Advanced Journal of Emergency Medicine最新文献

Introduction: Facial lesions usually have a benign self-limited prognosis, but in rare cases they have a poor outcome. Extranodal natural killer/T-cell lymphoma (ENK/TCL) is a rare aggressive lesion presenting with a midline facial lesion that can easily be misdiagnosed. Diagnosis is often difficult and requires a thorough clinical examination and the use of immunohistochemistry for analysis of biopsies. Such malignancies affecting the head and neck area provide an interesting but difficult diagnosis. The purpose of this article is to report a severe case of ENK/TCL-nasal type in a boy with a previous history of nasal trauma.

Case presentation: An 11-year-old boy was referred to the maxillofacial unit of Sulaimany Teaching Hospital, Iraq, with midline facial destruction. The patient stated that about 6 months prior he had fallen down and suffered nasal trauma; 3 months after the trauma, an asymptomatic ulcer appeared and gradually increased in size. Two biopsies were performed with no conclusive results. In the third biopsy, histology showed atypical lymphoid tissue surrounded by intense necrosis. The diagnosis was confirmed by immunohistochemistry. The treatment of choice was chemotherapy followed by radiotherapy. The patient had a satisfactory response but 2 months later during chemotherapy the patient unfortunately died from a pulmonary embolism.

Conclusion: Suspicious midline ulcerative lesions in the head and neck region must have ENK/TCL considered in the differential diagnosis and repeated biopsies may be necessary to confirm the diagnosis.

Introduction: pain management is an important and challenging issue in emergency medicine. Despite the conduct of several studies on this topic, pain is still handled improperly in many cases.

Objective: This study investigated the effectiveness of low-dose IN ketamine administration in reducing the need for opiates in patients in acute pain resulting from limb injury.

Method: This randomized, double-blind, placebo-controlled trial was conducted to assess the possible effect of low-dose intranasal (IN) ketamine administration in decreasing patients' narcotic need. Patients in emergency department suffering from acute isolated limb trauma were included. One group of patients received 0.5 mg/kg intravenous morphine sulfate and 0.02 ml/kg IN ketamine. The other group received the same dose of morphine sulfate and 0.02 ml/kg IN distilled water. Pain severity was measured using the 11 points numerical rating scale at 0, 10, 30, 60, 120, and 180 minutes.

Results: Ninety-one patients with mean age of 31.59 ± 11.33 years were enrolled (38.8% female). The number of requests for supplemental medication was significantly lower in patients who received ketamine (12 patients (30%)) than those who received placebo (27 patients (67.5%)) (p = 0.001).

Conclusion: It is likely that low-dose IN ketamine is effective in reducing the narcotic need of patients suffering from acute limb trauma.

Introduction: The Ottawa Subarachnoid Hemorrhage rule (OSR) is a clinical decision tool identified for ruling out subarachnoid hemorrhage (SAH) in those patient above 15 years of age who present to the emergency department (ED) with acute onset atraumatic headache.

Objective: The primary objective of this study was to externally validate the OSR in a single national health service (NHS) setting in the UK and secondly, to compare it with our current practice without using a decision rule.

Method: A retrospective review of computerized medical records was done for all patients registered with headaches from January to December 2016. The data were manually charted on a data sheet from individual patient records. Patients fulfilling the preset inclusion and exclusion criteria as per the OSR were enrolled in the analysis. According to the OSR, if patient had any of the 6 criteria enlisted (age > 40 years, neck stiffness/pain, witnessed loss of consciousness, onset during exertion, thunderclap headache, limited neck flexion on examination), further diagnostic decision was required. All patients were followed up for 6 months on the computer system as it gets highlighted if the patient is represented again to the ED or is deceased.

Results: A total of 737 ED visits with acute headache were reviewed for potential eligibility. Out of these, 649 were estimated to be eligible. On excluding 485 patients that could not meet the predetermined inclusion criteria and 19 patients as per the exclusion criteria, 145 (19.7%) patients were included in the analysis. There were 5 cases of SAH, yielding an incidence of 3.4 % (95% CI 1.3 % - 8.3 %). The sensitivity for SAH was 100% (95% CI, 46.3 % - 100 %); specificity of 44.2 % (95% CI, 36 % - 53 %); positive predictive value of 6.02 % (95% CI 2.2 % - 14.1 %); and negative predictive value of 100% (95% CI, 92.7 % - 100%).

Conclusion: Although being poorly specific, the OSR is a highly sensitive, simple tool for ruling out SAH in alert patients with a headache in ED settings.

Introduction: It could be claimed that extended focused assessment with sonography for trauma (e-FAST) is the most important use of ultrasound in every emergency department (ED). It is a rapid, repeatable, non-invasive bedside method that was designed to answer one single question, which is, "whether free fluid is present in the peritoneal, pleural and pericardial cavity or not?" This examination may also be used to evaluate the lungs for pneumothorax.

Objective: The current comparative study was conducted to assess the accuracy and reproducibility of e-FAST performed by emergency medicine residents (EMRs) and radiology consultants (RCs) in multiple trauma patients.

Method: This diagnostic accuracy study was conducted prospectively in patients presenting over a period of 12 months from January 1, 2013, to December 31, 2013 to the ED of Kerala Institute of Medical Sciences (KIMS), Kerala, India. All multiple trauma patients older than 18 years of age presenting within 24 hours of their traumatic event, who underwent both e-FAST and thoracoabdominal computed tomography (CT) scan were included. The e-FAST exams were first performed by the EMRs and then by RCs. The thoracoabdominal CT scan findings were considered as the gold standard. The results were compared between both groups to assess the inter-observer variability. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated both for EMRs and RCs.

Results: In the study period, 150 patients with a mean age of 42.06 ± 18.1 years were evaluated (76.7% male). Only 19 cases (12.7%) had a history of fall from a height, and the others were admitted due to RTA. Thirty-four cases (22.7%) did not require surgery; but the others underwent various interventions. Both EMRs and RCs reported positive findings in 20 cases (13.3%) and negative findings in 130 cases (86.7%). The correlation of e-FAST done by EMRs with that by RCs was 100%. E-FAST exam had a sensitivity of 90.4%, specificity 99.2%, PPV 95.0%, NPV 98.4%, and accuracy 98%, both for EMRs and RCs.

Conclusion: Based on the findings, the sensitivity, specificity, and accuracy of e-FAST exams performed by EMRs were equal to those performed by RCs. It seems that e-FAST performed by EMRs were almost accurate during the initial trauma resuscitation in the ED of a level one trauma center in India.

Introduction: Based on the existing standards, patients presenting to emergency department (ED) should receive a decision in a maximum of 6 hours after admission to ED and leave ED in this time. Unfortunately, most of the time, especially in general and referral hospitals, we witness patients staying in the ED for hours or even days after a decision has been made.

Objective: the present study was performed with the aim of evaluating the causes of patients' prolonged length of stay in ED of one of the major hospitals in Tehran, Iran.

Method: The present cross-sectional action research was carried out in the ED of Imam Khomeini Hospital, Tehran, Iran, in November and December 2016. The studied population consisted of patients who stayed in ED for more than 12 hours. In a panel consist of specialists, semi-structured and open questions were asked from the participants. All the interviews were recorded and converted to text. Effective factors of staying more than 12 hours in ED mentioned by the interviewees were extracted. A checklist of evaluating the causes of more than 12 hours stay in ED was prepared. In the next stage, by daily visit to the ED of the studied hospital, profile of the patients who had stayed in the ED for more than 12 hours was evaluated and the variables determined in the checklist were assessed.

Results: In the present study, 407 patients with the mean age of 54.07±20.18 years (minimum 1 and maximum 113 years) were studied, 270 (65.7%) of which were male. Respectively, 26 (6.4%) were admitted in triage level 1, 203 (49.9%) in triage level 2, 168 (41.3%) in triage level 3, 9 (2.2%) in triage level 4 and 1 (0.2%) in triage level 5. Based on these findings, "services not wanting to transfer patients with decisions to the service" was the most common factor.

Conclusion: In the present study, specialized services not tending to dislocate the patients that have been decided upon to their respective department, a considerable number of complicated patients and patients with advanced underlying illnesses among those presenting to ED, and shortage of beds in specialized departments and ICU, were the most common causes affecting more than 12 hours stay of patients in the studied ED.

Introduction: Most of the patients hospitalized in the emergency department (ED) are in need of transfer to other hospital wards or paraclinic units. This process is called intrahospital transfer (IHT) that may lead to a wide range of complications known as unexpected events (UE).

Objective: In the present study we decided to evaluate the effect of using a pre-designed protocol on decrease of UEs and safety improvement of IHT among patients hospitalized in ED.

Method: The present cross-sectional study was carried out in 2016 in the ED of Imam Khomeini Hospital, Tehran, Iran. All patients with triage levels of 1 and 2 who were in need of temporary or permanent transfer to other departments of the studied treatment center based on clinical indication as decided by the in-charge physician were enrolled in the study. This study was conducted in 3 phases of pre-intervention, intervention and post-intervention. Any UE was recorded in first phase. During intervention phase ED-IHT protocol was prepared and implemented. the checklist of complications and UEs during transfer was filled again and pre- and post-intervention results were compared.

Results: In this study, 207 patients with the mean age of 58.9 ± 20.6 years were evaluated (61.4% male). Demographic data and baseline characteristics of the studied patients in the phases before and after implementation of the protocol has no significant difference. Overall, before implementation of the protocol out of the 105 studied patients, a total of 35 patients (33.3%) were affected by UE during transfer, but after implementation of the protocol this rate decreased to 11 patients (10.8%) out of the 103 studied patients and this decrease was statistically significant (p < 0.001).

Conclusion: Based on the results obtained from this study, it seems that performing the IHT protocol specialized for ED patients has been effective in decreasing UE cases.