Emergency Medicine International http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Management of Fever in Postpneumococcal Vaccine Era: Comparison of Management Practices by Pediatric Emergency Medicine and General Emergency Medicine Physicians Sun, 01 Jun 2014 11:18:53 +0000 http://www.hindawi.com/journals/emi/2014/702053/ Background. The primary objective of this study was to compare management practices of general emergency physicians (GEMPs) and pediatric emergency medicine physicians (PEMPs) for well-appearing young febrile children. Methods. We retrospectively reviewed the charts of well-appearing febrile children aged 3–36 months who presented to a large urban children’s hospital (PED), staffed by PEMPs, or a large urban general emergency department (GED), staffed by GEMPs. Demographics, immunization status, laboratory tests ordered, antibiotic usage, and final diagnoses were collected. Results. 224 cases from the PED and 237 cases from the GED were reviewed. Children seen by PEMPs had significantly less CXRs (23 (10.3%) versus 51 (21.5%), ) and more rapid viral testing done (102 (45%) versus 40 (17%), ). A diagnosis of a viral infection was more common in the PED, while a diagnosis of bacterial infection (including otitis media) was more common in the GED. More GED patients were prescribed antibiotics (41% versus 27%, ), while more PED patients were treated with oseltamivir (6.7% versus 0.4%, ). Conclusions. Our findings identify important differences in the care of the young, well-appearing febrile child by PEMPs and GEMPs and highlight the need for standardization of care. Hnin Khine, David L. Goldman, and Jeffrey R. Avner Copyright © 2014 Hnin Khine et al. All rights reserved. Validation of the Diagnostic Score for Acute Lower Abdominal Pain in Women of Reproductive Age Sun, 25 May 2014 12:32:57 +0000 http://www.hindawi.com/journals/emi/2014/320926/ Background. The differential diagnoses of acute appendicitis obstetrics, and gynecological conditions (OB-GYNc) or nonspecific abdominal pain in young adult females with lower abdominal pain are clinically challenging. The present study aimed to validate the recently developed clinical score for the diagnosis of acute lower abdominal pain in female of reproductive age. Method. Medical records of reproductive age women (15–50 years) who were admitted for acute lower abdominal pain were collected. Validation data were obtained from patients admitted during a different period from the development data. Result. There were 302 patients in the validation cohort. For appendicitis, the score had a sensitivity of 91.9%, a specificity of 79.0%, and a positive likelihood ratio of 4.39. The sensitivity, specificity, and positive likelihood ratio in diagnosis of OB-GYNc were 73.0%, 91.6%, and 8.73, respectively. The areas under the receiver operating curves (ROC), the positive likelihood ratios, for appendicitis and OB-GYNc in the validation data were not significantly different from the development data, implying similar performances. Conclusion. The clinical score developed for the diagnosis of acute lower abdominal pain in female of reproductive age may be applied to guide differential diagnoses in these patients. Kijja Jearwattanakanok, Sirikan Yamada, Watcharin Suntornlimsiri, Waratsuda Smuthtai, and Jayanton Patumanond Copyright © 2014 Kijja Jearwattanakanok et al. All rights reserved. Exploring Factors Affecting Emergency Medical Services Staffs’ Decision about Transporting Medical Patients to Medical Facilities Wed, 07 May 2014 09:57:37 +0000 http://www.hindawi.com/journals/emi/2014/215329/ Transfer of patients in medical emergency situations is one of the most important missions of emergency medical service (EMS) staffs. So this study was performed to explore affecting factors in EMS staffs’ decision during transporting of patients in medical situations to medical facilities. The participants in this qualitative study consisted of 18 EMS staffs working in prehospital care facilities in Tehran, Iran. Data were gathered through semistructured interviews. The data were analyzed using a content analysis approach. The data analysis revealed the following theme: “degree of perceived risk in EMS staffs and their patients.” This theme consisted of two main categories: (1) patient’s condition’ and (2) the context of the EMS mission’. The patent’s condition category emerged from “physical health statuses,” “socioeconomic statuses,” and “cultural background” subcategories. The context of the EMS mission also emerged from two subcategories of “characteristics of the mission” and EMS staffs characteristics’. EMS system managers can consider adequate technical, informational, financial, educational, and emotional supports to facilitate the decision making of their staffs. Also, development of an effective and user-friendly checklist and scoring system was recommended for quick and easy recognition of patients’ needs for transportation in a prehospital situation. Abbasali Ebrahimian, Hesam Seyedin, Roohangiz Jamshidi-Orak, and Gholamreza Masoumi Copyright © 2014 Abbasali Ebrahimian et al. All rights reserved. Drug Utilization Study in Medical Emergency Unit of a Tertiary Care Hospital in North India Mon, 05 May 2014 16:18:15 +0000 http://www.hindawi.com/journals/emi/2014/973578/ Objective. To generate data on the drug utilization pattern and cost of drug treatment and to determine the rationality of prescriptions. Methods. A retrospective cross-sectional drug utilization study was conducted in the medical emergency unit of our hospital. Patient case records were reviewed to extract data on the pattern of drug use. Cost of drug treatment for the emergency visit was calculated by referring to the cost mentioned in Monthly Index of Medical Specialties and the rationality of prescriptions was evaluated using WHO core indicators of drug utilization. Results. 1100 case records were reviewed. Majority of patients received proton pump inhibitors followed by multivitamins. The median cost per prescription was 119.23$ (7.32$–7663.46$). Majority (49.9%) of drug cost was driven by antibiotics alone. An average of 4.9 drugs was prescribed per prescription. There were 14.89% encounters with antibiotics. 75.17% of the drugs were given as injectables and only 29.27% of the drugs were prescribed as generics. Conclusion. There is need to rationalize the drug therapy in terms of increasing prescribing of drugs by generic name and to avoid overuse of PPIs and multivitamins in emergency unit. Also the hospital pharmacy should be encouraged to procure more cost effective alternative antibiotics in future. Sharonjeet Kaur, Sujit Rajagopalan, Navjot Kaur, Nusrat Shafiq, Ashish Bhalla, Promila Pandhi, and Samir Malhotra Copyright © 2014 Sharonjeet Kaur et al. All rights reserved. The Efficacy of Nebulized Furosemide and Salbutamol Compared with Salbutamol Alone in Reactive Airway Disease: A Double Blind Randomized, Clinical Trial Sun, 27 Apr 2014 08:02:10 +0000 http://www.hindawi.com/journals/emi/2014/638102/ We undertook this randomized clinical trial to investigate whether adding furosemide to salbutamol could improve the peak expiratory flow rate (PEFR) and clinical signs of reactive airway disease (RAD) patients. Eligible 18- to 55-year-old patients were randomly divided into intervention and control groups. Patients received 5 mg of nebulized salbutamol and 40 mg of nebulized furosemide in the intervention group and 5 mg of nebulized salbutamol alone in the control group. Patients in both groups received 100 mg of methylprednisolone intravenously stat. Severity of the RAD was estimated before and 45 minutes after treatment in both groups. PEFR was estimated before treatment and at 15, 30, and 45 minutes later. Ninety patients were enrolled, 45 in each group. There were no significant differences between two groups regarding gender, mean age, and normalized PEFR. The baseline mean PEFR was not significantly different between groups (). A repeated measure analysis of variance revealed that the differences between the two treatments was significant () and the behavior of two treatments was not similar across the time (). Comparison of clinical severity of acute RAD revealed no significant differences between groups at the end of the trial (0.06). This study showed that adding nebulized furosemide to salbutamol in RAD patients improved PEFR. Kambiz Masoumi, Arash Forouzan, Maryam Haddadzadeh Shoushtari, Samaneh Porozan, Maryam Feli, Mehdi Fallah Bagher Sheidaee, and Ali Asgari Darian Copyright © 2014 Kambiz Masoumi et al. All rights reserved. Minimizing ED Waiting Times and Improving Patient Flow and Experience of Care Mon, 14 Apr 2014 11:52:14 +0000 http://www.hindawi.com/journals/emi/2014/981472/ We conducted a pre- and postintervention analysis to assess the impact of a process improvement project at the Cambridge Hospital ED. Through a comprehensive and collaborative process, we reengineered the emergency patient experience from arrival to departure. The ED operational changes have had a significant positive impact on all measured metrics. Ambulance diversion decreased from a mean of 148 hours per quarter before changes in July 2006 to 0 hours since April 2007. ED total length of stay decreased from a mean of 204 minutes before the changes to 132 minutes. Press Ganey patient satisfaction scores rose from the 12th percentile to the 59th percentile. ED patient volume grew by 11%, from a mean of 7,221 patients per quarter to 8,044 patients per quarter. Compliance with ED specific quality core measures improved from a mean of 71% to 97%. The mean rate of ED patients that left without being seen (LWBS) dropped from 4.1% to 0.9%. Improving ED operational efficiency allowed us to accommodate increasing volume while improving the quality of care and satisfaction of the ED patients with minimal additional resources, space, or staffing. Assaad Sayah, Loni Rogers, Karthik Devarajan, Lisa Kingsley-Rocker, and Luis F. Lobon Copyright © 2014 Assaad Sayah et al. All rights reserved. Which Dermatological Conditions Present to an Emergency Department in Australia? Mon, 31 Mar 2014 14:25:14 +0000 http://www.hindawi.com/journals/emi/2014/463026/ Background/Objectives. There is minimal data available on the types of dermatological conditions which present to tertiary emergency departments (ED). We analysed demographic and clinical features of dermatological presentations to an Australian adult ED. Methods. The St. Vincent’s Hospital Melbourne (SVHM) ED database was searched for dermatological presentations between 1 January 2009 and 31 December 2011 by keywords and ICD-10 diagnosis codes. The lists were merged, and the ICD-10 codes were grouped into 55 categories for analysis. Demographic and clinical data for these presentations were then analysed. Results. 123 345 people presented to SVHM ED during the 3-year period. 4817 (3.9%) presented for a primarily dermatological complaint. The most common conditions by ICD-10 diagnosis code were cellulitis (, 36.1%), allergy with skin involvement (, 19.5%), boils/furuncles/pilonidal sinuses (, 11.1%), eczema/dermatitis (, 5.7%), and varicella zoster infection (, 3.3%). Conclusion. The burden of dermatological disease presenting to ED is small but not insignificant. This information may assist in designing dermatological curricula for hospital clinicians and specialty training organisations as well as informing the allocation of dermatological resources to ED. Julia Lai-Kwon, Tracey J. Weiland, Alvin H. Chong, and George A. Jelinek Copyright © 2014 Julia Lai-Kwon et al. All rights reserved. E-Bike Injuries: Experience from an Urban Emergency Department—A Retrospective Study from Switzerland Thu, 20 Mar 2014 13:03:22 +0000 http://www.hindawi.com/journals/emi/2014/850236/ Background. Between 2005 and 2012, annual sales of E-bikes in Switzerland increased from 1,792 to 52,941. This continuous and rapid transition from human-powered bicycles to an electric bicycle technology may indicate the increasing demand for low-cost transportation technology in combination with a healthy lifestyle. Material and Methods. In the present study, from April 2012 to September 2013, we retrospectively analysed E-bike accidents treated in the Emergency Department of our hospital by focusing on the following parameters: age, gender, time, period, and cause of the accident, as well as injury and outcome. Results. Patients were predominantly male. The mean age of injured E-cyclists was 47.5 years. The main causes of injury were self-accident. Most injuries were to the head/neck. The mean ISS was 8.48. The outcome showed that 9 patients were treated as outpatients, 9 were inpatients, and 5 patients were kept in the Intensive Care Unit (ICU). Only six patients underwent surgery (S). Discussion. This is the first attempt to evaluate E-bike injuries in Switzerland in an acute hospital setting. Since there is increasing popular preference for E-bikes as means of transportation and injuries to the head or neck are prevalent among E-cyclists, the hazard should not to be underestimated. Sylvana Papoutsi, Luca Martinolli, Christian Tasso Braun, and Aristomenis K. Exadaktylos Copyright © 2014 Sylvana Papoutsi et al. All rights reserved. A Bioclinical Pattern for the Early Diagnosis of Cardioembolic Stroke Wed, 05 Mar 2014 09:05:21 +0000 http://www.hindawi.com/journals/emi/2014/242171/ Background and Scope. Early etiologic diagnosis of ischemic stroke subtype guides acute management and treatment. We aim to evaluate if plasma biomarkers can predict stroke subtypes in the early phase from stroke onset. Methods. Plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP), D-dimer, C-reactive protein, serum albumin, and globulin levels have been investigated in 114 consecutive patients presenting at the emergency room within 6 hours of the ischemic stroke onset. Plasma levels of biomarkers have been correlated with stroke aetiology (based on TOAST criteria) by multivariable logistic regression analysis, adjusted for several covariates. Results. Of the 114 patients, 34 (30%) had cardioembolic stroke, 27 (23%) atherothrombotic stroke, 19 (17%) lacunar stroke, and 34 (30%) stroke of undetermined origin. Patients with cardioembolic stroke had significantly higher levels of NT-proBNP and lower globulin/albumin (G/A) ratio compared with the other subgroups. At multiple logistic regression NT-proBN pg/mL, G/A rati and NIHSS score were independent predictors of cardioembolic stroke with high accuracy of the model, either including (AUC, 0.91) or excluding (AUC, 0.84) atrial fibrillation. Conclusions. A prediction model that includes NT-proBNP, G/A ratio, and NIHSS score can be useful for the early etiologic diagnosis of ischemic stroke. Bruno Zecca, Clara Mandelli, Alberto Maino, Chiara Casiraghi, Giovanbattista Bolla, Dario Consonni, Paola Santalucia, and Giuseppe Torgano Copyright © 2014 Bruno Zecca et al. All rights reserved. Indications of Brain Computed Tomography Scan in Children Younger Than 3 Years of Age with Minor Head Trauma Sun, 02 Mar 2014 12:20:33 +0000 http://www.hindawi.com/journals/emi/2014/248967/ Objective. To investigate the indications to receive brain computed tomography (CT) scan and to define the pathological findings in children younger than three years of age with minor head trauma in emergency departments. Methods. In this study, hospital case notes of 1350 children attending the emergency department of Bitlis State Hospital between January 2011 and June 2013 were retrospectively reviewed. 508 children under 3 years of age with minor head trauma were included in this study. We also asked 37 physicians about the indications for requiring CT in these children. Results. This study included 508 children, 233 (45,9%) of whom were female and 275 were male. In 476 (93,7%) children, the brain CT was completely normal. 89,2% of physicians asked in the emergency department during that time interval reported that they requested CT scan to protect themselves against malpractice litigation. Conclusion. In infants and children with minor head trauma, most CT scans were unnecessary and the fear of malpractice litigation of physicians was the most common reason for requesting a CT. İsmail Gülşen, Hakan Ak, Sevdegül Karadaş, İsmail Demır, Mehmet Deniz Bulut, and Soner Yaycioğlu Copyright © 2014 İsmail Gülşen et al. All rights reserved. Rivaroxaban and Hemostasis in Emergency Care Thu, 20 Feb 2014 11:40:45 +0000 http://www.hindawi.com/journals/emi/2014/935474/ Rivaroxaban is an oral, direct Factor Xa inhibitor, approved for the prevention and treatment of several thromboembolic disorders. Rivaroxaban does not require routine coagulation monitoring and has a short half-life. However, confirmation of rivaroxaban levels may be required in circumstances such as life-threatening bleeding or perioperative management. Here, we explore the management strategies in patients receiving rivaroxaban who have a bleeding emergency or require emergency surgery. Rivaroxaban plasma concentrations can be assessed quantitatively using anti-Factor Xa chromogenic assays, or qualitatively using prothrombin time assays (using rivaroxaban-sensitive reagents). In patients receiving long-term rivaroxaban therapy who require elective surgery, discontinuation of rivaroxaban 20–30 hours beforehand is normally sufficient to minimize bleeding risk. For emergency surgery, we advise against prophylactic use of hemostatic blood products, even with high rivaroxaban concentrations. Temporary rivaroxaban discontinuation is recommended if minor bleeding occurs; for severe bleeding, rivaroxaban withdrawal may be necessary, along with compression or appropriate surgical treatment. Supportive measures such as blood product administration might be beneficial. Life-threatening bleeding demands comprehensive hemostasis management, including potential use of agents such as prothrombin complex concentrate. Patients taking rivaroxaban who require emergency care for bleeding or surgery can be managed using established protocols and individualized assessment. Jürgen Koscielny and Edita Rutkauskaite Copyright © 2014 Jürgen Koscielny and Edita Rutkauskaite. All rights reserved. Emergency Ultrasound Predicting the Need for Therapeutic Laparotomy among Blunt Abdominal Trauma Patients in a Sub-Saharan African Hospital Thu, 13 Feb 2014 10:16:02 +0000 http://www.hindawi.com/journals/emi/2014/793437/ Background. The trauma burden globally accounts for high levels of mortality and morbidity. Blunt abdominal trauma (BAT) contributes significantly to this burden. Patient’s evaluation for BAT remains a diagnostic challenge for emergency physicians. SSORTT gives a score that can predict the need for laparotomy. The objective of this study was to assess the accuracy of SSORTT score in predicting the need for a therapeutic laparotomy after BAT. Method. A prospective observational study. Eligible patients were evaluated for shock and the presence of haemoperitoneum using a portable ultrasound machine. Further evaluation of patients following the standard of care (SOC) protocol was done. The accuracy of SSORTT score in predicting therapeutic laparotomy was compared to SOC. Results. In total, 195 patients were evaluated; M : F ratio was 6 : 1. The commonest injuries were to the head 80 (42%) and the abdomen 54 (28%). A SSORTT score of >2 appropriately identified patients that needed a therapeutic laparotomy (with sensitivity 90%, specificity 90%, PPV 53%, and NPV 98%). The overall mortality rate was 17%. Conclusion. Patients with a SSORTT score of 2 and above had a high likelihood of requiring a therapeutic laparotomy. SSORTT scoring should be adopted for routine practice in low technology settings. P. C. M. Musiitwa, M. Galukande, S. Bugeza, H. Wanzira, and R. Wangoda Copyright © 2014 P. C. M. Musiitwa et al. All rights reserved. Basic Life Support: A Questionnaire Survey to Assess Proficiency of Radiologists and Radiology Residents in Managing Adult Life Support in Cardiopulmonary Arrest and Acute Anaphylactic Reaction Wed, 12 Feb 2014 12:12:07 +0000 http://www.hindawi.com/journals/emi/2014/356967/ The aim of this paper is to assess proficiency of radiologists and radiology residents in managing adult life support in cardiopulmonary arrest and acute anaphylactic reaction. Tariq Alam, Yasir Jamil Khattak, Muhammad Anwar, and Asif Alam Khan Copyright © 2014 Tariq Alam et al. All rights reserved. Boarding Injuries: The Long and the Short of It Mon, 10 Feb 2014 06:19:42 +0000 http://www.hindawi.com/journals/emi/2014/924381/ As the popularity of longboarding increases, trauma centers are treating an increased number of high severity injuries. Current literature lacks descriptions of the types of injuries experienced by longboarders, a distinct subset of the skateboarding culture. A retrospective review of longboarding and skateboarding injury cases was conducted at a level II trauma center from January 1, 2006, through December 31, 2011. Specific injuries in addition to high injury severity factors (hospital and intensive care unit (ICU) length of stay (LOS), Injury Severity Score (ISS), patient treatment options, disposition, and outcome) were calculated to compare longboarder to skateboarder injuries. A total of 824 patients met the inclusion criteria. Skull fractures, traumatic brain injuries (TBI), and intracranial hemorrhage (ICH) were significantly more common among longboard patients than skateboarders (). All patients with an ISS above 15 were longboarders. Hospital and ICU LOS in days was also significantly greater for longboarders compared with skateboarders (). Of the three patients that died, each was a longboarder and each experienced a head injury. Longboard injuries account for a higher incidence rate of severe head injuries compared to skateboard injuries. Our data show that further, prospective investigation into the longboarding population demographics and injury patterns is necessary to contribute to effective injury prevention in this population. Leslie A. Fabian, Steven M. Thygerson, and Ray M. Merrill Copyright © 2014 Leslie A. Fabian et al. All rights reserved. Urgent and Nonurgent Presentations to a Psychiatric Emergency Service in Nigeria: Pattern and Correlates Thu, 30 Jan 2014 11:00:06 +0000 http://www.hindawi.com/journals/emi/2014/479081/ Psychiatric emergencies are acute mental health disturbances that require immediate intervention. However, the emergency department is increasingly being utilised for nonurgent mental health problems, thereby compromising the quality of care available for patients with urgent problems. This study assessed the level and correlates of urgency of mental health problems among patients presenting to an emergency department in Nigeria. The Crisis Triage Rating Scale, Clinical Global Impression Scale and a supplementary questionnaire were administered to 700 attendees at the emergency department of the Federal Neuro-Psychiatric Hospital Yaba, Lagos. Only 29.1% of the presentations constituted an “emergency” 10.9% were “urgent,” while 60% were “nonurgent.” The most common reason for nonurgent presentations was the need for medication refill. On regression analysis, level of urgency of presentations was independently associated with employment status, need for medication refill, substance abuse, suicidality, routine clinic attendance, and use of physical restraint before presentation. The majority of visits to the emergency department are for apparently “nonurgent problems.” However in a resource-poor setting, the emergency department may be the only safety net for the attendees. Our findings point to a need for education of service users and policy shifts in mental health care financing and organisation. Increase Ibukun Adeosun, Abosede Adekeji Adegbohun, Oyetayo Oyewunmi Jeje, Olufemi Oyeleke Oyekunle, and Modupeola Olugbemisola Omoniyi Copyright © 2014 Increase Ibukun Adeosun et al. All rights reserved. Recent Advances of Hemorrhage Management in Severe Trauma Thu, 30 Jan 2014 07:08:41 +0000 http://www.hindawi.com/journals/emi/2014/638956/ Trauma is one of the most common causes of mortality worldwide with a substantial percentage of deaths resulting secondary to haemorrhages, which are preventable and treatable when adequately managed. This paper offers a review of the current literature on how to successfully resuscitate patients with major haemorrhage. Mohamed El Sayad and Hussein Noureddine Copyright © 2014 Mohamed El Sayad and Hussein Noureddine. All rights reserved. Patients Hospitalized in General Wards via the Emergency Department: Early Identification of Predisposing Factors for Death or Unexpected Intensive Care Unit Admission—A Historical Prospective Wed, 29 Jan 2014 00:00:00 +0000 http://www.hindawi.com/journals/emi/2014/203747/ Background. To identify, upon emergency department (ED) admission, predictors of unexpected death or unplanned intensive care/high dependency units (ICU/HDU) admission during the first 15 days of hospitalization on regular wards. Methods. Prospective cohort study in a medical-surgical adult ED in a teaching hospital, including consecutive patients hospitalized on regular wards after ED visit, and identification of predictors by logistic regression and Cox proportional hazards model. Results. Among 4,619 included patients, 77 (1.67%) target events were observed: 32 unexpected deaths and 45 unplanned transfers to an ICU/HDU. We identified 9 predictors of the target event including the oxygen administration on the ED, unknown current medications, and use of psychoactive drug(s). All predictors put the patients at risk during the first 15 days of hospitalization. A logistic model for hospital mortality prediction (death of all causes) still comprised oxygen administration on the ED, unknown current medications, and the use of psychoactive drug(s) as risk factors. Conclusion. The “use of oxygen therapy on the ED,” the “current use of psychoactive drug(s)”, and the “lack of knowledge of current medications taken by the patients” were important predisposing factors to severe adverse events during the 15 days of hospitalization on regular wards following the ED visit. Thierry Boulain, Isabelle Runge, Nathalie Delorme, Angèle Bouju, and Antoine Valéry Copyright © 2014 Thierry Boulain et al. All rights reserved. The Global Burden of Road Injury: Its Relevance to the Emergency Physician Tue, 21 Jan 2014 07:29:46 +0000 http://www.hindawi.com/journals/emi/2014/139219/ Background. Road traffic crash fatalities in the United States are at the lowest level since 1950. The reduction in crash injury burden is attributed to several factors: public education and prevention programs, traffic safety policies and enforcement, improvements in vehicle design, and prehospital services coupled with emergency and acute trauma care. Globally, the disease burden of road traffic injuries is rising. In 1990, road traffic injuries ranked ninth in the ten leading causes of the global burden of disease. By 2030, estimates show that road traffic injuries will be the fifth leading causes of death in the world. Historically, emergency medicine has played a pivotal role in contributing to the success of the local, regional, and national traffic safety activities focused on crash and injury prevention. Objective. We report on the projected trend of the global burden of road traffic injuries and fatalities and describe ongoing global initiatives to reduce road traffic morbidity and mortality. Discussion. We present key domains where emergency medicine can contribute through international collaboration to address global road traffic-related morbidity and mortality. Conclusion. International collaborative programs and research offer important opportunities for emergency medicine physicians to make a meaningful impact on the global burden of disease. Sharon Chekijian, Melinda Paul, Vanessa P. Kohl, David M. Walker, Anthony J. Tomassoni, David C. Cone, and Federico E. Vaca Copyright © 2014 Sharon Chekijian et al. All rights reserved. Children’s Mental Health Visits to the Emergency Department: Factors Affecting Wait Times and Length of Stay Sun, 19 Jan 2014 07:30:08 +0000 http://www.hindawi.com/journals/emi/2014/897904/ Objective. This study explores the association of patient and emergency department (ED) mental health visit characteristics with wait time and length of stay (LOS). Methods. We examined data from 580 ED mental health visits made to two urban EDs by children aged ≤18 years from April 1, 2004, to March 31, 2006. Logistic regressions identified characteristics associated with wait time and LOS using hazard ratios (HR) with 95% confidence intervals (CIs). Results. Sex (male: , 95% –1.84), ED type (pediatric ED: , 95% –8.39), and triage level (Canadian Triage and Acuity Scale (CTAS) 2: , 95% –5.85) were statistically significant predictors of wait time. ED type (pediatric ED: , 95% –2.46), triage level (CTAS 5: , 95% –3.48), number of consultations (, 95% –0.69), and number of laboratory investigations (, 95% –0.85) predicted LOS. Conclusions. Based on our results, quality improvement initiatives to reduce ED waits and LOS for pediatric mental health visits may consider monitoring triage processes and the availability, access, and/or time to receipt of specialty consultations. Amanda S. Newton, Sachin Rathee, Simran Grewal, Nadia Dow, and Rhonda J. Rosychuk Copyright © 2014 Amanda S. Newton et al. All rights reserved. A Comparison between Emergency Medicine Residency Training Programs in the United States and Saudi Arabia from the Residents’ Perception Sun, 19 Jan 2014 06:56:57 +0000 http://www.hindawi.com/journals/emi/2014/362624/ Objectives. This study was designed to compare the trainees’ perception of emergency medicine (EM) training in the United States (US) and Saudi Arabia (SA) and to identify residents’ levels of confidence and points of satisfaction in education, procedural skills, and work environment. Method. An IRB-exempt anonymous web-based survey was distributed to five EM residency training programs in the USA and three residency regions in SA. Results. 342 residents were polled with a 20% response rate (16.8% USA and 25.8% SA). The Saudi residents responded less positively to the questions about preparation for their boards’ examinations, access to multiple educational resources, and weekly academic activities. The Saudi trainees felt less competent in less common procedures than US trainees. American trainees also more strongly agree that they have more faculty interest in their education compared to the Saudi trainees. The Saudi residents see more patients per hour compared to their US peers. Conclusion. These findings may be due to the differences in training techniques including less formal didactics and simulation experience in SA and more duty hour regulations in the USA. Khaled Alghamdi, Abdulaziz Alburaih, and Mary Jo Wagner Copyright © 2014 Khaled Alghamdi et al. All rights reserved. Imaging and Image Transfer in Emergency Medicine Thu, 19 Dec 2013 09:23:14 +0000 http://www.hindawi.com/journals/emi/2013/952672/ Tobias Lindner, Hein Lamprecht, Efthyvoulos Kyriacou, Raoul Breitkreutz, Stefan Puig, and Aristomenis K. Exadaktylos Copyright © 2013 Tobias Lindner et al. All rights reserved. Does the Integration of Personalized Ultrasound Change Patient Management in Critical Care Medicine? Observational Trials Wed, 18 Dec 2013 12:59:07 +0000 http://www.hindawi.com/journals/emi/2013/946059/ Objective. To test the influence of personalized ultrasound (PersUS) on patient management in critical care. Design of the Study. Prospective, observational, and critical care setting. Four substudies compared PersUS and mobile ultrasound, work distribution, and diagnostic and procedural quality. Patients and Interventions. 640 patient ultrasound exams including 548 focused diagnostic exams and 92 interventional procedures. Main Outcome Measures. Number of studies, physician’s judgement of feasibility, time of usage per patient, and referrals to echo lab. Results. Randomized availability of PersUS increased its application in ICU work shifts more than twofold from 33 to 68 exams mainly for detection and therapy of effusions. Diagnostic and procedural quality was rated as excellent/very good in PersUS-guided puncture in 95% of cases. Integrating PersUS within an initial physical examination of 48 randomized cases in an emergency department, PersUS extended the examination time by 100 seconds. Interestingly, PersUS integration into 53 randomized regular ward rounds of 1007 patients significantly reduced average contact time per patient by 103 seconds from 8.9 to 7.2 minutes. Moreover, it lowered the patient referral rate to an echo lab from 20% to 2% within the study population. Conclusions. We propose the development of novel ultrasound-based clinical pathways by integration of PersUS. Raoul Breitkreutz, Marco Campo delľ Orto, Christian Hamm, Colleen Cuca, Peter M. Zechner, Tanja Stenger, Felix Walcher, and Florian H. Seeger Copyright © 2013 Raoul Breitkreutz et al. All rights reserved. Clinical Scoring for Diagnosis of Acute Lower Abdominal Pain in Female of Reproductive Age Sat, 14 Dec 2013 12:33:35 +0000 http://www.hindawi.com/journals/emi/2013/730167/ Background. Obstetrics and gynecological conditions (OB-GYNc) are difficult to be differentiated from appendicitis in young adult females presenting with acute lower abdominal pain. Timely and correct diagnosis is clinically challenging. Method. A retrospective data analysis was performed on 542 female patients who were admitted to a tertiary care hospital with a chief complaint of acute lower abdominal pain. Diagnostic indicators of appendicitis and OB-GYNc were identified by stepwise multivariable polytomous logistic regression. Diagnostic performances of the scores were tested. Result. The developed clinical score is comprised of (1) guarding or rebound tenderness, (2) pregnancy, (3) sites of abdominal tenderness, (4) leukocytosis, (5) peripheral neutrophils ≥75%, and (6) presence of diarrhea. For diagnosis of appendicitis, the area under the ROC curve was 0.8696, and the sensitivity and specificity were 89.25% and 70.00%. For OB-GYNc, the corresponding values were 0.8450, 66.67%, and 94.85%, respectively. Conclusion. The clinical scoring system can differentiate the diagnosis of acute lower abdominal pain in young adult females. Time spent for diagnosis at the emergency room may be shortened, and the patients would be admitted to the appropriate departments in less time. Kijja Jearwattanakanok, Sirikan Yamada, Watcharin Suntornlimsiri, Waratsuda Smuthtai, and Jayanton Patumanond Copyright © 2013 Kijja Jearwattanakanok et al. All rights reserved. Reducing Radiation Dose in Emergency CT Scans While Maintaining Equal Image Quality: Just a Promise or Reality for Severely Injured Patients? Thu, 05 Dec 2013 13:49:11 +0000 http://www.hindawi.com/journals/emi/2013/984645/ Objective. This study aims to assess the impact of adaptive statistical iterative reconstruction (ASIR) on CT imaging quality, diagnostic interpretability, and radiation dose reduction for a proven CT acquisition protocol for total body trauma. Methods. 18 patients with multiple trauma () were examined either with a routine protocol (), 30% (), or 40% () of iterative reconstruction (IR) modification in the raw data domain of the routine protocol (140 kV, collimation: 40, noise index: 15). Study groups were matched by scan range and maximal abdominal diameter. Image noise was quantitatively measured. Image contrast, image noise, and overall interpretability were evaluated by two experienced and blinded readers. The amount of radiation dose reductions was evaluated. Results. No statistically significant differences between routine and IR protocols regarding image noise, contrast, and interpretability were present. Mean effective dose for the routine protocol was  mSv,  mSv for the IR 30, and  mSv for the IR 40 protocol, that is, 22.1% effective dose reduction for IR 30 () and 30.8% effective dose reduction for IR 40 (). Conclusions. IR does not reduce study interpretability in total body trauma protocols while providing a significant reduction in effective radiation dose. Ulrich Grupp, Max-Ludwig Schäfer, Henning Meyer, Alexander Lembcke, Alexander Pöllinger, Gero Wieners, Diane Renz, Philipp Schwabe, and Florian Streitparth Copyright © 2013 Ulrich Grupp et al. All rights reserved.