Journal of Emergency Medicine, Trauma and Acute Care - Volume 2023, Issue 2

Gastroduodenal artery (GDA) aneurysm rupture is a rare cause of upper gastrointestinal bleeding, which is often associated with a high mortality rate if diagnosis or intervention is delayed. Here, we report a case of a 70-year-old man who presented with acute, severe, diffuse abdominal pain and bloody vomiting for two days. The abdominal computed tomography (CT) scan revealed a moderate hemoperitoneum and enhancing focal area in the epigastric region, indicating the ruptured GDA aneurysm. An urgent laparotomy confirmed the diagnosis, and the ruptured GDA was successfully treated by ligation. Fortunately, the patient had an uneventful postoperative recovery and was discharged without complications. In conclusion, early diagnosis and intervention are crucial in reducing the mortality rate associated with GDA aneurysm rupture. Although endovascular repair is the preferred treatment modality, surgical repair may be necessary in cases of hemodynamic instability, unamenable anatomy, unavailable equipment, or lack of subspecialty experience. Thus, physicians must be vigilant in identifying the symptoms of this rare condition and act quickly to provide appropriate treatment.

Objective: In this study, we consider the heterogeneity of the results on the prognostic role of red cell distribution width (RDW) in COVID-19, and this study aimed to determine the relationship between RDW and mortality in COVID-19 patients.

Methods: This descriptive-analytical cross-sectional study was conducted on hospitalized COVID-19 patients whose disease was confirmed by PCR test positivity. Demographic characteristics, underlying diseases, and laboratory tests were the study variables. Patient outcomes were defined as in-hospital mortalities. The level of the Red Blood Cell Distribution Width-corpuscular volume (RDW-CV) in complete blood count (CBC) on arrival and the second day of hospitalization of patients and other variables were recorded in the checklist. The in-hospital mortalities were designated as the outcomes of the study.

Results: In this study, 201 patients were included, and the in-hospital mortality was 28 (13.9%). The correlation between variables in predicting in-hospital mortality using univariate regression analysis showed that there is a significant relationship between triage level, chronic lung disease and age, oxygen saturation, lymphocytes, BUN, and Cr CRP with in-hospital mortality; however, this significant relationship with RDW values of the patients on arrival and the first day of the hospitalization as well as △RDW (RDW on arrival – the first-day RDW) was not observed. Finally, based on the multivariate logistic regression model, there was a significant relationship between the triage level, age, and oxygen saturation with in-hospital mortality.

Conclusion: In COVID-19 patients, factors such as triage level, age, and oxygen saturation can play a significant role in predicting in-hospital mortality. The role of RDW in determining the outcome of the disease is still unclear.

Background: The body of evidence on surgical intensive care unit (SICU) mortality and its predictors is still being determined. This study analyzed the significant predicting factors for mortality in SICU patients.

Materials and Methods: The medical records of patients in SICUs at Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, from June 2020 to July 2021, were retrospectively reviewed. Patients were excluded if transferred from other hospitals and not undergoing orthopedics, otolaryngology, obstetrics, and gynecology surgeries.

Results: A total of 276 patients admitted to SICUs were included in this analysis, and 60.5% were men. The mean age was 60.07 ± 17.19 years. The average length of SICU stay was 8.1 ± 10.79 days, and the mortality rate was 23.6%. By univariate analysis, significant predictive factors for mortality rate in SICU patients were acute physiology and chronic health evaluation II (APACHE II) (p < 0.001), Glasgow coma scale (GCS) ≤ 8 (p < 0.001), sequential organ failure assessment (SOFA) score (p < 0.001), serum albumin < 2.5 (p = 0.013), and sepsis or septic shock (p < 0.001). From receiver operating characteristics (ROC) curve analysis to predict mortality, the best cut-off point of APACHE II and SOFA scores were 15.5 and 5.5, respectively. The multivariate logistic regression analysis significantly identified APACHE II > 15, GCS ≤ 8 and SOFA score > 5 as significant predictive factors associated with the mortality rate in SICU patients.

Conclusions: APACHE II > 15, GCS ≤ 8, and SOFA score > 5 are predictive mortality factors in SICU patients. Patients with these factors should be given priority for admission to the SICU when there is a discrepancy between the demand and the supply for SICU beds.

Introduction: Pain is the most common complaint in patients presenting to an emergency department (ED). Providing safe and effective pain management is an essential part and primary goal of initial ED management. It can be challenging, especially with a significant injury such as a humerus fracture or any long-bone injury. The movement of patients to get X-rays or transfer to a special bed can cause additional pain. Patients experiencing greater pain will more likely require extended hospital stays, be slower to mobilize, and experience a lower quality of life-related to their health.

Aim and Objectives: 1. This study aimed to compare the efficacy of ultrasound-guided supraclavicular brachial plexus block and intravenous tramadol in relieving pain in patients with isolated upper limb injuries who are presented to the ED. 2. To study the efficacy and safety of ultrasound-guided supraclavicular brachial plexus block for the management of pain caused due to upper limb injuries in ED.

Methods: A total of 40 patients with isolated upper extremity closed injuries (dislocations and fractures) who were presented to ED were investigated in this study. Eligible patients were asked to choose USG-guided SCB or intravenous tramadol treatment for pain management. For their initial analgesia, participants in Group A were given ultrasound-guided supraclavicular brachial plexus block, while Group B received 50 mg intravenous tramadol for over 10 min. After the treatment, patients were assessed for pain relief at 0 min, 15 min, 30 min, and 1 hour in both groups, and their vitals and pain score were recorded. The duration of pain relief, complication, and usage of rescue drugs was recorded, and the efficacy of both methods was compared. All patients were investigated with an X-ray or CT scan (if required) to confirm their diagnosis. Clinical information was recorded for 60 minutes, and patients were discharged or admitted.

Results: Of the patients who were presented with upper extremity injuries, only 40 were enrolled in this study. USG-guided SCB was performed on Group A (n = 20) patients. Alternatively, Group B (n = 20) patients received intravenous tramadol 50 mg. In Group A, female patients were higher in number. In contrast, the opposite was noted in Group B. Road traffic accidents was considered the most common way of causing injury, and the most common injury was fractures. The shoulder was more commonly injured than the other parts. The mean pain score in Group A patients on arrival was 8.2, while that of Group B patients was 7.1. After the therapy, the mean pain score in Group A was drastically reduced to 2.9; in Group B, it was reduced to only 4.45. Further, the requirement for additional analgesics was higher in the tramadol group than in the ultrasound-guided supraclavicular block group. 23 out of 40 patients were admitted for further care and management.

Conclusion: In patients with upper limb injuries to the ED, ultrasound-guided supraclavicular block can provide better pain relief and be more efficacious than parenteral tramadol treatment.

Diabetic ketoacidosis (DKA) is a common metabolic emergency in diabetic patients encountered by emergency departments (EDs). Euglycemic diabetic ketoacidosis (EDKA) is a rare type of DKA characterized by normal to slightly elevated blood glucose levels. Possible causes of EDKA include fasting, pregnancy, and alcohol consumption.

In this report, we are presenting a case of EDKA associated with the use of empagliflozin, an oral antihyperglycemic medication belonging to the sodium-glucose co-transporter 2 inhibitors (SGLT-2). The case is a 43-year-old diabetic male patient, who presented to the ED complaining of nausea, vomiting, and generalized weakness. Upon history taking, it was found that the patient started taking empagliflozin 10 days ago. Accordingly, appropriate diagnostic tests were requested, and the patient was found to have severe DKA despite normal to slightly elevated blood glucose results. A diagnosis of EDKA was confirmed, and the patient was successfully treated and discharged few days later.

Many reports have linked the use of SGLT-2 inhibitors with an increased risk of developing DKA, especially EDKA. Although the management of DKA and EDKA is similar, it is more challenging to diagnose the latter. We have highlighted these challenges and the most common precipitating factors. Additionally, we highlighted the mechanism for developing EDKA and the appropriate diagnostic approach to follow with diabetic patients using SGLT-2 inhibitors.

Background: With the advent of the Fédération Internationale de Football Association (FIFA) World Cup 2022 in Qatar, all healthcare systems were gearing up for an influx of patients. The Hamad Medical Corporation Ambulance Service (HMCAS) has also refined its patient supply chain (SC) processes to improve ambulance turnaround times (ATATs) at the emergency departments (EDs). International ambulance services (AS) are complex, and these ambulances are equipped with approximately 500 individual items, which include various types of medical consumables and equipment used during emergencies. By organizing individual medical items into stock units called “pre-packs”, according to the needs of the patients and type of clinical interventions, the inventory or stock-taking time of items stored in ambulances can be significantly reduced. Implementing reduced inventory lists of items and standardized pre-pack storage across the ambulance fleet has significantly improved the efficiency and accuracy of ambulance checking, restocking, and recovery time, improving overall ATAT at the ED.

Aim: This study evaluates the staff’s perceived impact of modular pre-pack kits on ambulance restocking processes and ED ATAT.

Methods: In this cross-sectional study, a fit-for-purpose survey was designed and distributed to all operational staff at HMCAS. The survey aims to assess HMCAS staff’s opinions about the implemented LEAN pre-pack system. Cronbach’s alpha was calculated to assess the reliability of the survey. The Mann-Whitney U-test was conducted to compare if there was a difference between the group’s opinions. The Shewhart control chart was created to monitor the impact of the implemented intervention on the ATAT at the ED. IBM-SPSS® (Statistical Package for Social Sciences) Version 26 was utilized for data analysis.

Results: A group of 287 employees with different backgrounds participated and completed the survey. The Cronbach’s alpha was equal to 0.739, indicating a satisfactory level of reliability of the Mann-Whitney U-test. The descriptive analysis and the Shewhart chart revealed that most staff found that the pre-pack concept helped improve LEAN restocking processes, access to clinical applications, and ambulance checks. Overall, this concept matched the international benchmarks for turnaround time.

Conclusion: The pre-pack concept promoted easy and quick processing of clinical applications, restocking procedures, and ambulance checks, and this positively impacted the ATAT at the ED. Further, it improved responses to emergency calls and enhanced access to effective care for patients. This approach also simplified the tasks above when many locum staff is employed on a short-term basis to cover mega-events such as the FIFA World Cup.

Background and Purpose: Pre-hospital emergency healthcare workers face various problems because of the complexities of providing care during emergencies. These challenges can affect their successful performance in achieving their professional goals. To identify these challenges, the present study was conducted to explain the challenges of pre-hospital emergency workers in providing care at the scene.

Materials and Methods: The present qualitative study was conducted at Shahrekord University of Medical Sciences in 2022 using the contractual content analysis method. Twenty pre-hospital emergency workers were selected purposefully, and data were collected using individual in-depth semistructured interviews and analyzed using Granheim and Lundman’s approach.

Results: The findings include three categories (systemic obstacles, society’s cultural ignorance, and religious obstacles) and seven subcategories (manpower-related obstacles, inappropriate and insufficient equipment, lack of attention and support, inconsistency between organizations, disruptive measures of care, wrong attitude and wrong belief, and gender-related barriers) of obstacles that cause emergency healthcare workers to face challenges in providing care at the scene.

Conclusion: The factors that need consideration in strengthening pre-hospital emergency healthcare include improving the training process of students, planning for in-service training of employees, increasing their motivation levels, noticing their psychological issues, developing inter-organizational protocols and policies, and educating, training, and employing women in pre-hospital emergency care.

Background: This study aimed to evaluate the feasibility of preoperative transperineal ultrasound (TPUS) in evaluating perianal abscesses and fistulas under a resource-limited setting and compared it with surgical findings as gold standards.

Material and Methods: A retrospective study conducted between February 2017 and March 2020, involving 85 patients who were presented to the emergency department with suspected perianal suppurative conditions and underwent TPUS with a 4- to 7-MHz curved transducer, were enrolled. Perianal abscesses and fistulas were classified according to the American Gastroenterological Association criteria and Parks’ classification. Data on patients’ characteristics, TPUS findings, and operative findings were analyzed. The sensitivity and accuracy of preoperative TPUS in detecting lesions were assessed and compared with the surgical findings as gold standards.

Result: The mean age of study participants was 32.12 ± 13.83 years and there were 69 (81.2%) men and 16 (18.8%) women. The TPUS findings were consistent with surgical results in 74 out of 85 patients. In 11 out of the 85 cases, preoperative TPUS missed the diagnosis, and in 5 (6.7%) out of 74 cases, TPUS showed other abnormalities. Perianal abscesses, fistula, and mixed abscesses (with fistula or sinus) were observed in 29 (39.2%), 34 (46%), and 6 (8.1%) cases, respectively. The sensitivity, specificity, and overall accuracy of TPUS in detecting perianal abscesses and fistulas were 86%, 100%, and 87%, respectively. TPUS correctly detected all perianal abscesses with their subtypes (sensitivity of 100%, excellent degree of correlation, k = 1). In the case of fistulas, the accuracy of TPUS in detecting subtype fistula was 87.5% (excellent degree of correlation, k = 0.81); however, it showed low sensitivity in identifying suprasphincteric fistula (5/10, 50%). Additionally, the accuracy of TPUS in detecting the number of external openings was 87.5%, with a reasonable degree of correlation (k = 0.78). However, the accuracy of TPUS in detecting the site of internal openings and tracts of the fistula was 82% and 95%, respectively. Within a mean follow-up of 6.571 ± 1.72 months, there was a recurrence in one fistula patient.

Conclusion: Although the TPUS was not precise enough to diagnose suprasphincteric fistulas, it provides good diagnostic accuracy in identifying perianal abscesses and fistulas. Under resource-limited settings where MRI is unavailable or under emergencies, we recommend TPUS as the first diagnostic test for patients with perianal abscesses and fistulas.