Journal of Emergency Medicine, Trauma and Acute Care - الأعداد السابقة

Background: Some measures have been proposed for the prediction of death after trauma; however, there is a lack of studies on this issue in trauma patients. Therefore, this study was conducted to compare the validity of four scales in predicting the death of trauma patients, and we hypothesized that the accuracies of various scales are different.

Methods: This descriptive-analytical study was conducted prospectively on 600 trauma patients admitted at the emergency ward of Imam Khomeini Hospital in Ilam, Ilam province, west of Iran. The subjects were selected by convenience sampling. Data were collected using the checklists developed for trauma patients, including the Full Outline of UnResponsiveness (FOUR) score, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS), and then the data were analyzed using the chi-square test and the area under the receiver operating characteristic curve (AUC).

Results: Among the 600 patients, most of them were male (76.8%), with a mean and standard deviation of the age of 31.16 ± 18.06 years, and road traffic accident was the most common cause of trauma (73%). The FOUR scale was the most valid in predicting the mortality of trauma patients, and its sensitivity, specificity, positive and negative predictive values, and accuracy were equal to 93.2, 94.5, 64.7, 99.2, and 94.3%, respectively. The AUC was equal to 0.938 for the FOUR scale, followed by the RTS (0.787).

Conclusion: Results of the study about the predictive value of the scales for mortality prediction of trauma patients showed that the FOUR scale had the highest accuracy compared to other scales. Thus, for applying this scale in trauma and emergency centers, besides our results, further studies are needed to support the study findings.

Ventricular tachycardia (VT) is a type of broad complex tachycardia originating from a focus in the ventricle. It is one of the four important rhythms which can lead to cardiac arrest. Accurate and timely diagnosis of true VT is the cornerstone for proper management in the emergency department (ED).

We present an interesting case of an electrocardiographic artifact mimicking VT, which led to a diagnostic dilemma in the ED.

Background: Phenol and botulinum toxin type A (BTX-A) injections are two options for treating spasticity with the ability to select a specific spastic muscle and determine the dosage based on spasticity degree. This study intends to compare the efficacy of BTX-A vs. phenol blockade in treating lower limb spasticity and to evaluate the performance improvement in gross motor functional outcomes among adult patients with upper motor neuron (UMN) lesions.

Methods: This randomized, double-blind clinical trial of 28 spastic lower limb adult patients with UMN was diagnosed between March 1, 2017, to April 30, 2019. Patients were randomized in a 1:1 ratio to a “BTX-A injections” or a “Phenol injections” group. The outcomes were measured through assessment spasticity by the Modified Ashworth Scale (MAS), active range of motion (AROM) of lower limb joint by a goniometer, Verbal Rating Scale (VRS), Visual Analog Scale (VAS), and Penn Spasm Frequency Scale (PSFS) as a baseline and post-injection follow-up at 24 hours, 3 weeks, and 3 months.

Results: All 28 randomized patients were analyzed. No significant difference between the two study arms, neither in demographic characteristics nor in MAS, AROM, VRS, VAS, and PSFS parameters prior to the procedures. AROM showed a significant decrease from baseline throughout the study in the phenol group. While in the BTX-A group, they improved significantly at 3 weeks; no more improvement was observed at 3 months, and the differences were statistically significant (p < 0.05). The reduction in MAS, VRS, VAS, and PSFS was statistically significant in each group at 24 hours, 3 weeks, and 3 months after the injection (p < 0.05). However, the differences were not significant between the phenol and BTX-A groups (p > 0.05), except for PSFS at the 3 months of follow-up in the Phenol group (p = 0.01). The need for re-injection at 6 months and 9 months was that 5 patients vs. 0 patients (p = 0.01) and 8 patients vs. 3 patients (p = 0.04) in the BTX-A and phenol groups, respectively, were statistically significant.

Conclusion: Phenol injection showed superior treatment effects in AROM, decreased spasm degree based on PSFS at 3 months, and less-frequent re-injection rate compared to BTX-A injections in adult patients with UMN lesions. However, both phenol and BTX-A injections effectively reduce spasticity without significant differences in efficacy and adverse effects. Future studies must be conducted with a longer duration of follow-up, and larger sample sizes better to compare both drugs’ effectiveness and side effects.

Trial registration: The study protocol was registered as a clinical trial under registration IRCT20170826035914N2 at the Iranian Registry of Clinical Trials (http://www.irct.ir).

Background: Airway management is one of the most vital skills used by advanced airway providers. Anticipating a difficult airway is crucial for the risk-benefit analysis and may help providers to determine the optimal airway management approach. Existing difficult airway assessment tools may have limited application in emergency airway management. In addition, these do not incorporate physiological factors. More recently, Davis and Olvera proposed the HEAVEN criteria as a novel difficult airway predictive tool for emergency airway management. The objective of this study is to review HEAVEN as a novel airway prediction tool.

Material and Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results of a comprehensive search in three major databases, as well as hand searching, were screened in title/abstract and full-text stages. We included the journal articles which review HEAVEN as a novel airway prediction tool with both retrospective and prospective study designs. The population included patients requiring rapid sequence intubation (RSI) or delayed sequence intubation (DSI). Two investigators independently extracted the data with an electronic table in Microsoft Word. Due to the heterogeneity in included study designs, settings, methods, study outcomes, and measurement of the studies, we did not carry out a meta-analysis. The risk of bias (RoB) was assessed using Joanna Briggs Institute checklist.

Results: Out of 103 records, only four studies were included. The most cited criterion was the anatomical challenge, which was significantly associated with first-attempt success in three studies. Most studies on HEAVEN did not support physiological factors as predictors of difficult intubation. Two studies reported significant associations between individual HEAVEN criteria and first-attempt success without desaturation. Some included studies reported significant associations between anatomical HEAVEN criteria (extremes of size, anatomical challenge, vomit/blood/fluid, and neck mobility) and difficult airway view. Furthermore, a prospective study reported that hypoxemia and vomit/blood/fluid were significantly associated with intubation complications. Based on the results of the RoB analysis, there wasn’t considerable bias in a great number of included studies.

Conclusion: The HEAVEN criteria may represent a development over the traditional approaches. HEAVEN assessment tool considers both physiological and anatomical factors. In addition, all HEAVEN elements can be performed in emergent situations. The HEAVEN criteria seem to be a useful tool to predict difficult airways. There was a variation among studies in the definition of the difficult airway. There is currently no consensus on the definition of a difficult airway, which may explain some of the heterogeneity of the results of this systematic review. Due to the heterogeneity in included studies, we did not carry out a meta-analysis. Therefore, we suggested that future studies should consider homogeneous patient populations, a uniform study design, a matching study setting, and a widely accepted definition of the difficult airway to provide the opportunity to perform meta-analyses. The controversial results of studies highlighted a requirement for more prospective studies with an appropriate study design and considering the possible confounding factors to reach more reliable evidence.

Background: The COVID-19 pandemic has impacted patient and safety issues globally, with special reference to device-associated infection in critical care patients.

Objective: To describe the incidence of device-associated infections, non-device-associated respiratory tract infections (RTIs), and antimicrobial use in critical COVID-19 patients during the first six months of the pandemic.

Methods: An observational study was conducted in an intensive care unit of a COVID-19-dedicated facility in Western Qatar from April 1 to September 30, 2020. Healthcare-associated infections (HAIs) were confirmed using the CDC definitions as per the corporate infection control program, except for other RTIs. Antimicrobial consumption was registered as days of therapy.

Results: During the study period, 30 patients (10.9%) with HAIs were reported from 275 patients admitted. Patients with HAI had a higher median Charlson index, hospital stay, mortality, and APACHE II score on admission. The use of devices (central and peripheral lines, urinary catheters, and ventilators) was more frequent in patients with HAI. The RTI (16 cases) and ventilator-associated pneumonia (VAP) (10 cases) were the most frequent localizations. The infection rate for device-associated infections was 7.84, 3.23, and 2.75 per 1000 device days for VAP, central line-associated bloodstream infection, and catheter-associated urinary tract infection, respectively. 49 isolates related to HAI were identified, with 20 isolates being multidrug-resistant organisms (40.8%). A longer duration of antibiotic therapy was observed in HAI patients (34.1 days versus 9.39 days).

Conclusion: The study provides evidence of the impact of COVID-19 on the incidence of device-associated infections in critically ill patients, antibiotics consumption, and antimicrobial resistance.

Objective: The study sought to determine if the arrival of patients experiencing ST-segment elevation myocardial infarction (STEMI) or cerebrovascular accident to the emergency department (ED) was delayed due to fear of COVID-19, among other factors. Both these disease processes are time-dependent, and great efforts have been made to intervene in this pathology quickly to help improve patient-centered outcomes.

Methods: A retrospective, case-control study was conducted using data from patient records from March to June 2019 and March to June 2020 from Spring Valley Hospital in Las Vegas, Nevada, USA. Chi-square analyses were performed to determine whether times to presentation for STEMIs and embolic strokes differed between 2019 and 2020 and between March and June using the times to present during the months following the U.S. COVID-19 emergency declaration on March 13^th, 2020 (March, April, May, and June). The 432 STEMI and 183 stroke activations were reported during these months.

Results: The results displayed an increase in presentation time for STEMI complaints (χ² [3, N = 2289] = 109.8, p < 0.01) and for stroke complaints (χ² [3, N = 1011] = 182.8, p < 0.01). The increase in times to presentation for STEMI and embolic stroke patients in the months following the emergency declaration compared to the year prior suggests that patients delayed presentation to the ED.

Conclusion: During the pandemic, there was an increase in time to seek treatment for STEMI and embolic stroke patients from the onset of symptoms to their arrival at the ED. This was likely due to patients’ hesitancy to seek treatment due to fear of contracting COVID-19, scarce emergency medical services (EMS) resources, and the flux of new hospital-based virus screening. Data from stroke patients was more heterogenous, likely due to both patients and observers being able to activate the EMS system. These findings may support changes to future public health pandemic guidelines and health education.

Stroke is a significant public health problem in Malaysia. The public needs to be educated and advocated for an early visit to the emergency department for treatment and rehabilitation to minimize the risk of disability and death. One way to increase the public’s awareness is by strengthening their knowledge of the recognition of stroke. The purpose of this study is to validate the content, face, and construct of the Stroke Knowledge Test Questionnaire (SKTQ-BM), a newly revised and improved stroke knowledge questionnaire in Bahasa Melayu aimed at the public in Malaysia. This study has two phases. Item adaptation and modification, content validity testing with expert panels, and face validity testing with 10 respondents comprised the first phase. The second phase, which included 201 responders, consisted of a psychometric test based on Item Response Theory (IRT). IRT revealed that the knowledge section consisted of 4 domains, with a total of 29 items being unidimensional, after removing items with high difficulty coefficients (outside the range of −3 to +3) and items with shallow discrimination values (0.35). The SKTQ-BM is a well-validated and dependable tool for evaluating the knowledge of early stroke recognition, which can be used to build future population stroke intervention programs that enhance effective knowledge conversion.

Introduction: Organophosphate (OP) poisoning is a serious public health problem in underdeveloped nations. Many cases of severe poisoning and more than 220,000 deaths are recorded every year. Early detection and treatment can save lives because OP poisoning has a significant fatality rate. The new Poisoning Mortality Score (PMS) has been developed for clinical decision-making and therapeutic guidance in patients with acute poisoning.

Methods: This is a retrospective study that included 236 patients with acute OP poisoning who got admitted to a tertiary care hospital over two years after obtaining permission from the institutional ethical committee. The PMS, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated based on patient details.

Results: The results showed that the mean age of patients was 32.8 ± 13.4 years; 50.8% were men and 49.2% were women. Out of 236 patients, 214 got discharged and 22 died. The mean ± SD of PMS, SOFA score, and APACHE II scores among the discharged patients were 51±7, 1 ± 2, and 5 ± 5, respectively, and those among the expired patients were 70 ± 12, 7 ± 3, and 28 ± 9, respectively. The best cut-off points for predicting mortality in acute OP poisoning patients for PMS, SOFA score, and APACHE II scores were >65, >3, and >15 with sensitivities of 77.27%, 95.45%, and 95.45%, specificities of 96.26%, 91.59%, and 95.79%, and areas under the receiver operating characteristic curve of 0.917, 0.970, and 0.984, respectively.

Conclusion: The study showed that the new PMS is significantly associated with the prediction of mortality in acute OP poisoning in comparison with SOFA and APACHE II scores.

Background: Deep venous thrombosis (DVT) is one of the most serious thrombotic events and one of the most common cardiovascular causes associated with death due to pulmonary embolism in the emergency department.

Objectives: This study aimed to determine the correlation between two-point compression ultrasonography (CUStwo-point) and doppler ultrasound (DUS) in the diagnosis of DVT of the lower extremities.

Methods: This descriptive–analytical cross-sectional study was conducted on all patients with suspected DVT referred to two emergency departments over 6 months. Initially, all patients underwent CUStwo-point using a linear probe on the common femoral and popliteal veins, which was performed by an emergency medicine specialist. Then DUS was performed on all patients by radiologists who were unaware of the results of CUStwo-point. The results obtained from the two procedures were recorded in a data collection form by a third-year emergency medicine assistant. The data was analyzed by SPSS 23 software.

Results: Overall, 129 patients were enrolled, the mean age of whom was 56.18 ± 16.33.68 years. There were 68 males (52.7%) and 61 females (47.3%) among the participants. The positivity or negativity of the data retrieved from CUStwo-point and DUS was assessed by the McNemar test, and a P-value of 1 indicated the homogeneity of both tests. Compared to DUS (as the gold standard), the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CUStwo-point method were obtained as 97.56%, 95.74%, 97.56%, 95.74%, and 96.9%, respectively. The accuracy of 96.9% of CUStwo-point along with Cohen’s kappa of 0.93 indicated a high agreement between the two ultrasound methods.

Conclusion: CUS seems to be a non-invasive, safe, and accessible method in the emergency department that can provide an appropriate alternative to DUS for the diagnosis of DVT in the lower extremities.

Introduction: A small proportion of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) become critically ill. Individuals’ blood group may influence their susceptibility to infection. However, the relationship between blood groups and clinical outcomes in severe Coronavirus disease 2019 (COVID-19) is not well established. Therefore, we conducted a study to investigate the association between blood groups and clinical outcomes in critically ill COVID-19 patients.

Methods: We retrospectively analyzed electronic health records of COVID-19 patients admitted to intensive care units (ICUs) at Hazm Mebaireek General Hospital, Qatar, from March 7^th, 2020, to July 15^th, 2020. The study population was divided based on their blood groups into types A, B, AB, O, Rhesus (Rh)-positive, and Rh-negative. The primary outcome studied in each blood group was all-cause ICU mortality. Secondary outcomes evaluated were the requirement and duration of mechanical ventilation, ICU days, hospitalization days, and C-reactive protein (CRP) value on admission.

Results: Eight hundred forty-eight patients were admitted to ICUs with severe COVID-19 during the study period. All-cause ICU mortality in the study population was 19.8% (168/848), and that in individuals with blood groups A, B, AB, O, Rh-positive, and Rh-negative was 22.6% (52/230), 18.1% (44/243), 22% (18/82), 18.4% (54/293), 20.4% (165/810), and 7.9% (3/38). Although the highest mortality was noted in blood group A, followed by AB, these observations failed to achieve statistical significance. Rh-negative blood type had lower odds of death compared to the Rh-positive one (odds ratio = 0.27; 95% confidence interval 0.08–0.99, P = 0.049). None of the blood groups showed an association with the need for mechanical ventilation, duration of mechanical ventilation, duration of ICU and hospital stay, and CRP value on admission.

Conclusion: This study revealed no association between ABO blood groups and unfavorable clinical outcomes in critically ill COVID-19 patients. The Rh-negative blood type was associated with slightly lower odds of death compared to the Rh-positive one.

Dystonia is defined as abnormal muscle contraction or twisting or repetitive movements that result in sustained and abnormal posture. Cervical dystonia (CD) is one form of dystonia that involves neck muscles and leads to involuntary movements of the neck and head. Many centrally acting medications such as antipsychotics and antidepressants were reported to cause acute dystonia, as they cause an extrapyramidal side effect.

We present the case of a female adult patient who had acute CD after 2 hours of the first dose of butamirate citrate, a centrally acting cough syrup, which rarely causes central nervous side effects. The patient developed neck pain, spasm, and rigidity, which worsened over time. She improved after the first dose of benztropine, an anticholinergic medication which is one of the treatment options for treating CD.

This case has shown that even in OTC medications with a good safety profile, critical side effects happen, which indicates that clinicians need to be more attentive to patient’s medication history prior to critical events such as acute CD.