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

Background: Accidents and injuries are known around the world as the leading cause of disability and mortality. Objective: This study aimed to investigate the epidemiology of deaths due to accidents and injuries and years of life lost due to it. Methods: The method used in this research is the documentary method analysis. The study population was all deaths recorded in the Statistics and Performance Analysis Unit of Golestan University of Medical Sciences during the years 2014–2018. Results: During the years 2014 to 2018, more than 4318 deaths due to accidents occurred in Golestan province, of which 76.3% were related to men and 23.7% were related to women. There were about 99,531 years of life lost due to premature death during the study period, with the proportion of men (75,737 years, 16 per 1,000) higher than women (23,794 years, 5.1 per 1,000). Conclusion: Promoting knowledge and education, especially in the younger age group, interventions to solve accident-prone areas, adopting policies to reduce traffic accidents and lack of easy access to pesticides, teaching safety principles are also recommended.

Background: Lumbosacral spinal stenosis (LSS) is one of the most common causes of back pain and disability. Its treatment varies from conservative and medical to surgical treatment, and the indications for its optimal management are not obviously defined. Epidural steroid injection is commonly used for pain relief in LSS. This study aims to compare the adjuvant efficacy of caudal epidural injection (CEI) of hyaluronidase with steroid versus hypertonic saline with steroid in patients with LSS. Methods: This clinical trial was done in a prospective, randomized, double-blind approach; it was conducted among 30 patients aged between 45 – 75 years who suffered from low back and leg pain in recent 6 months due to LSS. The patients were randomly allocated to two groups. Group A included 15 patients who received fluoroscopically guided CEI containing steroid, local anesthetic, and hyaluronidase, and Group B consisted of 15 patients who received fluoroscopically guided CEI containing steroid, local anesthetic, and hypertonic saline. The outcome measures included the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Quebec Back Pain Disability Scale (QBPDS), which were obtained from patients before the CEI as a baseline and after the second, fourth, and eighth weeks. Results: Before injection, there were no statistically significant differences between the two studied groups, neither in demographic characteristics nor in VAS, ODI, and QBPDS parameters. After injection, the mean of ODI and QBPDS improved from the baseline to the 2^nd, 4^th, and the 8^th weeks in both groups (p < 0.001) without any superiority between the two groups (p > 0.05). However, there was a significant improvement of the mean VAS score through the second and fourth weeks in Group A (p = 0.032, 0.050). VAS score in the eighth week was equal without any superiority in both groups (p > 0.05). Additionally, the mean social life status was significantly improved in group A in the 4^th and 8^th weeks after the intervention. Conclusions: In short-term follow-up, Caudal epidural injection of hyaluronidase, as well as hypertonic saline, seems to be effective in the management of LSS without any superiority in both materials. However, in the 2^nd and 4^th weeks after the procedure, better improvement of means VAS score was observed in the hyaluronidase group.

Introduction: Young driver behavior and safety are key concerns in Qatar, where they are disproportionately represented amongst road victims and fatalities. This paper summarizes the proceedings of a workshop, entitled “Enhancing the Safety of Young and Novice Drivers in Qatar”, held as a pre-conference workshop of the 24^th World Congress of the International Traffic Medicine Association (ITMA) in Doha, Qatar. Methods: A guided discussion was conducted amongst a selected multi-sectoral group of 50 stakeholders, representing Law Enforcement, Health, Society and Education, Transport, and Road Safety. Each group discussed the best evidence and local realities of young driver safety in the State of Qatar. Using a modified Delphi approach, key areas were identified and prioritized; consensus recommendations were obtained and summarized. Results: Based on the stakeholders’ discussions a list of twelve key recommendations has been developed and its elements have been classified in order of priority. These recommendations are supported by relevant published evidence as well as expert opinion and have been shared with the relevant authorities to inform future policies. Conclusions: This article summarizes the workshop presentations and the twelve key recommendations that arose from the discussions and put them forward to the concerned authorities. It should be emphasized that the concerned authorities concerned need to take action on at least the top three recommendations (GDL, improved police enforcement, and improved licensing and training), but also to prioritize all other recommendations that can be easily addressed such as improved roads and auditing and risk-based insurance.

Background: The abdomen is the third part of the body subjected to trauma. Abdominal trauma (AT) is divided into penetrating and blunt injuries, which differ in their distribution according to geographical areas. Early management can reduce its high morbidity and mortality rate. Objectives: To evaluate the socio-clinical, operative findings, complications, and fatality rate of subjects with AT. Patients and methods: Patients with isolated AT admitted to the emergency unit in the Al-Ramadi Teaching Hospital, Ramadi City, Iraq, and subjected to exploratory laparotomy were enrolled in the study. The study covered a period of 9 months (June 2019 to February 2020). Demographic, clinical, operative findings, and the outcomes were registered and analyzed for all patients. Results: At our hospital, 1119 patients were presented to the casualty with trauma during the study period, 74 (6.6%) of them with AT. Most of the patients were in the age group 18-30 years (50%) and the males formed 90.5% of the cases. Around 90% of the subjects were with penetrating AT, with gunshot (79.7%) being the commonest cause. Around 80% of the patients were presented within 1–12 hours following the trauma. There were 3 or more injured organs (58.1%) found during the operations. The small bowel (38/66) was the most injured organ in penetrating injury, while the liver (6/8) was the most traumatized organ in blunt trauma. The fatality rate showed a statistically significant effect with the age of the patients, time of presentation, mean systolic blood pressure, and hospitalization period (P-value < 0.05). Conclusion: AT showed a prevalence of 6.6%. Penetrating AT outnumbers the blunt injury. The mortality rate was 20.3%. Factors such as the youngest age group, a long time elapsed following trauma, lower mean systolic blood pressure, and long hospitalization period have increased the death rate.

Health professionals involved in invasive procedures such as central venous catheter placement should have a thorough knowledge of thoracic vascular anatomy. Various developmental anomalies of the large intra-thoracic veins can be incidentally discovered in normal adults. Amongst these congenital anomalies is a duplication of superior vena cava (SVC), which results from failure of the left superior cardinal vein to obliterate. Awareness about this anomaly and its variations is important to help overcome challenges in procedures, as well as avoid complications. In this article, we present a case of incidentally diagnosed double-SVC in an adult polytrauma patient after central line insertion in the Trauma Intensive care Unit.

Background: Emergency thoracotomy is a potentially life-saving maneuver for trauma patients in extremis. Since trauma scenarios, in rural locations, usually occur with a high incidence of a severe injury that leads to hemorrhagic shock or cardiopulmonary arrest. The objective of this study was to analyze the experience in emergency thoracotomy performed by a general surgeon in a rural area in Thailand. Methods: This retrospective study was conducted by analyzing the patient records including demographics, mechanisms of injuries, specific organ injury, surgical approach, life-saving surgical procedure, and postoperative outcome for all patients who underwent emergency thoracotomy in the Department of Surgery, Srinakharinwirot University hospital between January 2010 and December 2020. Results: Twelve patients underwent emergency thoracotomy within 1 hour after arrival and were equally divided between blunt and penetrating injuries with 6 (50%). A mean patient age of 34.8 ± 15.2 years (range 16–55), mean systolic blood pressure on arrival was 65.8 ± 35.2 mmHg (range 0–100 mmHg), and the mean injury severity score (ISS) was 54.6 ± 25.2 (range 26–75). Profound hemorrhagic shock is a major indication for emergency thoracotomy. The overall survival rate was 41.7% (5/12 patients) without survivors from cardiac injuries. Four patients (66.7%) in the penetrating and 1 patient (16.7%) in the blunt intrathoracic injury group were survived and discharged from the hospital. Conclusion: Emergency thoracotomy offers a chance for survival at 41.7% for trauma patients who present with extremes in this study. Rapid decision-making, good operative technique, and adequate patient selection are crucial for reasonable outcomes.

Introduction: One of the important COVID-19 management considerations was to prevent delayed intubation. There is a lack of objective criteria to decide the time of intubation. Previously, respiratory parameters were the only tools used to determine the success of high flow nasal cannula (HFNC) therapy, but several studies have reported on the role of respiratory rate oxygenation (ROX) index which combined respiratory rate (RR) and oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) in predicting intubation after receiving high flow nasal cannula (HFNC). The primary objective of this study was to evaluate the validity of the ROX index in predicting intubation in COVID-19 pneumonia receiving HFNC. Methods: This study is a systematic review that used online databases (PubMed, Science Direct, Google Scholar, and CENTRAL) in obtaining eligible journals. The sources of data were from published observational studies and preprints. The outcomes of this study were ROX index validity, intubation predictors, and factors associated with the ROX index. Results: Seven journals were yielded during the search. ROX index was significantly lower in the HFNC failure group at any time interval with high sensitivity and specificity in predicting intubation (p ≤  0.001). ROX index can be used to predict intubation starting at 4 hours after HFNC initiation and calculated repeatedly. Conclusion: ROX index was a good parameter in predicting intubation in COVID-19 pneumonia patients who receive HFNC. The higher value of the ROX index was associated with a higher chance of HFNC success and a lower risk of mortality.

Background: Due to the social isolation imposed by the COVID-19 pandemic, children have been forced to stay at home for extended periods of time. Besides the disease itself growing globally, this pandemic has inflicted many other healthcare problems. This study aims to look at the impact of the COVID-19 pandemic on pediatric home injuries. Methods: It is a prospective descriptive study conducted over a 5-month period from January 20, 2020 to June 12, 2020 of all children aged 0 to 18 years consulting the pediatric medical emergency department of the children's hospital in Rabat for home injuries. Results: A total of 13616 patients were admitted during the period from January 20, 2020 to June 12, 2020. Among them, 296 children were admitted for home injuries representing 1.5% of the total admissions before the lockdown and 4.3% during the lockdown. The mean age of the patients was 4 years. Most home injuries occurred in the evening from 6 pm onwards. The most frequent home injuries were foreign body ingestions (33.2%), drug intoxications (16.9%), CO intoxications (16.6%), and caustic ingestions (13.6%). The average admission delay after the accident was 14 hours before and during containment. During the confinement, 82% of the children received in the emergency room required hospitalization for specialized care or monitoring, and 18% were treated at home. Conclusion: The social isolation imposed by the COVID-19 pandemic has caused an increase in pediatric home injuries requiring admission to our department. Governments and healthcare authorities should proactively implement appropriate intervention programs and better plan resources to prevent these home injuries during the lockdown.

Background: Non-transported calls refer to calls received by dispatchers, ambulances dispatched, and the patient not being transported to any health facility. There is a need to analyze and scrutinize the number of such calls and the monetary cost associated with them as it will help to build an effective system to prevent wastage of money and time. Objective: The main objective of this study is to determine the cost and time lost due to the use of resources higher than required in non-emergency situations, and then a comparison is being made to determine the acceptable cost if the appropriate resources are used for such cases. Incidence of non-transported Emergency Medical Services (EMS) calls and the financial and time burdens in Jubail, classified non-urgent from 2017 to 2019, have wasted EMS resources. This information can be useful to improve EMS operations and allocate resources to control inappropriate usage. Methodology: A retrospective cross-sectional study was conducted to assess non-emergency EMS calls in Jubail, Saudi Arabia. Study data were obtained from the Royal Commission Health Services Program- Jubail (RCHSP-J) key performance indicator (KPIs) system from 2017 to 2019. Descriptive statistical measures (sum, mean, and percentage), and comparison methods were obtained. Results: The cost from 2017 to 2019 for the non-emergency calls by using the advanced life support ambulance (ALS) was 2,051,651 USD while the cost of emergency calls was 546,037 USD only. On the other hand, the time for the non-emergency calls was 6870 hours (78%) and the emergency calls were only 1769 hours (22%). Conclusion: In systems with limited resources and poor regulation; the non-emergency calls having higher costs and time more than emergency calls from 2017 to 2019, might have caused a delay in providing care for the more serious cases. This involves a significant financial waste that could have been planned to make the system work more efficiently avoiding massive waste of resources.

Background: Bedside optic nerve sheath diameter (ONSD) measurement is increasingly being used to monitor raised intracranial pressure (ICP) in patients coming to an emergency department. This study aims to measure the accuracy of optic nerve sheath diameter (ONSD) measurement by ultrasound as a non-invasive method for early detection of raised intracranial pressure (ICP) in patients with non-traumatic emergencies presenting in emergency department settings, in comparison to CT/MRI brain scan findings of raised ICP. Methods: A total of 100 patients with non-traumatic emergencies suspected of raised ICP were seen in the emergency department. Bedside ONSD measurement was done within one hour of arrival. Patients underwent a CT/MRI brain scan within one hour of the ONSD in search of raised ICP. MS Excel spreadsheet was used for coding, SPSS v23 for data analysis, independent sample ‘t-test for group comparison, Wilcoxon test for non-normally distributed data, Chi-square test for group comparison for categorical data, Fischer's exact test for frequency <  5 and 25 % of the cells, Pearson's and Spearman's correlation for linear correlation and statistical significance were kept at p <  0.05. Results: Using a cut-off ONSD value (mm) of 6.3 mm, this study found a sensitivity of 100%, specificity of 89.2%, PPV of 83.3%, NPV of 100%, and diagnostic accuracy of 93% for detection of raised ICP by bedside USG ONSD measurement compared to CT/MRI brain. Conclusions: The study shows that bedside ONSD measurement is a useful and acceptably reliable technique for detecting raised ICP of emergency department patients with non-traumatic emergencies and raised ICP.

Objectives: Recent evidence showed improved outcomes in surgical fixation, compared to conservative management, of flail chest and severe non-flail rib fractures patterns. The dedicated rib fixation systems are expensive and not available in most hospitals. This study aims to establish the feasibility of surgical stabilization of traumatic rib and sternum fractures with off-label utilization of cranio-maxillo-facial surgery titanium implants. Methods: Case series where data of patients, who underwent surgical stabilization of traumatic rib or sternum fractures with off-label utilization of cranio-maxillo-facial surgery titanium implants at Bufalini Hospital in Cesena, Italy, were retrospectively collected. Results: From August 2018 to June 2020, 13 patients were included. The mean operative time was 87.5 minutes (median ± SD: 85 ± 27.1). Post-operative complications were: pneumonia (46.2%), sepsis (7.7%) and superficial wound infection (15.4%). No patients underwent reintervention. No infection or displacement of plates occurred. The costs of the most utilized titanium plates and screws in our series (∅ 2.3–2.5 mm KLS Martin^®) were 122–245 € for one plate and, 13 € for a pack of five screws. Conclusions: The present study showed the feasibility of the off-label use, for rib stabilization, of devices from cranio-maxillo-facial surgery, usually easily available in hospitals and, in particular, in trauma centers, also without elective thoracic surgery departments. These devices are cheaper than the most widely utilized rib fixation systems and, being easily available in hospitals, could be used in urgent settings and could avoid the delay of rib fixation if dedicated thoracic fixation systems are not available. They could have a role also in low-income countries.

Objective/Background: While there is no universal agreement on the benefits of convalescent plasma (CP) in the treatment of COVID-19 infection, very little is known about whether CP affects the association between chronic diseases and mortality. It is known that chronic diseases are associated with worse outcomes, but it is not clear whether the transfusion of CP impacts this association. This study aims to evaluate this impact considering that few studies have discussed the treatment of COVID-19 patients with CP. Methods: A cross-sectional study was conducted among COVID-19 patients treated with CP at the main hospital for treatment and isolation of COVID-19 in Anbar/Iraq during the period of May to August 2020. A questionnaire on socio-demographic characteristics, smoking, and contact with COVID-19 was conducted. The presence of comorbidity, especially hypertension, heart failure, coronary artery disease, diabetes mellitus, chronic pulmonary diseases, asthma, and the hospital outcome (discharged home alive or cure/death) were included. The Chi-square test (or Fisher's exact test) was used to measure the association between comorbidity with the outcome. Logistic regression was used to assess the main predictors for cure (discharged home alive) and death outcome. Results: The mean age of the subjects was (53.05 ± 15.16), with a higher death rate among the older age group, especially those over 60-year with non-survivors at age of 65 or more. There was a statistically significant association between the presence of comorbidity and the mortality rate (P < 0.001). Subjects with chronic disease had a 5 times higher risk for death due to COVID-19 in comparison to those without the chronic disease (OR = 5.8, C.I. = 2.01-16.96, P = 0.001), hypertension showed the highest predictor (C.I = 1.43- 22.29, p = 0.013). Smoking and gender were not associated with mortality. Conclusion: The present study found a high mortality rate among COVID-19 patients treated with CP, specially for those with age over 60, or with comorbidities.