patients met the inclusion criteria and thus were included in the study. The mean age was found to be 71.9 years (SD = 11.8). Most patients arrived by private transport (85.1%). Weakness and loss of speech were the most common presenting signs (56.3%). Thirty-three patients (37.9%) presented within 4.5 hours of symptom onset. Nine patients (10.3%, 95% CI (5.5–18.5)) received rt-PA. The two groups (rt-PA versus non rt-PA) had similar outcomes (mortality, symptomatic intracerebral hemorrhage, modified Rankin scale scores, and residual deficit at hospital discharge). Conclusion. In our setting, rt-PA utilization was higher than expected. Delayed presentation was the main barrier to rt-PA administration. Public education regarding stroke is needed to decrease time from symptoms onset to ED presentation and potentially improve outcomes further. Mazen J. El Sayed, Tharwat El Zahran, and Hani Tamim Copyright © 2014 Mazen J. El Sayed et al. All rights reserved. Emergency Sonography Aids Diagnostic Accuracy of Torso Injuries: A Study in a Resource Limited Setting Tue, 08 Jul 2014 08:41:03 +0000 http://www.hindawi.com/journals/emi/2014/978795/ Introduction. Clinical evaluation of patients with torso trauma is often a diagnostic challenge. Extended focused assessment with sonography for trauma (EFAST) is an emergency ultrasound scan that adds to the evaluation of intrathoracic abdominal and pericardial cavities done in FAST (focused assessment with sonography for trauma). Objective. This study compares EFAST (the index test) with the routine standard of care (SoC) investigations (the standard reference test) for torso trauma injuries. Methods. A cross-sectional descriptive study was conducted over a 3-month period. Eligible patients underwent EFAST scanning and the SoC assessment. The diagnostic accuracy of EFAST was calculated using sensitivity and specificity scores. Results. We recruited 197 patients; the M : F ratio was 5 : 1, with mean age of 27 years (SD 11). The sensitivity of EFAST was 100%, the specificity was 97%, the PPV was 87%, and the NPV was 100%. It took 5 minutes on average to complete an EFAST scan. 168 (85%) patients were EFAST-scanned. Most patients (82) (48%) were discharged on the same day of hospitalization, while 7 (4%) were still at the hospital after two weeks. The mortality rate was 18 (9%). Conclusion. EFAST is a reliable method of diagnosing torso injuries in a resource limited context. Charles Edward Tunuka, Robert Wangoda, Sam Bugeza, and Moses Galukande Copyright © 2014 Charles Edward Tunuka et al. All rights reserved. Deliberate Self-Poisoning Presenting to an Emergency Medicine Network in South-East Melbourne: A Descriptive Study Thu, 12 Jun 2014 11:14:05 +0000 http://www.hindawi.com/journals/emi/2014/461841/ Background. Deliberate self-poisoning (DSP) comprises a small but significant proportion of presentations to the emergency department (ED). However, the prevalence and patient characteristics of self-poisoning attendances to EDs in Victoria have not been recently characterised. Aim. To identify and compare the characteristics of adult patients presenting to the three EDs of Monash Health following DSP. Methods. Retrospective clinical audit of adult DSP attendances between 1st July 2009 and 30th June 2012. Results. A total of 3558 cases over three years were identified fulfilling the search criteria. The mean age of patients was 36.3 years with the largest numbers aged between 18 and 30 (38%). About 30% of patients were born overseas. Forty-eight percent were discharged home, 15% were admitted to ED short stay units, and 5% required ICU admission. The median ED length of stay was 359 minutes (IQR 231–607). The most frequently reported substances in DSP were benzodiazepines (36.6%), paracetamol (22.2%), and antipsychotics (12.1%). Exposure to more than one substance for the episode of DSP was common (47%). Conclusion. This information may help identify the trends in poisoning substances used for DSP in Victoria, which in turn may provide clinicians with information to provide more focused and targeted interventions. Asheq Rahman, Catherine Martin, Andis Graudins, and Rose Chapman Copyright © 2014 Asheq Rahman et al. All rights reserved.