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

Introduction: The prognostic ability of the urea-to-albumin ratio (UAR), systemic immune-inflammation index (SII), and neutrophil-to-lymphocyte ratio (NLR) has not yet been assessed in local peritonitis. Therefore, our aim was to determine whether these prognostic tools can predict which patients are at increased risk for fatal outcomes.

Material and Methods: A retrospective analysis including 76 patients operated on for local peritonitis in an emergency setting at University Hospital Stara Zagora for the period January 2017–April 2022 was performed. We investigated the prognostic qualities of UAR, SII, and NLR, and then compared them with those of the prognostic scores quick-Sequential Organ Failure Assessment (qSOFA) and World Society of Emergency Surgery Sepsis Severity Score (WSES SSS) by ROC curve analysis.

Results: The established in-hospital mortality was 9.2%. The adverse outcome was successfully predicted by UAR (AUROC = 0.868, p = 0.002) and WSES SSS (AUROC = 0.770, p = 0.019). NLR (AUROC = 0.704, p = 0.077) and SII (AUROC = 0.571, p = 0.535) were observed as not helpful prognostic factors, while UAR showed high prognostic performance at an optimal cut-off value = 35.4 with a maximum sensitivity of 100% and a specificity of 77.8%.

Conclusion: A high-risk patient with local peritonitis can be identified quickly and inexpensively using UAR.

Purpose: This study aims to investigate the clinical presentation, etiology, and management outcomes of acute mechanical bowel obstruction (AMBO) in Yemen, focusing on predictors of postoperative complications and mortality.

Patients and Methods: A prospective observational study was conducted at Al-Thawra Modern General Hospital in Sana’a, Yemen, from October 2022 to October 2023. We enrolled 106 patients with AMBO, collecting data on demographics, clinical presentation, management strategies, surgical interventions, complications, and outcomes. Logistic regression identified risk factors for postoperative complications and mortality.

Results: The study population consisted predominantly of males (66%) aged 31–60 (51%). Common symptoms included vomiting (96.2%), constipation (90.6%), and abdominal distention (83.0%). Adhesions (41.5%) were the most frequent cause, followed by hernias and large bowel masses (22.6% each). Surgical intervention was necessary in 71.7% of cases, with resection and anastomosis as the most common procedure (29.2%). Postoperative complications occurred in 36.8% of surgical patients, with wound infections being the most prevalent (31.6%). Significant predictors of complications included resection and anastomosis (OR = 19.541, 95% CI: 3.655–104.466, p = 0.001) and delayed presentation (7–10 days) (OR = 11.433, 95% CI: 1.230–106.252, p = 0.032). Mortality was associated with ICU admission (OR = 1.719, 95% CI: 1.019–2.904, p = 0.029), sepsis (OR = 2.771, 95% CI: 1.451–5.292, p < 0.001), and hypothermia (OR = 1.451, 95% CI: 1.019–2.071, p = 0.042).

Conclusion: AMBO predominantly affects middle-aged males in Yemen, with adhesions being the leading cause. Surgical intervention, while often necessary, carries significant risks, particularly with delayed presentation. Early diagnosis and timely intervention are crucial to improving patient outcomes. Further studies are needed to validate these findings and develop optimized treatment protocols.

Background: Considering the aging society, there are few studies on the development of contrast-induced nephropathy (CIN) in emergency departments (EDs), especially in geriatric age groups. The aim of this study was to evaluate the effects of intravenous contrast media use for computed tomography on the development of acute kidney injury (AKI) in geriatric patients admitted to the ED.

Methods: This was a single-center, retrospective study. Patients aged ≥65 years presenting to the ED with an indication for contrast-enhanced computed tomography with serum Creatin and urea values within 8 h before imaging and 24–48 h after imaging were included in the study. The contrast agent used was IOHEKSOL (100 ml/300 mg). Patients with elevated serum creatine values 24–48 h after contrast-enhanced computed tomography were considered as contrast-induced acute kidney injury (CI-AKI).

Results: This study included 420 patients. The number of patients who developed CI-AKI was n = 35. When the characteristics of the patients were compared according to the development of CI-AKI, significant differences were found in terms of baseline creatinine value, eGFR and all severity indicators of CI-AKI (hypotension, hypoalbuminemia, and intensive care unit admission) (p < 0.05 for all).

Conclusion: Our study showed that the development of CIN in geriatric patients presenting to the ED was the same as in the general population and that the basal urea, sCr, and eGFR values of the patients also influenced the development of CIN. We believe that this study may be useful to know the comorbidities and laboratory values of patients before contrast extraction in order to be prepared for a possible complication.

Purpose: Head and facial lacerations often require effective anesthesia for proper repair and healing. This study aims to evaluate the effectiveness of lidocaine and diphenhydramine, administered via injection or margin push, in providing appropriate anesthesia for patients’ pain during suturing head and face lacerations.

Materials and Methods: This study involved 200 trauma patients with head and face lacerations. All patients had a 15 GCS. Patients were divided into 4 groups of 50. In the first group, lidocaine was injected around the wound, in the second group diphenhydramine was injected around the wound, in the third group lidocaine was pushed through the wound margin, and in the last group, diphenhydramine was pushed. After 5 minutes the pain intensity was evaluated based on the VAS system.

Results: Patients had an average age of 34.1 years. Regarding gender distribution, most patients were male (84.5%). The diphenhydramine injection method was the most effective in reducing pain, while the lidocaine push method was the least effective. Regardless of the agent used for anesthesia, the injection method showed better effects than the push method. In the injection methods, the diphenhydramine-injected group experienced lower pain levels than the lidocaine-injected group before and during suturing.

Conclusion: Diphenhydramine injection had a superior pain reduction compared to other methods. Considering the lack of substantial difference in the level of anesthesia between lidocaine injection and diphenhydramine injection and diphenhydramine push, diphenhydramine push can be used to prevent pain during the suturing procedure.

Purpose: To compare the efficacy of retromandibular approach (RM) to transmasseteric anteroparotid approach (TMAP) in open reduction and internal fixation of mandibular condylar fractures using various clinical parameters. The parameters evaluated include duration (time taken from incision to reach the fractured site, accessibility to reach the fractured site (intraoperative), facial nerve palsy, sialocele, and scarring (post-operative).

Materials and Methods: The sample size was 26 (13 per group). The study was conducted in patients with condylar fractures planned for open reduction and internal fixation. The choice of approaches was RM and TMAP. The post-operative parameters were analyzed during the first week, first month, and third month. The study was done between 2018 and 2020. Patients were randomly assigned to the groups. Group I contained RM and Group II had TMAP.

Results: On comparing efficacy, each approach was versatile in its own way. Considering duration no statistically significant difference was observed. In terms of accessibility there was no statistically significant difference but TMAP offered a better access compared to RM. A very minimal difference was observed in post-operative features like facial nerve palsy, sialocele, and scarring but none reached statistical significance. Only scaring pertaining to the length of the incision in TMAP was statistically significant. Considering RM, it was the fastest, easiest to reach the fractured site and more suitable for reducing medially displaced condyle fractures. TMAP credits with respect to direct access to the fracture site, placement of screws perpendicular to the fractured site, less chance of facial nerve palsy but resulted in inconspicuous scar. It was observed that both approaches had their own versatility, including good exposure and accessibility to fracture site. The choice depends on the type of condyle fracture and convenience of the surgeon.

Conclusion: Currently, very little has been published pertaining to the comparison between RM and TMAP for condyle fractures. RM resulted in less scarring, providing a better convenience and accessibility for reducing medially displaced subcondyle fracture. TMAP offered a more direct exposure of the fracture site with a better direct reduction, ease of placement of plate and screws with a favorable access.

Background: Limited tools are available to predict the mortality outcome in chronic kidney disease (CKD) patients. Recently, the Charlson Comorbidity Index (CCI), CHADS2, and CHA2DS2 scores were used to evaluate mortality among these patients. However, the effectiveness of these scoring systems for predicting mortality in hemodialysis (HD) patients remains unclear, and comparative data are limited. This study aimed to assess the utility of the CHADS2, CHA2DS2, and CCI scores in predicting mortality among HD patients in a resource-limited setting.

Patients and Methods: This retrospective study, conducted from March 2018 to September 2023, included 447 HD patients from the Nephrology Center of Al-Thora General Hospital in Yemen. The Kaplan–Meier and log-rank tests were used to evaluate and compare survival curves, and the proportional Cox hazard model was used to investigate the factors associated with mortality. CCI, CHADS2, and CHA2DS2 scores were calculated for each patient and categorized into three groups based on their scores: 0–1, 2–3, and >4. The correlation between these scores and mortality was analyzed using receiver operating characteristic (ROC) curves and multivariate analysis.

Results: The mean age of the patients was 48.9 ± 16.3 years, with 73 (16.3%) over the age of 65 and 21 (4.7%) over the age of 74. Among the cohort, 258 (57.7%) were male, and 189 (42.3%) were female, with the majority (n = 393, 87.9%) residing in Ibb city. The mean follow-up duration was 40.2 ± 13.7 months, and 97 patients (22%) had died by the end of the study. The median survival duration was 48 months, with 1-, 3-, and 5-year survival rates of 94%, 82%, and 69%, respectively. The mean scores for CHA2DS2, CHADS2, and CCI were 2.50 ± 1.45, 1.63 ± 1.03, and 3.98 ± 3.73, respectively. On multivariate analysis, residence outside Ibb city (HR: 0.38; 95% CI: 0.19–0.79, p = 0.009), positive HBV infection (HR: 3.46; 95% CI: 2.10–5.71, p < 0.001), history of diabetes mellitus (HR: 12.47; 95% CI: 2.86–54.27, p = 0.001), and history of the rheumatologic disease (HR: 518.05; 95% CI: 117.10–2291.84, p < 0.001) were the predictors of all-cause mortality. The areas under the ROC curve (AUC) for CCI, CHA2DS2, and CHADS2 scores were 0.991 (95% CI: 0.977–0.9), 0.829 (95% CI: 0.791–0.863), and 0.737 (95% CI: 0.694–0.777), respectively, indicating high predictive value for the CCI score (sensitivity: 100%, specificity: 93.4%), moderate predictive value for CHA2DS2 (sensitivity: 82.47%, specificity: 74.57%), and low predictive value for CHADS2 (sensitivity: 51.55%, specificity: 93.71%).

Conclusion: Our findings suggest that CCI, CHADS2, and CHA2DS2 scores can help predict mortality in newly admitted HD patients. Furthermore, factors such as residence outside Ibb city, positive HBV infection, history of diabetes mellitus, and history of rheumatologic disease, were the predictors of all-cause mortality in these patients.

Background: Current guidelines recommend the use of normal saline (NS) as the preferred resuscitative fluid in the treatment of diabetic ketoacidosis (DKA). However, due to the development of hyperchloremic metabolic acidosis when using NS, balanced crystalloids such as lactated Ringer’s solution (LRS) and plasma-lyte have been proposed as alternative treatments. Therefore, the current meta-analysis investigated the efficacy and safety of NS compared to LRS in managing DKA.

Methods: A comprehensive literature search directly comparing NS to LRS was conducted on PubMed, MEDLINE, Web of Science, and Google Scholar databases. This search was limited to articles authored in English; however, no time limitation was provided. A random-effects model was used to summarize the mean differences (MD) and their corresponding 95% confidence intervals (CI). Moreover, methodological quality appraisal was performed using Cochrane’s Risk of Bias tool and the Newcastle–Ottawa Scale.

Results: A total of six studies enrolling 50,330 patients with DKA were included. A pooled MD indicated no significant difference in the time to DKA resolution between the NS and LRS groups (MD: 1.12; 95% CI: −0.69 to 2.93; p = 0.23). Similarly, no significant difference was observed between the two groups in terms of the total volume of fluids administered (MD: 436.57; 95% CI: −280.92 to 1154.06; p = 0.23) and length of hospitalization (MD: −0.01; 95% CI: −0.53 to 0.50; p = 0.96). However, the pooled data indicated that the duration of intensive care unit (ICU) stay was significantly shorter in the LRS group (MD: 4.79; 95% CI: 1.98 to 7.59; p = 0.0008). Similarly, patients who received LRS showed significantly higher levels of post-resuscitation bicarbonate and lower levels of post-resuscitation chloride than those who received NS (MD: −1.22; 95% CI: −1.67 to −0.77; p < 0.00001 and MD: 4.74; 95% CI: −0.23 to 9.25; p = 0.04, respectively).

Conclusion: LRS was as effective as NS in resolving DKA. Therefore, LRS can be considered as an alternative treatment option for DKA.

Emergency medicine is a fast-paced and decision-making environment, critical where ensuring patient safety and care quality is of utmost importance. This review explores the evolving landscape of research methodologies used to improve safety and quality in emergency care, with a specific focus on studies conducted in India and their global implications. We delve into various research approaches, from observational studies that uncover patterns of errors and adverse outcomes to randomized controlled trials (RCTs) that test interventions aimed at enhancing safety in emergency departments (EDs). Qualitative research provides more in-depth understanding of the human and organizational factors that influence patient care, whereas mixed-methods research combines quantitative data with qualitative insights, offering a comprehensive view of complex safety challenges. Furthermore, implementation science plays a critical role in translating research findings into practice and ensuring the effective adoption of safety protocols in EDs. Despite the limited number of studies in India, the research conducted in the country highlights unique challenges such as overcrowding and resource constraints, making it essential to adapt global research findings to local contexts. By examining these diverse methodologies and their application in India, this review emphasizes the importance of context-specific solutions to enhance patient safety and care quality in resource-limited settings. The findings have global relevance, offering valuable insights for emergency health professionals committed to improving safety in EDs worldwide. This review aims to inspire further research and collaboration to ensure safer, more efficient emergency care for all patients.

Allergic disorders are steadily increasing, and so is the incidence of anaphylaxis. Epinephrine is the drug of choice for anaphylaxis. Fatalities from anaphylaxis occur if epinephrine is not administered or delayed in administration. Epinephrine is not effective orally but works rapidly if administered intramuscularly. Epinephrine can be delivered easily via Epinephrine AutoInjector (EAI), safely and soon after the onset of anaphylaxis, and can be carried portably. There are few approved EAI brands, but EpiPen is the most commonly used brand. Accidental EAI injuries are increasing in prevalence in the community and also among the healthcare workers while administering it. Injuries occur to any part but mostly to the limb digits. According to evidence, most injuries make full recovery. We present two cases of healthcare professionals who experienced accidental EAI injury at the primary care health center. The designs of alternate EAIs compared with EpiPen are safer for both the public and the healthcare professionals while delivering the same result. Regular training in the use of EAI reduces the accidental injuries.

Background: This study evaluated the outcomes and associated factors of emergency laparotomy in elderly patients at a referral hospital in Sana’a, Yemen.

Patients and methods: This prospective observational study was conducted at the Al-Gomhori Teaching Hospital Authority in Sana’a, Yemen, between August 2022 and May 2024. A total of 89 patients aged 60 years who underwent emergency laparotomy were included in the study. Data on demographic characteristics, preoperative comorbidities, intraoperative findings, and postoperative outcomes were collected and analyzed. Statistical analyses included descriptive statistics and Fisher’s exact test to determine associations between the study factors and mortality/morbidity, with a significance level of p < 0.05.

Results: The mean patient age was 65.87 ± 7.28 years, with a male predominance (65.2%). The most common indications for surgery were intestinal obstruction (53.9%) and peritonitis (37.1%). The 30-day post-operative mortality rate was 30.3%. Significant associations were found between mortality and preoperative factors such as ischemic heart disease (p = 0.030), chronic renal failure (p = 0.030), and preoperative respiratory dysfunction (p = 0.014). Intraoperative findings, such as mesenteric ischemia (p = 0.014), and postoperative complications, such as sepsis (p < 0.001), were also significantly associated with mortality. Morbidity was significantly associated with hypertension (p = 0.025), intensive care unit (ICU) admission (p = 0.008), and unstable hemodynamic status (p = 0.015).

Conclusion: Elderly patients undergoing emergency laparotomy in Yemen have high morbidity and mortality rates that are influenced by preoperative comorbidities, organ dysfunction, and specific intraoperative and postoperative complications. The challenges of delayed diagnosis, limited resources, and high sepsis rates highlight the difficulties of caring for elderly patients in low-resource settings. Improved preoperative assessment, perioperative care, and targeted postoperative management are crucial for improved outcomes. These findings highlight the importance of tailored surgical care protocols for the elderly in low-resource settings.

Background: Artificial intelligence (AI) is a multidisciplinary field that focuses on developing intelligent computer algorithms to carry out simple to complex tasks traditionally performed using human intelligence. In anesthesia, AI is rapidly becoming a transformative technology. However, its efficacy remains unknown. Therefore, this study aims to analyze the efficacy of AI in anesthesia by studying two main applications of AI: predicting anesthesia-related events and assisting with anesthesia-related procedures.

Methods: A systematic search was performed for English-language records published from inception until June 2024 in PubMed, Google Scholar, IEEE Xplore, and Web of Science databases. Studies were included in this meta-analysis if they examined the role of any AI model in predicting hypotension, hypoxemia, and post-operative nausea and vomiting (PONV). Moreover, studies investigating the role of AI in guiding anesthesia-related procedures, such as tracheal intubation and ultrasound-guided nerve blocks, were included. The CMA software and STATA 16.0 were used for statistical analyses, while the Newcastle–Ottawa Scale was used for quality evaluation.

Results: Twenty studies meeting the eligibility criteria were included in the analysis. The pooled results indicated that AI demonstrated good discrimination ability in predicting hypotension (area under the receiver operating characteristic curve (AUROC): 0.81), with the subgroup analysis showing that models incorporating machine-learning algorithms outperformed other models (AUROC: 0.93). Similarly, the pooled analysis showed that AI models had a good discriminatory capacity for predicting hypoxemia (AUROC: 0.81). However, AI demonstrated poor discriminatory capability in predicting PONV (AUROC: 0.68). Our analysis also showed that robotically assisted intubations were successful in both mannikins and humans (success rate: 98% and 92%). Similarly, robotically assisted ultrasound-guided blocks were successful in mannikins and humans (success rate: 96% for humans and mannikins).

Conclusion: This study suggests that AI is useful for predicting anesthesia-related events and automating procedures such as intubation and ultrasound-guided nerve blocks. However, multiple barriers hindering the integration of AI into anesthesia, such as cost, privacy and security concerns, data quality, “black box”, and ethical issues need to be addressed.

All challenging airway algorithms end with the situation of Cannot Intubate Cannot Oxygenate (CICO), which requires front of neck access (FONA) to secure a patent airway for the patient. The scalpel-bougie-tube is the standard technique recommended by difficult airway societies, which involves cutting the anterior neck with a surgical blade and making way for a 6-mm tube mounted over a bougie. This can be particularly challenging for anesthesiologists who have little experience with knives or this procedure in general. This is the primary reason FONA is executed late, even though the team is aware that it should be done. In this case report, we describe two cases (emergency and elective) in which we used the needle-catheter-wire technique with some modifications using Tritube to secure the airway and provide mechanical ventilation.