Emergency Medicine International http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Analysis of Repeated CT Scan Need in Blunt Head Trauma Tue, 03 Dec 2013 14:05:49 +0000 http://www.hindawi.com/journals/emi/2013/916253/ Background. Computed tomography (CT) is a vital tool in the workup of patients with closed head trauma. The aim of this study was to investigate the necessity of serial CT scans in patients with blunt head trauma. Methods. This is a retrospective study analyzing trauma patients between January and June 2012. Data were analysed by using frequencies, Kolmogorov-Smirnov (K-S), and Chi-square tests. Results. Of the total 351 control Head CTs, it was seen there were no different in 346 (98.6%). In CTs of another 3 patients (0.9%), there were increasing or new, in the other 2 (0.6%) there was a decrease in the pathology present. Of 24 (6.8%) patients who had a hemorrhage in the first CT, there was an increase in the hemorrhage in one of them, a decrease of the pathology in 2 of them. Of 27 (7.7%) patients who had fracture in first CT, 2 had a new intracranial hemorrhage. The relation of the results between the first and second CTs were statistically significant (, test). Conclusion. Repeated CT scans after 6 hours in EDs observation rooms are not necessary if first CT is normal in most situations. Special attention may be needed in patients with an underlying chronic disease. Serkan Emre Eroglu, Ozge Onur, Sefer Ozkaya, Arzu Denızbasi, Hasan Demır, and Cıgdem Ozpolat Copyright © 2013 Serkan Emre Eroglu et al. All rights reserved. Thorax, Trachea, and Lung Ultrasonography in Emergency and Critical Care Medicine: Assessment of an Objective Structured Training Concept Wed, 27 Nov 2013 08:42:14 +0000 http://www.hindawi.com/journals/emi/2013/312758/ Background and Study objective. Focused lung ultrasound (LUS) examinations are important tools in critical care medicine. There is evidence that LUS can be used for the detection of acute thoracic lesions. However, no validated training method is available. The goal of this study was to develop and assess an objective structured clinical examination (OSCE) curriculum for focused thorax, trachea, and lung ultrasound in emergency and critical care medicine (THOLUUSE). Methods. 39 trainees underwent a one-day training course in a prospective educational study, including lectures in sonoanatomy and -pathology of the thorax, case presentations, and hands-on training. Trainees’ pre- and posttest performances were assessed by multiple choice questionnaires, visual perception tests by interpretation video clips, practical performance of LUS, and identification of specific ultrasound findings. Results. Trainees postcourse scores of correct MCQ answers increased from to (mean± SD; ); visual perception skills increased from to (); practical ultrasound skills improved, and correct LUS was performed in 94%. Subgroup analysis revealed that learning success was independent from the trainees’ previous ultrasound experience. Conclusions. THOLUUSE significantly improves theoretical and practical skills for the diagnosis of acute thoracic lesions. We propose to implement THOLUUSE in emergency medicine training. Raoul Breitkreutz, Martina Dutiné, Patrick Scheiermann, Dorothea Hempel, Sandy Kujumdshiev, Hanns Ackermann, Florian Hartmut Seeger, Armin Seibel, Felix Walcher, and Tim Oliver Hirche Copyright © 2013 Raoul Breitkreutz et al. All rights reserved. Roles of Motorcycle Type and Protective Clothing in Motorcycle Crash Injuries Sun, 17 Nov 2013 15:52:36 +0000 http://www.hindawi.com/journals/emi/2013/760205/ Background. The aims of this study were to identify subgroups of motorcyclists with a higher accident risk and evaluate the efficiency of protective clothing for preventing injuries. Methods. A 1-year prospective study of motorcycle crashes was conducted beginning in June 2012. Participants were patients involved in motorcycle crashes and admitted to our emergency department. Results. A total of 226 patients were included in the study. In total, 174 patients were involved in crashes with light motorcycles. Patients involved in a motorcycle accident without a helmet had a higher incidence of head and maxillofacial trauma. Motorcycle jackets were not protective for systemic injuries () or upper extremity fractures (). Motorcycle pants () and motorcycle shoes () were not protective against leg and foot fractures. However, motorcycle protective clothes were protective against soft-tissue injuries (). Conclusion. Riders of heavy motorcycles rode more safely than riders of light motorcycles. Light motorcycle riders were the most vulnerable and comprised the largest percentage of motorcyclists. Helmets may be effective for preventing head and facial injuries. Other protective clothes were not effective against fractures or systemic injuries. Mehmet Ozgür Erdogan, Ozgur Sogut, Sahin Colak, Harun Ayhan, Mustafa Ahmet Afacan, and Dilay Satilmis Copyright © 2013 Mehmet Ozgür Erdogan et al. All rights reserved. What is New and Innovative in Emergency Neurosurgery? Emerging Diagnostic Technologies Provide Better Care and Influence Outcome: A Specialist Review Thu, 14 Nov 2013 14:39:20 +0000 http://www.hindawi.com/journals/emi/2013/568960/ The development of emergency medical services and especially neurosurgical emergencies during recent decades has necessitated the development of novel tools. Although the gadgets that the neurosurgeon uses today in emergencies give him important help in diagnosis and treatment, we still need new technology, which has rapidly developed. This review presents the latest diagnostic tools, which offer precious help in everyday emergency neurosurgery practice. New ultrasound devices make the diagnosis of haematomas easier. In stroke, the introduction of noninvasive new gadgets aims to provide better treatment to the patient. Finally, the entire development of computed tomography and progress in radiology have resulted in innovative CT scans and angiographic devices that advance the diagnosis, treatment, and outcome of the patent. The pressure on physicians to be quick and effective and to avoid any misjudgement of the patient has been transferred to the technology, with the emphasis on developing new systems that will provide our patients with a better outcome and quality of life. Athanasios K. Zisakis, Vassilios Varsos, and Aristomenis Exadaktylos Copyright © 2013 Athanasios K. Zisakis et al. All rights reserved. Location of Sternal Fractures as a Possible Marker for Associated Injuries Wed, 13 Nov 2013 11:08:47 +0000 http://www.hindawi.com/journals/emi/2013/407589/ Introduction. Sternal fractures often occur together with serious and life-threatening additional injuries. This retrospective study was designed to assess concomitant injuries and develop a correlation between fracture location and the severity of injury. Methods. All patients () diagnosed with a fracture of the sternum by means of a CT scan were analysed with respect to accident circumstances, fracture morphology and topography, associated injuries, and outcome. Results. Isolated sternal fractures occurred in 9%. In all other admissions, concomitant injuries were diagnosed: mainly rip fractures (64%), injury to the head (48%), the thoracic spine (38%), lumbar spine (27%), and cervical spine (22%). Predominant fracture location was the manubrium sterni. In these locations, the observed mean ISS was the highest. They were strongly associated with thoracic spine and other chest injuries. Furthermore, the incidence of head injuries was significantly higher. ICU admission was significantly higher in patients with manubrium sterni fractures. Conclusion. Sternal fractures are frequently associated with other injuries. It appears that the fracture location can provide important information regarding concomitant injuries. In particular, in fractures of manubrium sterni, the need for further detailed clinical and radiologic workup is necessary to detect the frequently associated injuries and reduce the increased mortality. Max J. Scheyerer, Stefan M. Zimmermann, Samy Bouaicha, Hans-Peter Simmen, Guido A. Wanner, and Clément M. L. Werner Copyright © 2013 Max J. Scheyerer et al. All rights reserved. Assessment of a New E-Learning System on Thorax, Trachea, and Lung Ultrasound Tue, 12 Nov 2013 14:15:55 +0000 http://www.hindawi.com/journals/emi/2013/145361/ Background. Lung ultrasound has become an emerging tool in acute and critical care medicine. Combined theoretical and hands-on training has been required to teach ultrasound diagnostics. Current computer technology allows for display, explanation, and animation of information in a remote-learning environment. Objective. Development and assessment of an e-learning program for lung ultrasound. Methods. An interactive online tutorial was created. A prospective learning success study was conducted with medical students using a multiple-choice test (Trial A). This e-learning program was used as preparation for a certified course followed by an evaluation of trained doctors (Trial B) by linear analogue scales. Pretests were compared with postcourse tests and sustainability tests as well as a posttest of a one-day custom classroom training. Results. In Trial A, during the learning success study (), the increase of correct answers was 11.7 to 17/20 in the post-test and to 16.6/20 in the sustainability test (relative change 45.1%, ). E-learning almost equalled scores of classroom-based training regarding gain and retention of factual knowledge. In Trial B, nineteen participating doctors found a 79.5% increase of knowledge (median, 95% CI: 69%; 88%). Conclusion. The basics of lung ultrasound can be taught in a highly effective manner using e-learning. Colleen Cuca, Patrick Scheiermann, Dorothea Hempel, Gabriele Via, Armin Seibel, Magnus Barth, Tim O. Hirche, Felix Walcher, and Raoul Breitkreutz Copyright © 2013 Colleen Cuca et al. All rights reserved. Comparison of GlideScope Videolaryngoscopy to Direct Laryngoscopy for Intubation of a Pediatric Simulator by Novice Physicians Thu, 31 Oct 2013 15:22:52 +0000 http://www.hindawi.com/journals/emi/2013/407547/ Objective. To compare novice clinicians’ performance using GlideScope videolaryngoscopy (GVL) to direct laryngoscopy (DL). Methods. This was a prospective, randomized crossover study. Incoming pediatric interns intubated pediatric simulators in four normal and difficult airway scenarios with GVL and DL. Primary outcomes included time to intubation and rate of successful intubation. Interns rated their satisfaction of the devices and chose the preferred device. Results. Twenty-five interns were included. In the normal airway scenario, there were no differences in mean time for intubation with GVL or DL (61.4 versus 67.4 seconds, ) or number of successful intubations (19 versus 18, ). In the difficult airway scenario, interns took longer to intubate with GVL than DL (87.7 versus 61.3 seconds, ), but there were no differences in successful intubations (14 versus 15, ). There was a trend towards higher satisfaction for GVL than DL (7.3 versus 6.4, ), and GVL was chosen as the preferred device by a majority of interns (17/25, 68%). Conclusions. For novice clinicians, GVL does not improve time to intubation or intubation success rates in a pediatric simulator model of normal and difficult airway scenarios. Still, these novice clinicians overall preferred GVL. Joni E. Rabiner, Marc Auerbach, Jeffrey R. Avner, Dina Daswani, and Hnin Khine Copyright © 2013 Joni E. Rabiner et al. All rights reserved. Urinary Tract Infections due to Multidrug-Resistant Enterobacteriaceae: Prevalence and Risk Factors in a Chicago Emergency Department Thu, 31 Oct 2013 11:41:20 +0000 http://www.hindawi.com/journals/emi/2013/258517/ Background. Selection of empiric antibiotics for urinary tract infections (UTIs) has become more challenging because of the increasing rates of multidrug-resistant Enterobacteriaceae (MDRE) infections. Methods. This retrospective study was conducted to determine antibiotic resistance patterns, risk factors, and appropriate empiric antibiotic selection for MDRE UTIs. Adult patients seen in the Emergency Department (ED) with Enterobacteriaceae UTIs during 2008-2009 were identified from review of microbiology records. MDRE were defined as organisms resistant to at least 3 categories of antibiotics. Results. There were 431 eligible patients; 83 (19%) had MDRE UTIs. Resistance rates for individual antibiotics among MDRE UTIs were significantly greater than non-MDRE UTIs: levofloxacin, 72% versus 14%; TMP-SMX, 77% versus 12%; amoxicillin-clavulanate, 35% versus 4%; nitrofurantoin, 21% versus 12%, and ceftriaxone, 20% versus 0%. All Enterobacteriaceae isolates were susceptible to ertapenem (MIC ≤ 2 mg/L). Independent risk factors for MDRE UTI were prior fluoroquinolone use within 3 months (adjusted odds ratio (aOR) 3.64; ), healthcare-associated risks (aOR 2.32; ), and obstructive uropathy (aOR 2.22; ). Conclusion. Our study suggests that once-daily intravenous or intramuscular ertapenem may be appropriate for outpatient treatment of ED patients with MDRE UTI. Thana Khawcharoenporn, Shawn Vasoo, and Kamaljit Singh Copyright © 2013 Thana Khawcharoenporn et al. All rights reserved. Assessment of a Low-Cost Ultrasound Pericardiocentesis Model Tue, 29 Oct 2013 15:03:13 +0000 http://www.hindawi.com/journals/emi/2013/376415/ Introduction. The use of ultrasound during resuscitation is emphasized in the latest European resuscitation council guidelines of 2013 to identify treatable conditions such as pericardial tamponade. The recommended standard treatment of tamponade in various guidelines is pericardiocentesis. As ultrasound guidance lowers the complication rates and increases the patient’s safety, pericardiocentesis should be performed under ultrasound guidance. Acute care physicians actually need to train emergency pericardiocentesis. Methods. We describe in detail a pericardiocentesis ultrasound model, using materials at a cost of about 60 euros. During training courses of focused echocardiography participants tested the phantom and completed a 16-item questionnaire, assessing the model using a visual analogue scale (VAS). Results. Eleven of fourteen questions were answered with a mean VAS score higher than 60% and thus regarded as showing the strengths of the model. Unrealistically outer appearance and heart shape were rated as weakness of the model. A total mean VAS score of all questions of 63% showed that participants gained confidence for further interventions. Conclusions. Our low-cost pericardiocentesis model, which can be easily constructed, may serve as an effective training tool of ultrasound-guided pericardiocentesis for acute and critical care physicians. Marco Campo dell'Orto, Dorothea Hempel, Agnieszka Starzetz, Armin Seibel, Ulf Hannemann, Felix Walcher, and Raoul Breitkreutz Copyright © 2013 Marco Campo dell'Orto et al. All rights reserved. Motorcycle Related Injuries among Rural Dwellers in Irrua, Nigeria: Characteristics and Correlates Sun, 20 Oct 2013 15:41:12 +0000 http://www.hindawi.com/journals/emi/2013/569103/ Background. The escalating use of motorcycle for commercial transportation of commuters and goods has resulted in an increase in morbidity and mortality from road traffic injuries. Objectives. To study the characteristics of motorcycle injuries seen in Irrua, Nigeria. Materials and Methods. This is a one-year prospective study of all patients seen from January 1, 2009, to December 31, 2009. A structured proforma was filled for all consecutive crash victims involving a motorcycle. Results. Motorcycle injuries accounted for 11.6% of attendance in surgical emergency room (142 out of 1,214); 76.8% were males. Amongst victims 47.1% were riders, 42.9%, passengers, and 7.8% pedestrians. Extremity injury accounted for 42.2% while head injury occurred in 21.8%. There were 9 deaths (6.3%). In this study no victim used crash helmet. Conclusion. Banning of motorcycle for commercial use and the introduction of tricycles into rural/suburban comminutes may be an important preventive strategy. A. E. Dongo, E. B. Kesieme, A. Eighemherio, O. Nwokike, E. Esezobor, and E. Alufohai Copyright © 2013 A. E. Dongo et al. All rights reserved. The Impact on Emergency Department Utilization and Patient Flows after Integrating with a General Practitioner Cooperative: An Observational Study Thu, 03 Oct 2013 08:08:31 +0000 http://www.hindawi.com/journals/emi/2013/364659/ Introduction. A new model, an emergency care access point (ECAP) for after-hours emergency care, is emerging in The Netherlands. This study assessed the effect on emergency department (ED) utilization and patient flows. Methods. Routinely recorded clinical ED patient data, covering a six-year period, was collected. Segmented regression analysis was used to analyze after-hours changes over time. Results. 59.182 patients attended the ED before the start of the ECAP and 51.513 patients after, a decrease of 13%. Self-referred ED patients decreased 99.5% (OR 0.003; 95% CI 0.002–0.004). Referred patients increased by 213.4% and ED hospital admissions increased by 20.2%. A planned outpatient follow-up increased by 5.8% (OR 1.968 95% CI 1.870–2.071). The latter changed from fewer contacts to more contacts (OR 1.015 95% CI 1.013–1.017). Consultations at the regional genereral practitioner cooperative (GPC) increased by 26.0% (183.782 versus 232.246). Conclusion. ECAP implementation resulted in a decrease in ED utilization, a near absence of self-referring patients, and a higher probability of hospital admission and clinical follow-up. This suggests either an increase of ED patients with a higher acuity or a lower threshold of admitting referred patients compared to self-referred patients. Overall, increased collaboration with after-hours primary care and emergency care seemed to optimize ED utilization. W. A. M. H. Thijssen, M. Wijnen-van Houts, J. Koetsenruijter, P. Giesen, and M. Wensing Copyright © 2013 W. A. M. H. Thijssen et al. All rights reserved.