ISRN Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Antibiotic Prescriptions for Upper Respiratory Infection in the Emergency Department: A Population-Based Study Mon, 10 Mar 2014 11:54:32 +0000 Study Objective. Antibiotics prescriptions for upper respiratory infections (URI) are not uncommon, but the benefits for these groups had seldom been evaluated. We aimed to utilize a sampled National Health Insurance (NHI) claims data containing one million beneficiaries to explore if the use of antibiotics could reduce the possibility of unscheduled returns. Methods. We identified patients presented to ambulatory clinics with the discharged diagnoses of URI. The prescriptions of antibiotics were identified. We further matched each patient in the antibiotic group to the patient in the control group by selected covariates using a standard propensity score greedy-matching algorithm. The risks of unscheduled revisits were compared between the two groups. Results. A total of 6915140 visits were identified between 2005 and 2010. The proportions of antibiotics prescriptions are similar among these years, ranging from 9.99% to 13.38 %. In the propensity score assignment, 9190 patients (4595 in each group) were further selected. The odds ratio of unscheduled revisits among antibiotics group and control group was 0.92 (95% CI, 0.70–1.22) with value equal to 0.569. Conclusions. Overall, antibiotics prescriptions did not seem to decrease the unscheduled revisits in patients presented to the ED with URI. Emergency physicians should reduce the unnecessary prescriptions and save antibiotics to patients with real benefits. Sheng-Wen Hou, Yi-Kung Lee, Chen-Yang Hsu, Ching-Chih Lee, and Yung-Cheng Su Copyright © 2014 Sheng-Wen Hou et al. All rights reserved. Effects of Full-Moon Definition on Psychiatric Emergency Department Presentations Sun, 12 Jan 2014 16:53:35 +0000 Objectives. The lunar cycle is believed to be related to psychiatric episodes and emergency department (ED) admissions. This belief is held by both mental health professionals and the general population. Previous studies analyzing the lunar effect have yielded inconsistent results. Methods. ED records from two tertiary care hospitals were used to assess the impact of three different definitions of the full-moon period, commonly found in the literature. The full-moon definitions used in this study were 6 hours before and 6 hours after the full moon (a 12-hour model); 12 hours before and 12 hours after the full moon (a 24-hour model); and 24 hours before and after the day of the full moon (a 3-day model). Results. Different significant results were found for each full-moon model. Significantly fewer patients with anxiety disorders presented during the 12-hour and 24-hour models; however, this was not true of the 3-day model. For the 24-hour model, significantly, more patients presented with a diagnosis of personality disorders. Patients also presented with more urgent triage scores during this period. In the 3-day model, no significant differences were found between the full-moon presentations and the non-full-moon presentations. Conclusions. The discrepancies in the findings of full moon studies may relate to different definitions of “full moon.” The definition of the “full moon” should be standardized for future research. Varinder S. Parmar, Ewa Talikowska-Szymczak, Emily Downs, Peter Szymczak, Erin Meiklejohn, and Dianne Groll Copyright © 2014 Varinder S. Parmar et al. All rights reserved. Acute Poisoning Surveillance in Thailand: The Current State of Affairs and a Vision for the Future Tue, 24 Dec 2013 17:38:33 +0000 Acute poisoning is a major public health threat worldwide, including Thailand, a country in Southeast Asia with over 67 million inhabitants. The incidence and characteristics of poisoning in Thailand vary greatly depending on the reporting body. This systematic review aims to provide a comprehensive description of the state of poisoning in Thailand. It identifies common trends and differences in poisoning by reporting centers and regional studies. Almost half of the cases and three-fourths of the deaths involved pesticide poisonings associated with agricultural occupations. However, increasing urbanization has led to an increase in drug and household chemical poisoning. Though the majority of reported poisonings remain intentional, a trend towards unintentional poisonings in pediatric and geriatric populations should not be dismissed. Unique poisonings such as mushroom, botulism, and tetrodotoxin poisonings are also closely related to the Thai lifestyle. Following this extensive review of the Thai poisoning literature, it is apparent that further support of the poison control center in Thailand is needed to improve poisoning surveillance, research, prevention, and intervention. Jutamas Saoraya and Pholaphat Charles Inboriboon Copyright © 2013 Jutamas Saoraya and Pholaphat Charles Inboriboon. All rights reserved. Evaluation of Serum Creatine Kinase and Urinary Myoglobin as Markers in Detecting Development of Acute Renal Failure in Severely Injured Trauma Patients Wed, 25 Sep 2013 13:24:54 +0000 Background. Presence of myoglobinuria, particularly in the early phases of renal failure, and elevation of creatinine kinase are seen to correlate with the development of acute renal failure. Aim. To evaluate the efficiency of serum creatine kinase (CK) and urine myoglobin in assessing development of renal failure. Materials and Method. We prospectively studied trauma patients over a period of 3 months. Samples of 107 patients were routinely analyzed on the 1st, 3rd, and 5th days post trauma, for myoglobinuria and serum CK concentration. Results. 107 patients with median age 28 (4–83) yrs were studied, of which 83.2% were males. 56% had head injury, and 17.1% had high injury severity (ISS > 24). Incidence of renal failure was 9.3%. Myoglobinuria was present in 57 patients on admission, 33 on 3rd day and 22 on the 5th day. The association of myoglobinuria with renal failure was statistically insignificant. The cutoff values of serum CK on the 1st, 3rd, and 5th days were ≥1320 IU/L, ≥1146 IU/L, and ≥1754 IU/L, respectively. Mortality rate was 24 (22.4%), of which 6 had renal failure. Conclusion. Myoglobin is clinically insignificant in the detection of renal failure; serum CK is a sensitive predicting marker for the progression of renal failure following traumatic injury. Arulselvi Subramanian, Deepti Sukheeja, Vivek Trikha, Arbind Kumar Pandey, Venencia Albert, and Ravindra Mohan Pandey Copyright © 2013 Arulselvi Subramanian et al. All rights reserved. Detecting Substance Abuse in the Emergency Department: A 10-Year Comparative Study Thu, 12 Sep 2013 12:49:03 +0000 Aims. We have retrospectively analyzed the variations in the clinical profile of patients with a positive consumption of alcohol and/or drugs of abuse that have been confirmed and treated in the Emergency Department of a Virgen de La Arrixaca University Hospital in Murcia (Spain) after a period of 10 years. Secondly, we have assessed if the use of urine toxicology screen tests had any influence on the improvement of the management and/or referral of these patients to specialized services from the Emergency Department or at the time of discharge from hospital, regardless of the specialist or service where they had been treated. Method. 415 patients were selected in the year 2000 and 452 in the year 2010 who had tested positive for alcohol and drugs, assessing the reason for consultation, specific symptoms, drug used, record, diagnosis, and patient management. Results. The most frequent reasons for going to the Emergency Department was common illness, mainly psychiatric disorders, and the type of drug taken, alcohol. There were no significant differences between both groups, but approximately 50% of the patients were not referred for treatment of the abuse or dependency. Conclusions. The clinical profession should consider measures to improve detection and referral of patients with substance abuse disorders. Fernando Espi Martinez, Joaquin Nieto Munuera, Jose Antonio Noguera Velasco, and Fernando Espi Forcen Copyright © 2013 Fernando Espi Martinez et al. All rights reserved. Early and Rapid Diagnosis with Multislice CT Reduces Lethality in Trauma Patients Requiring Intensive Care: Findings of a Prospective Study Thu, 12 Sep 2013 08:21:04 +0000 Objective. The objective of this study was to investigate if short diagnostic times by MSCT have an influence on lethal outcomes. Methods. In three different patient populations, hospital mortality was examined. Group 1: retrospective data derived from conventional diagnostic methods in the trauma room between 2002 and 2003; group 2: data from the same centre taken prospectively between 2004 and 2010 after modification of the trauma room algorithm; group 3: a reference population from the TraumaRegister DGU (TR-DGU) from 2004 to 2010. Injury severity was determined using the ISS and lethality was predicted on the basis of the RISC. Results. At the singular centre, data from 943 polytraumatised patients requiring intensive care between 2002 and 2010 were examined. With the new trauma room algorithm, lethality was likewise significantly lower (9.1% versus 15%; ) compared to the population from 2002 to 2003, with a comparable ISS (28.5 versus 30.2). The ISS (28.5) was comparable with the TR-DGU (24.9) population and lethality was significantly lower. Conclusion. Early diagnostic approaches using MSCT during the first minutes of trauma room treatment, as an integral part of a stringently timed, highly structured concept, have been found to reduce lethality as compared to the TR-DGU and our own retrospective historical data. This trial is registered with DRKS00005055; TR-DGU-Projekt-ID: 2009-005. Peter Hilbert, Karsten zur Nieden, Ingmar Kaden, Gunther O. Hofmann, and Ralph Stuttmann Copyright © 2013 Peter Hilbert et al. All rights reserved. Depression Symptoms and Risk Factors in Adult Emergency Department Patients: A Multisite Cross-Sectional Prevalence Survey Thu, 05 Sep 2013 13:39:35 +0000 Objectives. To identify the proportion of adult emergency department (ED) patients who screen positive for depression. Secondary aims were to identify factors associated with a positive depression screen and determine predictors of a positive depression screen. Methods. This cross-sectional, prevalence survey of ED patients was conducted at two inner-city hospitals. 350 ED patients were screened for depression using the Patient Health Questionnaire-9 (PHQ-9). Clinical and demographic risk factors were examined through medical records and additional questionnaires. Results. Of 350 participants screened, 50 (14.3%; 95% CI = 11.0–18.4%) screened positive. Independent predictors of depression risk included self-reported depression and/or a previous diagnosis of depression (OR = 8.345; 95% CI = 3.524–19.762), seeing a mental health service provider in the past 6 months (OR = 4.518; 95% CI = 2.107–9.690), and previous discussion about mental health with a local doctor (OR = 2.369; 95% CI = 1.025–5.475). Conclusion. ED patients were found to be at a higher risk of depression than the general population. ED-based depression screening, particularly of high-risk populations, has the potential to increase case detection rates and allow earlier management of these patients. Further research and validation of an ED-based depression screening tool are required. Nancy Khav, Tracey J. Weiland, George A. Jelinek, Jonathan C. Knott, and Michael Salzberg Copyright © 2013 Nancy Khav et al. All rights reserved. The Mortality in Emergency Department Sepsis Score as a Predictor of 1-Month Mortality among Adult Patients with Sepsis: Weighing the Evidence Wed, 07 Aug 2013 11:09:34 +0000 Objective. To evaluate the performance of Mortality in Emergency Department Sepsis (MEDS) score in comparison to biomarkers as a predictor of mortality in adult emergency department (ED) patients with sepsis. Methods. A literature search was performed using PubMed, ScienceDirect, SpringerLink, and Ovid databases. Studies were appraised by using the C2010 Consensus Process for Levels of Evidence for prognostic studies. The respective values for area under the curve (AUC) were obtained from the selected articles. Results. Four relevant articles met the selection process. Three studies defined the 1-month mortality as death occurring within 28 days of ED presentation, while the remaining one subcategorised the outcome measure as (5-day) early and (6- to 30-day) late mortality. In all four studies, the MEDS score performed better than the respective comparators (C-reactive protein, lactate, procalcitonin, and interleukin-6) in predicting mortality with an AUC ranging from 0.78 to 0.89 across the studies. Conclusion. The MEDS score has a better prognostic value than the respective comparators in predicting 1-month mortality in adult ED patients with suspected sepsis. Bayushi Eka Putra and Ling Tiah Copyright © 2013 Bayushi Eka Putra and Ling Tiah. All rights reserved. Early Endoscopy Can Shorten the Duration of Hospitalization in Suspected Variceal Hemorrhage Wed, 24 Jul 2013 09:41:36 +0000 Background. Endoscopic treatment in patients with acute variceal hemorrhage should be performed within 12 hours, but the recommendation is based on the experts’ opinion. Objective. Our study investigated if time to endoscopy was a significant factor that could alter the outcomes of patients with suspected variceal hemorrhage. The primary outcome was the length of hospital stay and the mortality. The secondary outcomes were complications during observation periods. Methods. Patients were included if variceal hemorrhage was suspected in the emergency department. Patients were further divided into early (receiving endoscopy within 12 hours) and delayed groups (receiving endoscopy after 12 hours), and each patient was matched using a standard propensity score greedy-matching algorithm. The primary and secondary outcomes were compared accordingly. Results. 1442 patients met our inclusion criteria and therefore were enrolled for further analysis. In the Cox regression model, log time to endoscopy was not a significant factor. In the propensity score assignment, 566 patients (283 in each group) were further selected into the subcohort (P value = 0.8001). Kaplan-Meier curves showed a discharge benefit favoring the early endoscopy over the control group. The mortality rates and complications were not statistically different between the two groups (P value = 0.0045). Conclusion. Early endoscopy before 12 hours in patients with suspected variceal hemorrhage could result in shorter length of hospitalization without increasing the mortalities and complications. The results would help emergency physicians in decisions making when these patients are encountered. Hong-Lin Guan, Hsin-Yi Lin, Yi-Kung Lee, Chen-Yang Hsu, and Yung-Cheng Su Copyright © 2013 Hong-Lin Guan et al. All rights reserved. Management of Pain in the Emergency Department Thu, 16 May 2013 16:51:17 +0000 Since pain is a primary impetus for patient presentation to the Emergency Department (ED), its treatment should be a priority for acute care providers. Historically, the ED has been marked by shortcomings in both the evaluation and amelioration of pain. Over the past decade, improvements in the science of pain assessment and management have combined to facilitate care improvements in the ED. The purpose of this review is to address selected topics within the realm of ED pain management. Commencing with general principles and definitions, the review continues with an assessment of areas of controversy and advancing knowledge in acute pain care. Some barriers to optimal pain care are discussed, and potential mechanisms to overcome these barriers are offered. While the review is not intended as a resource for specific pain conditions or drug information, selected agents and approaches are mentioned with respect to evolving evidence and areas for future research. Stephen H. Thomas Copyright © 2013 Stephen H. Thomas. All rights reserved. Clinical Findings in Albanian Patients with 2009 Influenza AH1N1 Admitted at the Intensive Care Unit Wed, 08 May 2013 14:49:36 +0000 Due to the ease of cross-continent spread of infectious diseases, the 2009 influenza AH1N1 (H1N1) affected many countries. This observational prospective study looked at Albanian patients admitted with 2009 H1N1 at the ICU of the Department of Infectious Diseases at the University Hospital Center of Tirana, from November 2009 to March 2010. Demographic data, symptoms, comorbidities, and clinical outcomes were collected from each patient. The number of days spent in the ICU was recorded for each patient along with their radiological and laboratory findings, and outcome at discharge. Critical illness occurred in 31 patients admitted with confirmed 2009 H1N1. The median age of patients was 35 years. Five (16.1%) patients required endotracheal intubation; noninvasive oxygen therapy (NIV) was used in 15 (48.4%) patients via nasal tube; and continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) oxygen masks were used in 11 (35.5%) patients. All patients were treated with oseltamivir. Four patients admitted and treated did not survive. Critical illness in the setting of 2009 H1N1 admitted in the ICU predominantly affected young adults. NIV could play a role in treating 2009 influenza H1N1 infection-related hypoxemic respiratory failure that was associated with severe hypoxemia, pneumonia, requirement for prolonged mechanical ventilation, and the frequent use of antiviral therapy. Arben Ndreu, Dhimitër Kraja, Silva Bino, Artan Simaku, Iris Hatibi, Najada Çomo, Arjan Harxhi, Ilir Ohri, Kastriot Shytaj, Entela Kolovani, Hektor Sula, Arben Pilaca, Shane Morrison, Vania Rashidi, and Ervin Çerçiz Mingomataj Copyright © 2013 Arben Ndreu et al. All rights reserved. Self-Limited Pneumoporta in the Era of Computed Tomography: A Case Report and Review of the Literature Mon, 10 Dec 2012 15:10:05 +0000 Pneumoporta in patients with abdominal pain has been thought to be suggestive of fatal underlying conditions, such as mesenteric infarct, requiring emergency treatment. Widespread use of computed tomography (CT) has increased the frequency of detection of pneumoporta in patients with diseases other than mesenteric infarct. The natural course of resolution of pneumoporta has been rarely discussed in the literature and mainly focused on patients with iatrogenic diseases. Herein, we report the case of a 64-year-old woman who presented at our emergency department with positive peritoneal signs and pneumoporta. A 10 cm long segment of resolved ischemic bowel was detected on exploratory laparotomy, and bowel resection was not performed. Follow-up CT performed 62 hours later revealed complete resolution of pneumoporta. The patient was discharged uneventfully and was administered short-term prophylactic therapy with enoxaparin for thromboembolism. The epidemiology, etiology, and resolution of pneumoporta are also reviewed. Yu-Tso Liao, Hong-Shee Lai, Rey-Heng Hu, Po-Huang Lee, and Cheng-Maw Ho Copyright © 2012 Yu-Tso Liao et al. All rights reserved. Challenges of Managing Emergency Ileostomy: Nutrition—A Neglected Aspect Tue, 04 Dec 2012 14:04:22 +0000 Objective. The present study was carried out with an aim to study the nutritional status of patients undergoing emergency ileostomy using simple bedside tools in a developing country. Methods. Nutritional assessment (anthropometry, biochemical, immunological, and dietary) was done within 24–36 hours of admission and 6 weeks postoperatively. Primary endpoint was the study of the nutritional status of the patients with ileostomy. Results. , 47 males with mean age 32 years. Postoperatively 50 (86.2%) patients experienced some complications including those related to ileostomy. Malnutrition varied from 7 (12.1%) using BMI to 54 (93.1%) by triceps skinfold thickness. At 6 weeks, despite adequate nutritional intake, there was a significant decrease in almost all nutritional parameters except serum albumin which was normal in most patients. Factors contributing to weight loss in 41 (70.7%) patients were decreased length of proximal bowel left (), increased ileostomy output (), delayed surgery (), and increased disease severity score (). Conclusion. Majority of patients undergoing emergency ileostomy were malnourished and had significant nutritional depletion despite adequate nutritional support. Serial assessment helps to assess nutritional recovery in these patients. Ravindra Singh Mohil, Nitisha Narayan, S. Sreenivas, Namrata Singh, Abhinav Bansal, and Gulshan Jit Singh Copyright © 2012 Ravindra Singh Mohil et al. All rights reserved. Community Stepdown Care: A Safe Alternative for Selected Elderly Patients Attending Emergency Department? Tue, 04 Dec 2012 14:01:52 +0000 Background. The Community Stepdown Care Initiative attempts to provide right siting of care for elderly emergency department attendees whose main need is rehabilitation. Objectives. The aim of this study was to compare reattendance and rehospitalisation rates, length of stay, medical complication rates, and discharge destination between the community hospital cohort and the acute hospital cohort. Methods. A retrospective cohort study was conducted from June 2007 to November 2008. Results. Two hundred and thirty patients were enrolled in the study. 68 patients were successfully transferred to stepdown care; 162 patients were admitted to acute hospital. The odds ratio of reattendance was similar in both cohorts at 2 weeks, 6 months, and 12 months. The odds ratio of rehospitalisation was similar in both cohorts at 2 weeks, 3 months, 6 months, and 12 months. There was no statistical difference in the medical complication rates between the cohorts. Patients were more likely to be discharged home from the community hospital compared to acute hospital (adjusted OR 4.11, ). 14% of patients from the acute hospital cohort was discharged to community hospital. Conclusions. For selective elderly emergency department attendees whose predominant need is rehabilitation, stepdown care is a safe alternative compared to usual acute hospital care. Chee Kheong Ooi, Chik Loon Foo, Alicia Vasu, and Eillyne Seow Copyright © 2012 Chee Kheong Ooi et al. All rights reserved. The Effects of QuikClot Combat Gauze, Fluid Resuscitation, and Movement on Hemorrhage Control in a Porcine Model Thu, 29 Nov 2012 15:27:11 +0000 The purpose of this study was to compare the effectiveness of QuikClot Combat Gauze (QCG) compared to a control group on hemorrhage control; the amount of crystalloid volume infusion on rebleeding; the effect of movement on hemorrhage. This was a prospective, experimental design. Swine were randomly assigned to either the QCG () or the control group (). Investigators transected the femoral artery and vein in each swine. After one minute of uncontrolled hemorrhage, the hemostatic agent, QCG, was placed into the wound followed by standard wound packing. The control group underwent the same procedures but without a hemostatic agent. After five minutes of direct pressure, a standard pressure dressing was applied. After 30 minutes, dressings were removed, and the wound was observed for rebleeding for 5 minutes. If hemostasis occurred, 5 liters of crystalloid was given over 5 minutes, and the wound was observed for rebleeding for 5 additional minutes. If no bleeding occurred, the extremity on the side of the injury was moved. There were significant differences in the amount of hemorrhage (), the amount of fluid administration (), and the number of movements () between the QCG and control. Don Johnson, Brian Gegel, James Burgert, John Gasko, Carrie Cromwell, Monika Jaskowska, Rachel Steward, and Alexis Taylor Copyright © 2012 Don Johnson et al. All rights reserved. Attitudes and Beliefs towards Patients with Hazardous Alcohol Use: A Systematic Review Wed, 28 Nov 2012 16:35:08 +0000 Objective. To describe emergency department (ED) staff attitudes and beliefs towards patients presenting with hazardous alcohol use and their clinical management. Methods. A search of MEDLINE, EMBASE, CINAHL, SCOPUS from 1990 to 2010, and reference lists from included studies was conducted. Two reviewers independently screened for inclusion and assessed study quality. One reviewer extracted the data and a second checked for completeness and accuracy. Results. Among nine studies four reported varied beliefs on whether screening was worthwhile for identifying hazardous alcohol use (physicians: 42%–88%; nurses: 50%–100%). Physicians in three studies were divided on intervention provision (32%–54% in support of intervention provision) as were nurses in two studies (39% and 64% nurses in support of intervention provision). Referral for treatment was identified in two studies as an important part of ED management (physicians: 62% and 97%; nurses: 95%). Other attitudes and beliefs identified across the studies included concern that asking about alcohol consumption would be seen as obtrusive or offensive, and a perceived lack of time and resources available for providing care and referrals. Conclusions. ED staff had varying attitudes towards ED management of patients with hazardous alcohol use. Investigations into improving clinical care for hazardous alcohol use are needed to optimize ED management for these patients. Neelam Mabood, Hansen Zhou, Kathryn A. Dong, Samina Ali, T. Cameron Wild, and Amanda S. Newton Copyright © 2012 Neelam Mabood et al. All rights reserved. Lipothymia and Syncope—Aetiology and Outcome in a Prehospital Setting: A Retrospective Study Sun, 25 Nov 2012 08:39:04 +0000 Background. A firm aetiology of lipothymia or syncope can be difficult to establish prehospitally. The aim of the study was to investigate patients initially assigned the diagnosis of lipothymia or syncope prehospitally and establish the aetiology of their condition either based on prehospital or in-hospital medical records. Methods. From May 1, 2006 to April 30, 2010, all patients receiving the diagnosis of lipothymia or syncope by the MECU were investigated. If admitted to hospital, the patients’ medical records were investigated to confirm the prehospital diagnosis. Results. Within 17980 MECU runs registered, 678 were assignments in which the patients were diagnosed with lipothymia or syncope (3.8%). 578 patients (85%) were admitted to hospital. 278 of the patients were discharged directly from the emergency department, while 271 were admitted to a ward. 112 patients refused treatment offered by the MECU or at the emergency department, died, or were left at the scene following treatment. 17 were lost to followup. Of all patients investigated, 299 were discharged with the diagnosis of lipothymia or syncope. 250 patients were discharged with other diagnoses. Conclusions. In 44% of the patients presenting with lipothymia or syncope, no other diagnosis was established at the hospital, and no explanatory aetiology was found. Stine T. Zwisler and Søren Mikkelsen Copyright © 2012 Stine T. Zwisler and Søren Mikkelsen. All rights reserved. Ultrasound for the Detection of Pleural Effusions and Guidance of the Thoracentesis Procedure Tue, 20 Nov 2012 08:15:07 +0000 Objective. To review the use of ultrasound for the detection of pleural effusions and guidance of the thoracentesis procedure. Methods. Two clinical cases will be presented in which ultrasound proved beneficial in guiding the diagnosis and management of patients with pleural effusions and respiratory distress. The ultrasound techniques for the evaluation of pleural effusions and performance of the thoracentesis procedure are discussed. A review of the most current literature follows to present the known diagnostic and safety benefits of ultrasound guidance for thoracentesis. Conclusions. Ultrasound improves the diagnostic accuracy for the detection of pleural effusions over standard chest radiographs. Ultrasound can also diagnose a complicated pleural effusion that may be at higher risk for an adverse outcome during a thoracentesis. Optimally, thoracentesis should be performed under direct ultrasound guidance to decrease the complication rate and improve patient safety. Kamila Sikora, Phillips Perera, Thomas Mailhot, and Diku Mandavia Copyright © 2012 Kamila Sikora et al. All rights reserved. Prediction of Repeat Visits by Victims of Intimate Partner Violence to a Level III Trauma Centre Wed, 14 Nov 2012 16:01:05 +0000 Background. The purpose of this study was to describe and contrast the population of persons presenting to a Vancouver hospital emergency department two or more times with those presenting once. Methods. Subjects for this study had disclosed intimate partner violence on at least one visit to Vancouver General Hospital Emergency Department during the study period 1997–2009. We compared sociodemographic characteristics, presenting complaints and disposition on discharge among single versus repeat visitors. Results. We identified 2246 single visitors and 257 repeat visitors. In a multivariate model, repeat visitors to the ER were more likely to be of First Nations (aboriginal) status, odds ratio (OR) 2.29, 95% confidence intervals (1.30–4.01); to have had a history of previous abuse 3.38 (1.88–6.08); to have received threats of homicide 2.98 (1.74–5.08); and to present with mental illness 3.03 (1.59–5.77). Police involvement was protective against repeat visits 0.54 (0.36–0.98). Conclusion. Persons with potential for multiple visits to the emergency room can be characterized by a number of factors, the presence of which should trigger targeted assessment for violence exposure in settings where assessment is not routine. Patricia Janssen and Kathleen Mackay Copyright © 2012 Patricia Janssen and Kathleen Mackay. All rights reserved. Optimizing Transport Time from Accident to Hospital: When to Drive and When to Fly? Tue, 23 Oct 2012 08:30:51 +0000 Objective. In prehospital emergency medicine, rapid transport to a hospital is often required. Transport can be done by ambulance or HEMS (Helicopter Emergency Medical Service). Factors influencing transport time are mostly unknown. This study aims to identify these factors and optimize prehospital transport times. Methods. This is a retrospective study with HEMS data from 2010-2011. Trauma mechanism, patient characteristics, and weather conditions were collected from each transport. Distance to the hospital, predicted transport time, and the actual transport time were calculated. Each factor was analysed to determine influence on transport time. Results. We analysed 732 cases (612 by ambulance and 120 by helicopter) and found no association between mechanism of trauma, age, time of day, or weather conditions on transport time. However, transport by HEMS helicopter was nearly always faster, even at short distances. The average transport time of ambulance transport was 79% (95% CI 77.1–80.3) of target time, while in helicopter transport this was 39% (95% CI 37.4–42.9). Conclusion. This study shows the advantage of the HEMS helicopter in rapid transport from the scene to the hospital. Transport by helicopter was twice as fast as ground transport, independent of trauma mechanism, distance to hospital, or weather conditions. D. V. Weerheijm, M. H. Wieringa, J. Biert, and N. Hoogerwerf Copyright © 2012 D. V. Weerheijm et al. All rights reserved. Emergency Peripartum Hysterectomy: A 10-Year Review Tue, 16 Oct 2012 09:36:02 +0000 Background. Emergency peripartum hysterectomy (EPH), although rare in modern obstetrics, remains a life-saving procedure in cases of severe hemorrhage. Purpose. To determine the incidence, risk factors, indications, outcomes, and complications of EPH performed in a tertiary teaching hospital and to compare the results with other reports in the literature. Methods. The medical records of 13 patients who had undergone EPH, between January 2000 and December 2010, were reviewed retrospectively. Maternal characteristics and characteristics of the present pregnancy and delivery, hysterectomy indications, operative complications, postoperative conditions, and maternal and neonatal outcomes were evaluated. Results. There were 13 EPHs out of 31.767 deliveries, a rate of 0.41 per 1,000 deliveries. Eight hysterectomies were performed after cesarean delivery and five after vaginal delivery. The most common indication for hysterectomy was uterine atony (10/13), followed by placenta previa (2/13). There were one case of intraoperative bladder injury and one case of relaparotomy because of hemoperitoneum. We had one maternal death because of septic shock. There were no cases of neonatal morbidity and mortality. Conclusion. Postpartum hemorrhage is one of the leading causes of maternal mortality and morbidity and represents the most challenging complication that an obstetrician will face. Joana Ferreira Carvalho, Adelaide Cubal, Sílvia Torres, Fernanda Costa, and Olímpia do Carmo Copyright © 2012 Joana Ferreira Carvalho et al. All rights reserved. Teaching Emergency Surgical Skills for Trauma Resuscitation-Mechanical Simulator versus Animal Model Mon, 15 Oct 2012 15:55:05 +0000 Background. Traditionally, surgical skills in trauma resuscitation have been taught using animal models in the advanced trauma life support (ATLS) course. We compare one mechanical model (TraumaMan simulator) as an alternative teaching tool for these skills. Method. Eighteen providers and 14 instructors performed four surgical procedures on TraumaMan and compared educational effectiveness with the porcine model. Evaluation was conducted (Likert system 1: very poor to 5: excellent). The participants indicated if TraumaMan was a suitable (scale 1: not suitable to 4: excellent) ATLS teaching model considering cost, animal ethics concerns, and other factors. Comments were solicited for both models. Results. Overall ratings for educational effectiveness of the 4 skills ranged from 3.58 to 4.36 for the porcine and 3.48 to 4.29 for the TraumaMan model. TraumaMan suitability was rated 3-4 (mean 3.38) by 84% participants. TraumaMan as a substitute for the porcine model was recommended by 85% participants. With no ethical or cost concerns, 44% students and 71% instructors preferred TraumaMan. Considering all factors, TraumaMan was preferred by 78% students and 93% instructors. Conclusions. TraumaMan is a suitable alternative to the porcine model and considering all factors it may be the preferred method for teaching ATLS emergency trauma surgical skills. Jameel Ali, Anne Sorvari, and Anand Pandya Copyright © 2012 Jameel Ali et al. All rights reserved. Patient Use of Tablet Computers to Facilitate Emergency Department Pain Assessment and Documentation Sun, 14 Oct 2012 15:51:43 +0000 Introduction. The goal of this project is to pilot automated pain tracker (APT) hardware/software system allowing patients to indicate their pain levels and whether they want analgesia, using tablet computers. Methods. Patients in an academic emergency department (ED) used a tablet computer (iPad, Apple Computer Company, Cupertino, CA, USA), programmed to allow them to indicate their pain level, whether pain medication was desired, and prompted the subject at regular intervals to indicate their pain level. The iPad was linked to a monitor in the ED's nursing/physician station. The pain assessment information was printed for scanning and inclusion in the ED's electronic medical records (EMR) system. A 5-point Likert scale questionnaire was used to assess the perceptions of patients and nurses about the utility of the APT. Results. The majority of 30 subjects (28 of 30; 93%) agreed or strongly agreed that the number of pain assessments was adequate. All of the subjects indicated the APT was easy to use, and 28 of 30 subjects (93%) thought the APT should be used more in the ED. Conclusions. The benefits of the iPad pain-tracking and reporting-system include patient satisfaction, improved pain care, operational efficiency, and improved pain assessment documentation. Annette O. Arthur, Samantha Whiteside, Loren Brown, Cynthia Minor, and Stephen H. Thomas Copyright © 2012 Annette O. Arthur et al. All rights reserved. Racial Disparities in Healthcare: Are We Prepared for the Future? Brief Report on Emergency Medical Services in a County Health Department in California Sun, 14 Oct 2012 15:50:42 +0000 Demographic trends indicate that ethnic minority populations constitute 25 percent of the current population and will be the majority of the United States population in 2050. Forty percent of the demographic in California are ethnic minorities making encounters between healthcare workers and patients from different cultural backgrounds commonplace. Research also indicates that ethnic minority patients are more likely to utilize emergency medical services as an entry point into the health system due to lack of medical insurance and access to primary care. Our qualitative study attempts to understand health disparities through focus groups with 76 patients and their feedback on the use of emergency medical services. Patients revealed challenges in both service provision and delivery of emergency medical services. Implications include the development of cultural competence training programs and the selection of diverse groups of county emergency medical first responders in California. Ken Russell Coelho and Virginia T. Nguyen Copyright © 2012 Ken Russell Coelho and Virginia T. Nguyen. All rights reserved. Amatoxin: A Review Mon, 03 Sep 2012 10:25:54 +0000 This paper presents a comprehensive review of amatoxin poisoning. The paper discusses the biochemistry of amatoxin, as well as the clinical manifestations of amatoxin ingestion. In addition, the evaluation of the patient with amatoxin ingestion is discussed, along with the treatment—including newer therapy—and the ultimate prognosis of the syndrome. Brandon Allen, Bobby Desai, and Nate Lisenbee Copyright © 2012 Brandon Allen et al. All rights reserved. Challenges Faced by the Intensive Care Unit during a Terrorist Attack: The Riyadh Experience Thu, 30 Aug 2012 12:14:40 +0000 Background. Globally, we are facing a “terror epidemic” with incidences of terrorist attacks on innocent civilians increasing worldwide. The volume and nature of injuries resulting from such attacks challenge even the most sophisticated and well-prepared trauma systems and health institutions. Over seventy percent of terror attacks involve bomb explosions with improvised explosive devices (IEDs) resulting in a unique pattern of injuries to the victims. Here, we present data on the terrorist attacks on the city of Riyadh, Saudi Arabia, between March 1991 to the present and discuss in retrospect the event outcomes and features which may be useful for the preparedness of the intensive care unit (ICU) in the wake of future attacks. Methods. Data from nine hospitals in Riyadh that catered to patients during terrorist strikes were collected retrospectively. Details of the incidents were collected from news media archives. Results. The majority of terror strikes (~80%) involved a bomb blast with the use of explosives. The victims included 148 casualties, 45 hospitalizations, 103 discharges after first aid, and 3 incidences of admission to the critical care unit. Conclusion. Using the Riyadh experience, we analyze data and the series of events in the ICU following terrorist explosions. The analysis provides important insights for the trauma unit so that it is better prepared and organized for such incidents in the future. Abdullah Al-Shimemeri Copyright © 2012 Abdullah Al-Shimemeri. All rights reserved. Comparison of Full Blood Count Parameters Using Capillary and Venous Samples in Patients Presenting to the Emergency Department Thu, 23 Aug 2012 08:25:55 +0000 Full blood count (FBC) analysis is a common investigation done in the emergency department (ED). The aim of this study was to determine the accuracy of bedside FBC analysis using capillary blood samples from a finger stab at point of care (POC) compared to a conventional venous blood sample analysis. A total of 314 consecutive patients presenting to the ED were recruited. After consenting, a sample of the patient’s venous (V) blood was obtained via venepuncture and sent to the haematology laboratory for analysis as standard practice. This was followed immediately by collection of a capillary (C) blood sample from a finger stab which was analysed at site using an automated FBC analyser at POC. Agreement between the paired samples for blood parameters including the total white cell count, hemoglobin, and platelet count was assessed by the statistical method of Bland and Altman using V sample as the gold standard. The results showed a statistically significant deviation between capillary and venous samples only for platelet counts (𝑃<0.001) and haemoglobin (𝑃<0.001). However, the magnitudes of this difference 7.3 × 109/L and 0.5 g/dL respectively, were not clinically significant. The study suggest that the analysis of capillary samples for FBC parameters is a reliable and acceptable alternative to conventional methods with the benefits of being a rapid, convenient, and minimally invasive technique. R. Ponampalam, Stephanie Man Chung Fook Chong, and Sau Chew Tan Copyright © 2012 R. Ponampalam et al. All rights reserved. Paramedics Manage the Airway Easier with Laryngeal Mask Airway Than with Intubation during Simulated CPR Scenarios Fri, 17 Aug 2012 14:22:33 +0000 Objectives. In this study, we investigated whether minimally trained paramedics with no previous experience in securing the airway would be more efficient in placing laryngeal mask airway (LMA) than intubating the trachea with direct laryngoscopy using 2 manikin scenarios: without chest compressions (non-CPR scenario) and with continuous chest compressions (CPR scenario). Methods. One hundred and twenty-four paramedics with no previous experience in managing the airway comprised our study population. Three 20 min lectures on the anatomy of the airway and endotracheal intubation with the Macintosh blade and LMA placement were given. Each participant attempted to insert a LMA or to intubate a manikin with the Macintosh blade using 2 different scenarios: without chest compressions and with continuous chest compressions. Results. All participants managed to place a LMA in both scenarios, but only 85% of them managed to intubate the trachea using the Macintosh blade in the non-CPR and even less than (80%) in the CPR scenario. Insertion of the LMA was statistically significantly faster than intubation with the Macintosh blade in both scenarios (𝑃<0.001). Conclusions. Our results provide evidence that for minimally trained paramedics, LMA insertion is much faster than endotracheal intubation. Eleni Bassiakou, Konstantinos Stroumpoulis, and Theodoros Xanthos Copyright © 2012 Eleni Bassiakou et al. All rights reserved. A Profile of Emergency Departments in Slovenia Thu, 19 Jul 2012 19:01:19 +0000 Objectives. Emergency departments (EDs) are the basic unit of emergency medicine (EM), but there is often significant heterogeneity and differences in ED organization. We sought to describe and characterize EDs in Slovenia. Methods. All EDs open 24/7 to the general public were surveyed using the National ED Inventories survey instrument. Staff were asked about ED characteristics with reference to calendar year 2007. Results. Fifty-five EDs participated (81% response). All EDs treated children and adults. Eleven (20%) of the EDs were hospital based and 44 (80%) were non-hospital based. The median number of annual visits for hospital-based EDs was 21,400 (interquartile range, 19,900–34,200) and 5,000 (interquartile range, 1,100–9,300) for non-hospital-based EDs. All hospital-based EDs had triage to service, and only one was an independent department. Most respondents (76%, 95% CI 64–89%) thought their ED was at good balance or capacity. While hospital-based EDs had high availability of technological resources and ability to treat virtually all emergency types 24/7, these characteristics were less frequent in non-hospital-based EDs. Conclusions. The organization of emergency care in Slovenia is complex, with some variation in the layout, characteristics, and capabilities of its EDs. This initial study establishes a benchmark for future investigations into intra-country comparisons of different types of EDs. Blanka Jaklic, Leana S. Wen, Ashley F. Sullivan, and Carlos A. Camargo Jr. Copyright © 2012 Blanka Jaklic et al. All rights reserved. Caval Aorta Index and Central Venous Pressure Correlation in Assessing Fluid Status! “Ultrasound Bridging the Gap” Sun, 08 Jul 2012 14:25:52 +0000 Accurate body fluid assessment and estimation of fluid status are essential in guiding fluid therapy in emergency setup. This prospective cross-sectional descriptive study conducted to ascertain the effectiveness of inferior vena cava and aorta (IVC/Aorta) index in assessing the fluid status by comparing it with the central venous pressure (CVP). Results showed the mean IVC/Aorta index in patients who had normal CVP range was 1.2 ± 0.12 SD, while in patients with low CVP, the mean index was 0.7 ± 0.09 SD, and, patients with high CVP, the mean index was 1.6 ± 0.05 SD. In conclusion, the sonographic IVC/Aorta index assessment seems to be a quick, simple, noninvasive, and reliable method to access the fluid status in a busy setup like an emergency room. Harshitha Sridhar, Pavan Mangalore, V. P. Chandrasekaran, and Rishya Manikam Copyright © 2012 Harshitha Sridhar et al. All rights reserved.