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

Several studies have reported on developing neurological complications following scrub typhus, however vocal cord palsy (VCP) symptoms in this case have never been reported. This work reports on a case where a twelve-year-old male child has been presented to the emergency department with stridor due to bilateral vocal cord palsy as a complication of post-scrub typhus infection.

The temporary pacemaker (TPM) insertion must be done in symptomatic bradycardia to provide adequate heart rate and stable hemodynamic. Transvenous TPM is inserted under fluoroscopy guidance. However, in an extraordinary situation, such as the unavailability of the catheterization laboratory, transvenous TPM insertion can be performed using the blind approach. This case report focused on the procedural aspects of blind transvenous TPM insertion using femoral vein access when fluoroscopy is unavailable. By performing the blind transvenous TPM insertion, the patient should be stabilized as soon as possible. The confirmation of the lead placement using fluoroscopy was needed to ensure that the tip of the electrode was in the proper position.

Double j stent is commonly used in urological procedures. Its main purpose is to afford the sufficient drainage from the renal pelvis to the urinary bladder. Following increased usage of double-J stent, several consequences associated to it have been reported. In this work, we report on a case of “forgotten” double j stent for 1 year in a 32-year-old male patient who visited emergency department with bilateral flank pain, fever, and vomiting for a duration of 3 days. A double-J stent was detected in the plain abdominal X-ray. It was also observed that a 20 × 15 mm stone has impacted the left renal pelvis. Therefore, two operations were performed successfully until the full recovery of the patient. Hence; the main aim of this paper is to increase awareness about the potential complications of “forgotten” double J Stent.

Massive goiter with retrosternal extension is most frequently found in the anterior mediastinum; however, 10%–15% of the cases are found in the posterior mediastinum. It may induce symptoms caused by tracheal, esophageal, and recurrent laryngeal nerve compression. Surgery for such a huge mass requires a high degree of experience to avoid serious complications, particularly if it weighs >500 g. Herein, we report the case of a 64-year-old man who complained of neck swelling which was gradually increasing in size during the past 19 years and breathing difficulty that worsened during the past years. A 31 × 16 cm heterogeneous enhancing mass that expanded the thyroid gland with retrosternal extension, pushing the main vessels posterolaterally and compressing the trachea, was detected during computed tomography of the neck and chest. Total thyroidectomy was performed safely via a transcervical approach. The recovery period was uneventful, and the patient was discharged 5 days later. Given the rarity of a massive goiter that pushes the main vessels and compresses the trachea in the posterior mediastinum, this case report emphasizes the treatment options and outcome of this condition.

Aggression and violence against paramedics by patients or their relatives are frequent events. Therefore, the aim of this study is to estimate the prevalence of aggression / violence against paramedics in Germany and the impact on their mental health. To perform this study, a nationwide survey method was followed where items of the Perceptions of Prevalence of Aggression Scale (POPAS) and the short version of the Depression-Anxiety-Stress-Scale (DASS-21) were used. The results obtained from the feedback of 786 participants (52.42% female) showed that verbal aggression was experienced by 96.44%, provocative aggressive behavior by 79.62% and threatening verbal aggression by 75.16% of the participants; respectively. Mild and severe physical violence were experienced by 59.75% and 16.82% of all participants; respectively. Moreover, the results indicated a significantly higher risk of experiencing humiliating aggressive behavior (OR: 1.38 [95% CI: 1.00; 1.90]; p = 0.049) of female participants. Correlations between DASS-21 subscale for depression and anxiety were seen for frequency of experiencing different kind of aggressive / violent behaviors. Nevertheless, based on rho values ranging from 0.14 to 0.27 DASS-21 stress subscale indicated the largest correlations with investigated kinds of aggression / violence.

To this end, this work indicated a high prevalence of aggression and violence against German paramedics and the implementation of an aggression / violence monitoring system might help to improve their situation.

Background: The rapid spread of COVID-19 disease in Iraq has been a daunting challenge. Given the overwhelmed Iraqi healthcare system, healthcare directors struggled to manage this unprecedented crisis. The role of telemedicine during the coronavirus pandemic has evolved to allow for social distancing while providing appropriate health care to the community at large. Telemedicine emerged as a reasonable solution to deliver appropriate care to COVID-19 and non-COVID-19 patients in the era of the COVID-19 pandemic. Objectives: This study explores the role of telemedicine using the “WhatsApp” application between doctors and patients at home in the “Al-Anbar” province west of Iraq. Patients and Methods: All patients diagnosed with COVID-19 disease who were managed by a group of physicians willing to offer telemedicine service in many cities of the ”Al-Anbar” province west of Iraq were included in this study. Patients’ demographics included age, gender, disease severity, and mortality rate. All patients were followed until they were declared cured of the disease or otherwise. The telemedicine service was provided using the “WhatsApp” platform. The data were entered into a digital database for final analysis. Results: from April through July 2020, at the beginning of the disease in Iraq, 716 patients were managed inclusive of diagnosis, treatment, and follow-up using telemedicine services. Of these, 414 (57.8%) were male, and 302 (42.2%) were female. Of the males, 12 patients succumbed to the disease, resulting in a survival rate of 97.10%, whereas of the females, nine patients succumbed to the disease, resulting in a survival rate of 97.02%. Most COVID-19 patients contracted mild-to-moderate disease with a reported mortality rate of 1.2%. Those with severe disease had a higher mortality rate of 17.5%. There was a statistically significant association between the mortality rate and increasing age and COVID-19 disease severity. Conclusions: We believe that our experience using telemedicine in its most basic form proved effective in managing COVID-19 patients in areas where resources are scarce. It provided essential health care while minimizing the risk of disease spread among healthcare workers, patients, and their families.

Dysrhythmias are commonly encountered in the Emergency Department (ED). Timely management and recognition of dysrhythmia in the ED is essential and crucial. Physicians working in the ED should be familiar with atypical presentation of common dysrhythmias. This case report illustrates atrioventricular nodal re-entrant tachycardia (AVNRT) with an unusually slow heart rate in an adolescent.

A 16-year-old male presented to the ED twice for palpitations. His electrocardiograms showed narrow complex tachycardia with absent P waves. Electrophysiology studies confirmed typical slow-fast AVNRT which was treated successfully with radiofrequency ablation of the slow pathway.

Diagnosing rare dysrhythmias or common dysrhythmias which manifest atypically can be challenging for non-cardiologists. Although AVNRT generally occurs with a heart rate of >130 bpm, emergency physicians should be aware that AVNRT can take place with a relatively slower rate in both the elderly and young.

Background: Traumatic hemothorax is a common consequence of blunt chest trauma. A hemothorax that is missed by initial chest X-ray, but diagnosed by computed tomography (CT), is known as an occult hemothorax. The present study aims at investigating the clinical outcomes of conservative management of occult hemothorax in mechanically ventilated trauma patients. Methods: A retrospective study of all adult blunt chest trauma patients with occult hemothorax requiring mechanical ventilation in a level 1 trauma center was conducted (2010- 2017). Data were obtained from the trauma registry and electronic medical records. Patients were categorized into (a) successful conservative treatment group, and (b) tube thoracostomy group. Results: During the study period, 78 blunt chest trauma patients who had occult hemothorax required mechanical ventilation. Occult hemothorax was managed conservatively in 69% of the patients, while 31% underwent tube thoracostomy. The main indication for tube thoracostomy was the progression of hemothorax on follow-up chest radiographs. Comparison between groups showed that pulmonary contusions (59% vs. 83%), bilateral hemothorax (26% vs. 58%) and chest infections (9% vs. 29%) were lower in conservatively treated group (p < 0.05). Length of stays in ICU and hospital were also lower (p < 0.05). Longer duration of mechanical ventilation and maximum PEEP were significantly associated with tube thoracostomy. Overall mortality was 12% and was comparable between groups. Conclusion: Mechanically ventilated patients with occult hemothorax following blunt chest trauma can be managed conservatively without tube thoracostomy. Tube thoracostomy can be restricted to patients who had evidence of progression of hemothorax on follow-up or developed respiratory compromise.

As a global parasitic disease, Ascariasis has the highest prevalence in the tropical areas of developing countries, such as Yemen. This study was conducted to present our experience in three cases of surgical complications of ascariasis, represented by intestinal obstruction, acute acalculous cholecystitis, and acute appendicitis. Occasional severe manifestations and a high morbidity and mortality rate, especially in endemic areas, make ascariasis a heavy health burden in tropical and subtropical countries. We aim to increase physicians’ knowledge and alertness toward ascariasis diagnosis and its severe manifestations.

Purpose: This retrospective study compares point-of-care ocular ultrasound to MRI in order to establish preliminary data for and identify challenges to a multicenter study into the utility of ocular ultrasound for diagnosing optic neuritis. Methods: Our ultrasound archive was queried to identify subjects suspected of having optic neuritis who underwent ocular ultrasound and MRI of the brain or orbit. Blinded ultrasounds were reviewed by ultrasound faculty. The presence of optic disc elevation, optic nerve, or sheath dilation, and overall impression were recorded and compared to MRI results. Sensitivity and specificity of each ultrasound finding and the overall impression, as well as agreement between the raters, were calculated. Results: Sensitivity and specificity of ultrasound for MRI confirmed optic neuritis was 100 % (95 % CI 54.1-100) and 58.3 % (95 % CI 27.7-84.8). Optic nerve sheath diameter had nearly perfect agreement (κ = 0.8828), however agreement on optic disc elevation (κ = 0.5641), nerve diameter (κ = 0.2174), and overall agreement (κ = 0.1818) were moderate, fair, and poor, respectively. Conclusions: This preliminary study estimates test characteristics of ocular ultrasound for the diagnosis of optic neuritis for the purposes of power analysis and to identify potential pitfalls in preparation for a larger prospective investigation.

Background: The available data on gender differences in a) markers of cardiac involvement, b) peripheral blood parameters, and c) clinical adverse outcomes related to COVID-19 pneumonia severity are limited in the literature.:Objectives: To investigate gender differences in ECG markers of increased risk for malignant arrhythmias. This includes T from peak to end (Tp-e) interval, corrected QT (QTc), transmural dispersion of repolarization (TDR)(Tp-e/QTc), and index of cardiac electrophysiological balance (iCEB)(QTc/QRS), peripheral blood parameters, and in-hospital adverse outcomes in patients with COVID-19 pneumonia. Methods: A cross sectional study enrolled patients with COVID-19 pneumonia admitted to hospital from August 20^th, to September 30^th, 2020. Results: A total of 197 patients were included. Ninety-six (47%) were men and 101 women. There were no significant gender related differences concerning comorbidities. Men had higher QRS values, Tp-e interval and TDR, and lower values of iCEB. No significant gender differences were observed in the distribution of QTc interval. Men stayed longer in the hospital and had more extensive lung injury than women. In men, prolonged QTc interval, low lymphocytes %, high platelet distribution width (PDW), and low hemoglobin (Hb) were the main predictors of adverse in-hospital outcome, while prolonged QTc interval, high PDW, and low platelet count were the main predictors of adverse in-hospital outcome for women. Conclusions: Men had higher TDR values, lower iCEB, stayed longer in the hospital, and had more extensive lung injury than women, suggesting that, despite that there was no significant difference in mortality incidents between the two genders, the difference in surrogate markers may indicate that men are at a higher risk for adverse outcomes.

Background: There are shared guidelines about Non-Operative Management (NOM) of splenic injuries, but some unanswered questions remain. The aim of the present study is to establish the usefulness of a standardized protocol for management and follow-up of NOM patients with splenic injuries. Methods: Multicenter retrospective observational study including patients with major blunt trauma (ISS >15) with splenic injuries managed between January 1^st 2014 and December 31^st 2016 in two Italian I level Trauma Centers: one with a standardized management and follow-up protocol for NOM (Bufalini Hospital, Cesena, BH), and the other without it (ASST Papa Giovanni XXIII Hospital, Bergamo, PG23H). Comparison between patients’ outcomes were performed and a propensity score model was calculated. Results: 47 patients managed in BH and 49 patients in PG23H were included. In BH, a higher proportion of patients was treated with NOM (72.3 % vs. 53.1 %, p = 0.051). There was no difference in complication rate and mortality in patients treated with NOM in the two hospitals. A borderline significant trend to a higher NOM failure rate in PG23H was found (BH 0.0 % vs. PG23H 11.3 %, p = 0.076). The total splenic conservation rate was significantly higher in BH (BH 72.3 % vs. PG23H 46.9 %, p = 0.011). After the Propensity Score based matching, 72 patients were included and the total splenic conservation rate was significantly higher in BH (BH: 77.8 % vs. PG23H: 50.9 %, p = 0.014). Conclusions: The application of a protocol for in-hospital management and follow-up for NOM of patients with splenic injury could decrease the NOM failure rate and improve splenic conservation rate.

Background: Hypertriglyceridemia-induced pancreatitis accounts for up to 15 % of all acute pancreatitis admitted to hospitals. It is important to diagnose the etiology to provide adequate and timely management of the case and reduce complications. Epidemiological and clinical data on hypertriglyceridemia-induced pancreatitis in the Intensive Care Unit (ICU) are scarce, especially in Middle Eastern countries. We are reporting a case series of 18 patients admitted managed in the ICU over a period of 10 months. Methods: All patients above 18 years of age were diagnosed with hypertriglyceridemia-induced pancreatitis admitted to the ICU and High Dependency Unit (HDU), were included. Our objectives were to characterize the clinical and epidemiological features of hypertriglyceridemia-induced pancreatitis (HTG-AP) and calculate the number of insulin infusion days required to manage HIP. Results: Patients were mostly middle-aged males from different ethnicity. Most of the patients presented with abdominal pain elevated pancreatic enzymes, and triglyceride. The mean triglyceride level on admission was 15.68 mmol/L. Most clinical findings were resolved when the triglyceride level dropped to below 5.6 mmol/L within 3.5 days. All patients presented with mild forms of pancreatitis without major complications. Fifty percent of our patients showed radiological features of acute pancreatitis, but no one developed local complications. Conclusion: Our case series showed that hypertriglyceridemia is a common cause of acute pancreatitis in Qatar. Upon admission, the mean triglyceride level was 15.68 mmol/L and the cause of the hypertriglyceridemia was unclear but could be related to ethnicity. Patients were primarily managed with insulin therapy and supportive care. None of the patients developed any local complications such as necrotizing pancreatitis or abscess formation. Around 16% of the patients had systemic complications, which were managed successfully.

Objective: Inflammation and pain are normally present concomitantly, which requires using a combination of anti-inflammatory and pain killer medications. This could potentially decrease patient adherence to such combinations. Therefore, there is an urgent need to develop combinations of anti-inflammatory and analgesic therapies. This study is designed to evaluate the analgesic and anti-inflammatory activities of a newly synthetic compound of ibuprofen and gabapentin. Method: The study protocol includes two stages. The first stage: the evaluation of the analgesic effectiveness of tested compounds via using hot plate and acetic acid induced-writhing tests. The second stage: the investigation of the anti-inflammatory activity via using dextran induced- peritonitis, cotton pelt induced- granulomas, and formalin induced- paw edema analyses. Rats were randomly divided into four groups (six rats in each group): Group A (control): rats were orally treated with vehicle (propylene glycol 50 % v/v); Group B: rats were orally treated with ibuprofen (10 mg/ kg); Group C: rats were orally treated with gabapentin (200 mg/ kg); and Group D: rats were orally treated with the synthetic compound (ibuprofen-gabapentin) in dose equivalent to 10 mg/ kg ibuprofen and 200 mg/kg gabapentin. Result: It was found that the newly synthesized compound of ibuprofen and gabapentin has significantly reduced the pain in comparison with control groups. Additionally, this compound has significant anti-inflammatory properties compared to medications admitted to the control group as well. Conclusion: The newly synthesized compound (ibuprofen-gabapentin) demonstrates remarkable analgesic and anti-inflammatory activities in comparison with the conventional compounds.