Journal of Emergency Medicine, Trauma and Acute Care - Current Issue

Patients with Community-Acquired Pneumonia (CAP) complicated with pleural effusion mostly present with shortness of breath and pleuritic chest pain, and usually, pleural fluid (PE) progresses gradually. In this report, a case of CAP patient complicated with PE presented with left shoulder pain is discussed. The PE was found to have rapidly accumulated as a massive effusion within 24 hours of presentation. Thoracocentesis was performed and revealed an exudative picture. Patients with CAP can present with atypical symptoms on admission but may develop massive parapneumonic pleural effusion within a short time that would need definite management via urgent chest tube placement.

Background: Acute cholangitis (AC) is a life-threatening condition with a mortality risk of 8%–10%. Despite no gold standard for diagnosis, Charcot's triad was introduced to diagnose AC. However, the triad had a low sensitivity (50%–70%). Recently, Tokyo guidelines (TG) for the diagnosis of AC gained international recognition for their excellent diagnostic rate. Objective: In this study, we aimed to apply TG18 guidelines in a retrospective manner to diagnose AC in Qatar to validate TG18. Methods: This retrospective observational study recruited 295 patients with clinically proven AC between January 2016 and July 2018. Results: Of the 213 patients, 72.2% were men. The mean age was 51.4 ± 17.5 years. The most common co-morbidity was hypertension (36.3%). Common bile duct stones were the most common cause of biliary obstruction found in 165 (55.9%) patients. The diagnostic rate of TG18 was 91.9% in contrast to Charcot's triad (34.9%). By TG18 grading, 150 (50.8%) patients were grade I. ERCP was done in 62% patients, and 52.5% of them were grade I. Conclusion: AC management in Qatar meets the international standards with a low mortality rate. TG18 guidelines had a high diagnostic rate among our patient population.

Background: Recently, biological dressings have become popular in treating burn injuries. Fish skin has non-infectious microbiota, high levels of type 1 and type 3 collagen, and a structural property similar to human skin, making it a promising xenograft for managing burn wounds. In this study, we aimed to evaluate the effectiveness of fish skin as a physiological dressing cover in patients with burn injuries. Method: From June 2017 to June 2021, 18 patients who were admitted to our center within 3 days from a thermal injury, burns with a partial thickness of approximately 20% of the total body surface area (TBSA) or complete partial-thickness burns ranging from 5% to 15% of the TBSA, and treated with the Shaour (Lethrinus lentjan) fish skin xenografts were enrolled in this retrospective study. The demographic characteristics of the participants, wound healing process, and final outcome were analyzed. Results: The mean age of the patients was 31.86 ± 9.14 years (range 19–46) which encompassed 12 (66.7%) men and 6 (33.3%) women. Superficial partial-thickness burns were seen in 13 (72.2%) patients, whereas full-thickness burns were seen in five (27.8%) patients. The mean time to 90% epithelialization and 100% epithelialization were 11.05 ± 2.57 days and 17.27 ± 2.05 days, respectively. The mean pain scores were 6.94 ± 0.72 and 5.22 ± 0.64 on days 7 and 15, respectively. Neither negative consequence nor allergic reaction was associated with using the fish skin grafts. The main reduction in the pain score from the first visit (7 days) to the second visit (15 days) was 1.72 ± 0.95 (p <  0.001). Conclusion: Acellular fish skin is a useful tool for wound healing treatment in complete and partial thickness burns. To validate this result, prospective cohort studies with long-term post-procedural follow-up are needed.

Background: The coronavirus disease 2019 (COVID-19) pandemic has tested the limits of national public health infrastructures to an unprecedented extent. A huge challenge has been regarding how to safely manage large public gatherings and how to efficiently administer vaccines to a large population. Method: We evaluated three case studies in project management implemented by the Primary Healthcare Corporation (PHCC) over the course of 2020 and 2021, including: COVID-19 screening for the HH Amir Cup and Asian Football Confederation (AFC) Finals 2020, the FIFA Club World Cup 2020, and finally Qatar's National COVID-19 Mass Vaccination Project in the Qatar National Convention Centre (QNCC) in 2021. Results: The key themes arising from all the three projects include the importance of developing a strategic plan, project management planning, clarifying and communicating roles and responsibilities, situational decision making, strong leadership, flexibility, result orientation in implementing the project, strong logistical support for providing necessary resources on the ground, and ensuring that staff at all levels are fully supported in performing their duties. In addition, the project management team was successful in building knowledge and experience across events with each successive project benefitting from lessons learned from previous projects. As a result of the strong record of project management established over the course of these experiences, PHCC was able to successfully manage the mass vaccination project with a high level of efficiency in comparison to similar national programs implemented elsewhere, both regionally and globally. Conclusion: The successful implementation of these projects, maintaining a high level of client and staff safety and satisfaction, demonstrates the value of project planning and continuous monitoring in successful implementation even in the context of uncertain conditions such as a global pandemic. Public and community health authorities may benefit by applying similar principles as the COVID-19 pandemic continues to unfold.

Small bowel obstruction is a common surgical emergency and needs timely intervention to prevent the development of complications. Acute appendicitis is a very rare, uncommon, and unnoticed cause of intestinal obstruction. Although functional obstruction due to paralytic ileus is common in acute appendicitis, mechanical obstruction is a fairly uncommon complication of this extremely prevalent disease. Furthermore, a normal appendix causing full-blown small bowel obstruction due to the tourniquet effect on the terminal ileum is exceptionally rare and the diagnosis is often overlooked. This work report on an extremely rare case of mechanical small bowel obstruction caused by a normal appendix forming tourniquet around an ileum loop. A 40-year-old male patient presented with clinical manifestations of small bowel obstruction, and the appendiceal tourniquet was discovered to be the cause during laparotomy. The patient was subjected to an appendectomy. The histopathological examination of the specimen reported normal appendiceal morphology. The case is unique in that it is the first report of a mechanical small bowel obstruction caused by an appendiceal tourniquet with normal histopathology.

Penetrating trauma to male external genitalia is a rare trauma case. It accounts for 20% of all genitourinary trauma cases, and penile involvements are presented between 10- 16% of all cases. Male genital trauma is considered a urological emergency due to the high risk of infection, sexual dysfunction, and infertility. In this work, a 17-year-old male patient presented with scrotal and penile injuries due to a low-velocity gunshot wound. Genital examination revealed tissue loss in the foreskin, glans, anterior urethra (distal third), cavernous corpora, and total loss of right testis with a scrotal laceration. The patient was treated with partial penectomy, penile reconstruction, and urethral repair with an excellent uneventful postoperative cosmetic and functional outcome. In conclusion, penetrating male external genital injuries are rare with extremely serious consequences due to the functional, psychological, and aesthetic consequences. The best treatment with penile reconstruction and urethral and cavernous corpora repair may be achieved.

Many drugs can cause methemoglobinemia, and dapsone is one of the most familiar. Dapsone is used to treat skin disorders like leprosy, and infections like Pneumocystis jiroveci pneumonia. It is also used off-label in conditions like dermatitis herpetiformis, and relapsing polychondritis. In this case report, a 26-year-old male presented to the emergency department with fever and generalized weakness complaints. He was on treatment for lepromatous leprosy with dapsone, clofazimine, and rifampicin. His room air oxygen saturation was 80 %, so he was started on high-flow oxygen therapy and vitamin C. His blood gas and methemoglobin levels were frequently monitored till the methemoglobin level was normal. By the third day, he maintained his saturation above 95% on room air. The results in this work emphasize the importance of evaluating hypoxia for uncommon causes like methemoglobinemia as misdiagnosis can lead to fatal complications.

Objective: To evaluate the effects of estrogen on the prognosis of patients with diffuse axonal injury due to severe traumatic brain injury. Design: Triple-blind placebo-controlled randomized clinical trial study Setting: The study was conducted at the Neurosurgery Department of Imam Reza Hospital of Tabriz University of Medical Sciences Patients: A total of 200 patients were enrolled in the study Methods: Two hundred patients were randomly allocated into two cases, with a control group of 100 each. The case group daily received 8μg/kg of estrogen by nasogastric for three days and the control group only received a placebo. The Glasgow Coma Scale (GCS) at discharge, Glasgow Outcome Score (GOS) at discharge, and the GOS three months later were investigated to evaluate the effect of estrogen on patients with diffuse axonal injury (DAI) following traumatic brain injury (TBI) in the case and control group. Results: It was shown that there is a significant difference between the case and control groups based on GCS at discharge (p-value = 0.007), GOS at discharge (p-value = 0.02), and GOS at a 3-months follow-up period (p-value = 0.025). Ten patients (5 patients in each group) died during the study. Conclusion: This study indicated the efficacy of estrogen in patients with Diffuse Axonal Injury (DAI) following TBI.

Introduction: Although various scoring systems are already available for early prognostic evaluation of patients with complicated intra-abdominal infections (cIAIs), none has shown the ideal characteristics in everyday practice. In this study, we aimed to find the most reliable prognostic score in patients with cIAIs. Methods: This retrospective study involved 110 patients with cIAIs admitted to the Department of Surgical Diseases at University Hospital, “Prof. Dr. Stoyan Kirkovich” Stara Zagora from January 2017 to July 2019. We compared the prognostic values of Mannheim Peritonitis Index (MPI), World Society of Emergency Surgery Sepsis Severity Score (WSES SSS), quick sequential (sepsis-related) organ failure assessment score (qSOFA), and systemic inflammatory response syndrome (SIRS) using area under receiver operating characteristics (AUROC) curves. Bivariate correlation analysis was used to evaluate the association between scoring systems and the final outcome. Results: The observed in-hospital mortality was 22.7%. Significant correlations were found between MPI and outcome (r = 0.500, p <  0.001), WSES SSS and outcome (r = 0.483, p <  0.001), and qSOFA and outcome (r = 0.356, p <  0.001). Of all the scoring systems, MPI showed the best prognostic performance (AUROC = 0.844, 95% confidence interval (CI) = 0.763–0.924). The identified sensitivity and specificity for MPI cut-off value >25 points were 80% and 77.6%, respectively. Conclusion: The MPI is still one of the best options for prognostic evaluation of patients with cIAIs.

Background: The outcomes of patients with ST-elevation myocardial infarction (STEMI) transferred to percutaneous coronary intervention (PCI) facility is strongly related to certain demographic and clinical factors, important timelines, door-to-electrocardiography (ECG) time, door-in door-out (DIDO) time, door to balloon time (DTBT), the use of emergency medical services (EMS), and the existence of a STEMI network. In the study, we examined the inter-facility transfer for patients with STEMI analyzing certain characteristics and timings between the involved institutions. Method: This was a retrospective observational study on the inter-facility transfer of patients with STEMI admitted between January 01, 2018, and December 31, 2019. The electronic medical records of both the institutions were used to collect data on patient demographics, clinical characteristics and scores, ECG manifestations, laboratory values, treatment interventions, and outcomes with a major focus on the timelines for door-to-ECG, DIDO, and DTBT. Results: A total of 141 patients with STEMI who were transferred to a PCI center were included in this study. Their mean age was 52.26 ± 12.45 years and were mainly men (87.9%, p <  0.001). Men developed STEMI at a younger mean age (53.15 ± 12.53 years, p = 0.003). Chest pain was the most common notable symptom (129, 91.5%). Diabetes mellitus (DM) and hypertension were noted to be the comorbid factors in a majority of patients (70, 49.6%). Only 47 patients (33.3%, p <  0.001) were brought by EMS. Mean door-to-ECG and DIDO times were 8 minutes (IQR: 4–12) and 32.5 minutes (IQR: 24–46), respectively. Only 112 patients (79.4%) underwent PCI on arrival with a DTBT of 90 minutes (IQR: 70.5–105). Only door-to-ECG time and DTBT could be attained as required in this study (p <  0.001). Conclusion: This study reveals a few beneficial statistics for the inter-facility transfer of patients with STEMI concerning their demographics, clinical characteristics, and important timelines. The door-to-ECG time, DTBT, and DIDO time were in the considerable recommended time, and this reflects the importance of establishing a STEMI network.

Background: Till date, there is no consensus reached on the foremost tool for identifying the propensity of risk in critically sick patients. In this study, we plan to assess the nutritional risk in critically ill patients admitted to the medical ICU using the modified nutrition risk in critically ill (mNUTRIC) score and to anticipate the outcome in terms of overall mortality, 72-hour mortality, and the use of mechanical ventilation. Method: A total of 1,990 patients were analyzed by calculating their mNUTRIC scores using various variables, which were a part of the scoring system, such as age, a thorough history and clinical examination, and pre-existing comorbidities. Group differences were compared using the t-test or the Wilcoxon test for continuously distributed data and the chi-squared test for categorical data. Results: In this study, the mean age of the patients were 50.48 ± 17.58 years. Of them, 395 died while 1,595 survived; and 799 had a high ( ≥ 6) mNUTRIC score, and 1191 had a low ( ≤ 5) mNUTRIC score. The area under the curve for mNUTRIC score in predicting overall mortality and 72-hour mortality was 0.938 and 0.89, respectively, thus demonstrating better diagnostic performance. Conclusion: The discriminative performance of mNUTRIC scores for assessing overall mortality and the need for mechanical ventilation was found to be effective in this study.

Background: In this study, we compared the efficacy, patient satisfaction, and adverse effects of nebulized ketamine to those of Entonox in reducing acute traumatic pain in the Emergency Department. Methods: This was a randomized, single-centre pilot study. Eligible patients were selected from triage and divided into two groups which was nebulized ketamine and Entonox. Nebulized ketamine 50 mg (mean 0.7 mg/kg for an average adult) was administered in a concentration of 5 mL of 10 mg/mL diluted with 1 mL normal saline in a nebulizer. Entonox delivery was self-regulated by the patients. The primary outcome was efficacy of pain reduction according to the visual analogue scale (VAS) in 30 minutes. Adverse effects were monitored in both the groups. Results: A total of 26 patients were divided equally into two groups with n = 13 for each group. Mean reduction in VAS after 5 and 30 minutes was 0.62 ± 0.77 mm and 28.5 ± 12.1 mm for nebulized ketamine and 0.46 ± 0.78 mm and 30 ± 5.8 mm for Entonox. No significant difference was seen in pain reduction (5 min p = 0.616, 30 min p = 0.684). Mean satisfaction with analgesia according to a Likert scale of 1 to 6 was ketamine 4.92 ± 0.64 and Entonox 5.0 ± 0.41 (p = 0.718). No serious adverse events were reported. Conclusion: Nebulized ketamine is a comparable substitute to Entonox in managing acute traumatic pain in the Emergency Department. Further studies are required on the use of inhaled ketamine as an adjunct in managing severe pain and reducing the need for opioids.