Journal of Emergency Medicine, Trauma and Acute Care - Volume 2024, Issue 7

Currently, surgery in children is optimally managed using a multimodal approach aimed at reducing opioid use. Some studies suggest that epidural anesthesia is the gold standard, but it still has limitations due to its short duration with a single injection. Therefore, the latest approach is continuous caudal anesthesia. However, there are currently no systematic review studies on this approach. This research will focus on the administration method and outcomes of continuous caudal anesthesia in children undergoing surgery. We conducted a literature search to compare the effects of continuous caudal anesthesia in pediatric patients based on the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) from 2014 to 2024. Data extracted from the studies included study type, sample size, type of surgery, body weight, age, intervention, initial dose, maintenance dose, catheter location, rescue anesthesia, induction time, postoperative pain assessment, and complications. The risk of bias was assessed using the cross-sectional/prevalence study quality scale. This study included five research studies with a total sample of 142 patients. Different types of surgery and analgesia were used in these studies. All of the studies showed improvement in pain after surgery. Complications such as difficulty breathing, transient unilateral motor weakness, dural tap, bleeding into the tap, and catheter leakage were more commonly related to anesthesia technique and dosage. The continuous caudal epidural approach can be considered a standard anesthesia technique, particularly in children undergoing specific thoracic and abdominal surgeries.

Simultaneous fractures of the acetabular and subtrochanteric femur are relatively uncommon and present a complex clinical challenge. These fractures are often the result of high-energy trauma, such as automobile accidents or falls from a height. Managing both fractures simultaneously is challenging and requires a comprehensive surgical plan to optimize patient outcomes. We highlight the successful management of simultaneous acetabular and subtrochanteric femur fractures through a single surgical approach in a single sitting.

Background: Septic shock remains a critical medical condition with significant morbidity and mortality rates worldwide. Early and accurate risk assessment is crucial for optimizing patient management and improving outcomes. Various clinical indices and biochemical markers have been proposed as predictive tools for assessing the severity of septic shock and its associated morbidity and mortality. The aim of the study was to compare the predictive validity of the MSI (modified shock index), SI (shock index), ASI (age shock index), and qSOFA (quick sequential organ failure assessment) score with metabolic acidosis, anion gap, base deficit, and lactate levels in the assessment of morbidity and mortality outcomes in adult patients diagnosed with septic shock.

Methods: A prospective observational study was conducted in a tertiary care hospital. This study included 264 patients who were diagnosed with sepsis. Ethical approval was obtained from the institutional ethical committee. A data collection sheet was used for collecting data, including both clinical and metabolic parameters. Receiver operating characteristic analysis was performed using coGuide REAP.

Results: The median age of participants was 60 years (IQR (interquantile range): 45–70 years). The predictive validity of metabolic parameters was higher in predicting “mortality” as indicated by the area under the curve (AUC) values (lactate: 0.816, base deficit: 0.816) compared with clinical parameters (ASI: 077, SI: 0.709). The predictive validity of clinical parameters was higher in predicting “morbidity” as indicated by AUC values (ASI: 0.761, MSI: 0.698) compared with metabolic parameters (base deficit: 0.728, anion gap: 0.611).

Conclusions: Predictive validity was higher for clinical parameters related to morbidity and higher for metabolic parameters related to mortality.

Introduction: Catamenial pneumothorax is a rare but potentially life-threatening condition that affects women of reproductive age. It is characterized by the recurrent occurrence of pneumothorax during or around the menstrual period. The pathophysiology of catamenial pneumothorax is not well understood, but is thought to be related to the presence of endometrial tissue in the pleural cavity.

Case Presentation: A 42-year-old woman was referred to our outpatient department for further thoracic surgical treatment. She already had two previous episodes of pneumothorax that occurred during her menstrual period. A chest X-ray revealed a right-sided pneumothorax and she was admitted to the hospital where a chest tube was placed to treat the pneumothorax. CT scan revealed the presence of endometrial tissue under the right diaphragm. The patient underwent a total laparoscopic hysterectomy to remove the source of endometrial tissue. The subdiaphragmatic endometrial tissue was also removed. She subsequently underwent thoracoscopic treatment to treat the pneumothorax.

Conclusion: The aim of this study was to review the clinical features, diagnostic criteria, and treatment options for catamenial pneumothorax. In addition, the study highlights the importance of a multidisciplinary approach to the management of catamenial pneumothorax, involving pulmonologists, gynecologists, and thoracic surgeons. Further studies are needed to optimize the management of this rare condition.

Objectives: The aim of this study was to evaluate the level of paramedics’ knowledge toward first aids of road traffic accidents and to determine the effectiveness of an educational program on paramedics’ knowledge about first aids.

Methods: A quantitative approach using a pre-experimental design was carried out to determine the effectiveness of an educational program on paramedics’ knowledge about first aids. Purposive sampling, which is a non-probability sampling technique, was selected to obtain reliable and representative data from a total of 50 paramedics working at the Immediate Ambulance Division of Medical Operations Department in Al-Diwaniyah city, Iraq. Study instruments consisted of two parts. The first part included the demographic sheet that contained sociodemographic information about the paramedics and included five items. The second part included paramedics’ knowledge about first aids of road traffic accidents according to an Australian version protocol and included three domains that consisted of 26 items. Descriptive and inferential data analyses were used to analyze the study data.

Results: The paramedics’ knowledge about first aids of road traffic accidents was fair in the pre-assessment and good in the post-assessment.

Conclusion: The paramedics’ knowledge about first aids of road traffic accidents was improved after implementation of the educational program in the post-assessment.

Recommendations: This study recommends regularly updating information for paramedics through educational programs that contain updated information and follow global protocols approved by the WHO and the Iraqi Health Organization.

Background: Patient-centered care is a foundation for high-quality healthcare delivery and is recognized by the Institute of Medicine as one of the six key elements of healthcare quality. It is fundamental to improving health outcomes, patient satisfaction, and overall healthcare system performance. In contemporary healthcare, we are encouraged to optimize our practices and deliver patient-centered care by actively seeking and analyzing patient feedback. This study explored patients’ decision to refuse transportation to a medical facility after receiving on-scene pre-hospital emergency treatment.

Methods: A qualitative analysis approach was applied using semi-structured telephone interviews with 210 patients who had requested Hamad Medical Corporation Ambulance Service pre-hospital emergency care from June 15 to August 1, 2023 and decided not to proceed with hospital conveyance. A thematic analysis with inductive coding of the open-ended feedback was performed using Nvivo^® software version 12.

Results: Data saturation was achieved with 32 responses. The thematic analysis revealed five critical themes: “Rationales for using 999 emergency services”, which primarily focused on acute medical needs and the absence of alternative healthcare solutions; “Reasons for declining hospital conveyance”, which included family obligations and previous unsatisfactory encounters at the hospital; “Subsequent steps after declining hospital transportation”, which disclosed that most respondents remained at home after the intervention, while a minority sought further medical consultation through alternative means; “Service satisfaction level”, which was predominantly positive; and “Language barriers”, which highlighted specific challenges during the emergency call-taking process.

Conclusion: The study provided an understanding of the factors influencing patient decision-making in emergency medical contexts. It advocated targeted quality improvement interventions such as gender-responsive services and linguistic inclusivity. These findings highlighted the need for an integrative, patient-centered model that is attuned to the cultural and linguistic intricacies, thereby informing policy and practice to increase the efficacy of emergency medical services in Qatar.

Background: Pain associated with rib fractures can last particularly long. While it is commonly advised in the outpatient setting to anticipate rib fracture pain to improve relatively within a few weeks, there is no evidence to support this statement. The aim of this study was to examine the duration of pain-related disability following single rib fractures based on the objective clinical records.

Methods: This study retrospectively reviews the clinical inpatient and outpatient records of 37 patients with single rib fractures treated conservatively at our multi-hospital healthcare system from January to December 2022. The duration of pain-related disability was deduced based on several criteria documented in the patients' clinical records. Univariate and multivariate analyses of risk factors (patient age, sex, injury severity score, smoking status, fractured rib, and side) were performed to find a potential correlation with the time to pain improvement.

Results: In this study, the clinical data of 22 males and 15 females with a single rib fracture and a mean age of 54.4 years (range 18.3–81.5 years) were assessed. According to the available clinical records, the mean duration of pain-related disability was 3.12 weeks (range 4–54 days). Analysis of risk factors showed a significant correlation between duration of pain and increased injury severity scores.

Conclusion: While prolonged chest pain is common with rib fractures, a patient with a single rib fracture may be advised that their chest pain and associated disability would significantly improve within an average of 3–4 weeks. The severity of associated injuries was associated with a longer time to pain improvement.

Objective: Research in the field of EMS (emergency medical services) has been primarily limited to individual aspects of EMS systems and patient care. However, there is a need for a broad outcome-based analysis of the impacts of the overall system design. The aim of this study was to explore the associations between various EMS system design characteristics and patient outcomes post-hospital discharge.

Methods: Data indicators were obtained according to the characteristics of 30 US EMS systems in large metropolitan areas, which account for 41.5% of the US population. Examples of indicators were the density of unit deployment, the use of ALS (advanced life support) first response, and the accreditation status of the dispatch center. Data were compared with local outcome/mortality data from national healthcare databases. Partial least squares structural equation modeling was used to identify relationships between the variables.

Results: Of the nine latent variables studied, representing 29 individual indicators, local Medicare hospital rating scores (-.366 coefficient, p < 0.001, CI: -.485,-.134) and underlying socioeconomic and public health status (-.334, p < 0.001, CI: -.474, -.138) were the primary latent variables that showed practical significance (overall model R²  = .736). Outcome measures described the relationship between the variables but cannot isolate EMS as the sole causal factor in outcomes.

Conclusions: None of the EMS system-specific characteristics of the variables studied were associated with decreased patient mortality. The only two variables that showed a practically significant outcome were the indicators related to socioeconomic and public health data and the Medicare ratings of local hospitals.

Introduction: The COVID-19 pandemic posed significant global challenges to healthcare systems, necessitating rapid education and training adaptations for frontline workers. In Qatar, Hamad Medical Corporation Ambulance Service (HMCAS) has transitioned to distance learning platforms to ensure the continuing professional development of paramedics. The aim of this study was to evaluate the effectiveness of these online learning platforms in meeting the educational needs of HMCAS paramedics in pre-hospital care.

Methods: A retrospective observational study design was followed using an online survey. Data were collected using a validated tool focused on accessibility, feasibility, and perception of online learning during the pandemic. Descriptive and inferential statistics (ANOVA) were used to estimate differences in satisfaction scores across themes and analyze the data.

Results: The findings revealed that HMCAS paramedics reported high levels of satisfaction (mean 3.93 out of 5) with online learning, citing its ability to meet their educational needs, enhance academic performance, and provide a safe learning environment. However, challenges such as poor internet connectivity, financial constraints, and lack of face-to-face interactions were identified as limitations. ANOVA results indicated that there was higher satisfaction with the online learning program, and that it met their patient care management expectations.

Conclusion: This study highlights the potential of online learning to meet the educational needs of paramedics during a global health crisis. The findings suggest that online learning can be an effective and resilient approach to education and training in future public health emergencies with appropriate quality control measures, improved feedback mechanisms, and strategies to enhance interaction and engagement.

Purpose: Effective face mask ventilation is a life-saving skill. Loss of muscle tone under general anesthesia may lead to tongue fall and pharyngeal collapse and reduce the efficiency of face mask ventilation. It has been suggested that lateral head rotation may improve the efficiency of face mask ventilation. The aim of this study was to compare face mask ventilation in neutral and head-rotated positions in adult patients under general anesthesia.

Methods: This randomized crossover study was conducted on 42 patients of both genders, aged 18–60 years, who were randomly assigned to group NRN (face mask ventilation performed in neutral–rotated–neutral head positions for one minute each) and group RNR (face mask ventilation performed in rotated–neutral–rotated head positions for one minute each). The primary outcome was the expired tidal volume (VTE) measured in both head positions during pressure control mode of ventilation with a peak inspiratory pressure of 15 cmH2O. Secondary outcomes included the number of patients with airway obstruction or low VTE during mask ventilation and the effects of age, height, Mallampati class, and airway obstruction or low VTE on VTE in the head-rotated position.

Results: The mean VTE was significantly higher in the neutral position (637.93 ± 186.62 ml) compared to the head-rotated position (625.30 ± 183.52 ml) (p = 0.036). The VTE was comparable in group NRN and group RNR in neutral (p = 0.455) and head-rotated positions (p = 0.464). The incidence of airway obstruction was similar in both positions and no patient had low VTE during mask ventilation. Age, height, Mallampati class, and airway obstruction or low VTE in neutral position had no effect on VTE in the head-rotated position.

Conclusion: There was a significant decrease in the VTE in the rotated head position compared to the neutral head position during mask ventilation in patients under general anesthesia.

Background: There is a scarcity in the literature on the management of retained bullet injuries (RBIs), and there are no comprehensive treatment guidelines. This study reports a single-center experience in the management of thoracoabdominal RBIs in resource-limited settings.

Patients and Methods: A retrospective study of 103 patients diagnosed with RBIs was conducted between January 2004 and December 2020 at Al-Nasar Hospital in Ibb, Yemen. Clinical demographic data, RBI occurrence and settings, injury characteristics, management, and outcomes were collected and analyzed.

Results: The mean age was 36.0 ± 16.2 years, and most cases (75.7%) were men. Most RBIs occurred during wedding ceremonies (52.4%), while 37 (35.9%) occurred during war and political rallies, and 12 (11.7%) occurred during usual times. RBIs during wedding ceremonies were statistically significant compared with other injury times (p < 0.001). Among the victims, 42.7% were unaware of the injury. The chest wall was the most common site of RBIs (n = 42, 40.8%), followed by the thoracoabdominal area in 28 (27.2%) cases and the back in 15 (14.6%) cases. All patients underwent surgical exploration except for four (3.9%) cases, and chest tube insertion was the most common procedure (n = 42, 40.8%). Four patients (3.9%) were permanently disabled, while nine (8.7%) died in the hospital during or after surgery. Mortality rates were significantly associated with time to hospital arrival, with longer delays resulting in death (p < 0.001).

Conclusion: In this study, RBIs primarily affected adult men during wedding ceremonies, with chest wall injuries being the most common and chest tube insertion being the most common procedure. Mortality rates were higher with delayed hospital admissions. Strategies of prevention initiatives should focus on raising awareness, vigilant law enforcement, and improving prehospital care.

Surfer's myelopathy is a rare, non-traumatic spinal cord injury that presents with acute paraparesis, typically following activities involving back hyperextension, such as surfing. This report describes a 13-year-old boy who developed lower extremity weakness and sensory loss after his first surfing lesson. MRI showed hyperintense T2 signals from T9 to T12, indicating spinal cord ischemia. Treatment included dexamethasone and phenylephrine to maintain a mean arterial pressure of 85 mmHg, enhancing spinal perfusion. The patient's motor function improved with early intervention, and intensive rehabilitation further supported recovery, allowing him to ambulate with minimal assistance within one month. This case highlights the importance of early intervention and rehabilitation in promoting recovery from surfer's myelopathy.