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

Background: The study aimed to compare the Macintosh and Airtraq laryngoscopes in terms of laryngoscopy time, laryngeal view, and soft tissue displacement during laryngoscopy.

Methods: Twenty-five adult patients of either sex, aged 18 to 50 years, scheduled for surgery under image control, were enrolled in the study. After administration of General Anaesthesia (GA), laryngoscopy was first performed using a Macintosh laryngoscope and followed by a second laryngoscopy with an Airtraq laryngoscope. Two X-ray images of the lateral cervical spine were taken following each laryngoscopy. During each laryngoscopy, the laryngeal view was graded on modified Cormack-Lehane (CL) grading. Laryngoscopy time in seconds with both laryngoscopes was recorded until the best view of the glottis was seen. Mean arterial pressure (MAP), Heart rate (HR), and Oxygen saturation (SpO2) were recorded before and after induction and immediately after both laryngoscopies. Soft tissue displacement was also calculated from the radiological image.

Results: Mean laryngoscopy time recorded using Airtraq was 5.04 ± 0.60 seconds as compared to Macintosh (8.14 ± 0.36 seconds; P < 0.001). Soft tissue displacement with Macintosh was 4.88 ± 1.03 and with Airtraq was 3.90 ± 1.39 mm (P = 0.064). No significant change in hemodynamic parameters was found after intubation with both laryngoscopes, when compared with baseline values.

Conclusion: We conclude that Airtraq produces a rapid and better laryngoscopic view of the glottis compared to the Macintosh laryngoscope. Less soft tissue displacement can further result in better hemodynamic stability with the use of Airtraq.

Background: Pain is the most common presentation in the Emergency Department (ED), yet its management is often suboptimal due to a busy environment, leading to oligoanalgesia. Traditional blind landmark-based nerve blocks and procedural sedation have notable disadvantages. Ultrasound-guided regional anesthesia (UGRA) offers a safe and effective alternative, addressing the complications of conventional methods.

Methodology: This prospective observational study was conducted at the ED of a tertiary care center from October 2022 to March 2024. Patients meeting the inclusion and exclusion criteria were enrolled after informed consent. Pain scores were recorded before and after the procedure. Pain relief was considered successful if there was at least a two-point reduction in pain score 30 minutes after the procedure. If the patient experienced discomfort during the procedure, it was considered an inadequate block, and additional analgesia was administered. If there was no pain reduction within 20 minutes, the block was deemed a failure.

Results: A total of 101 UGRA procedures were performed. Overall, 94.1% of patients had successful blocks, while 5.9% experienced block failure. The mean pain score at baseline was 7.4, which significantly dropped to 1.4 after 30 minutes of UGRA. Physicians reported high satisfaction with the ease of procedure, anatomical visibility, and local anesthetic spread.

Conclusion: The study demonstrates that UGRA is a highly effective and safe technique for pain management in the ED, with a high success rate and minimal complications when performed by emergency physicians.

Introduction: Ambulance resource allocation by using an evidence-based approach is very much required so that pre-hospital care service allocation is targeted to areas that prove to have a high incidence burden of injuries on the road. Hence, we conducted a geographic information system (GIS) hotspot analysis in a district to identify hotspot areas and temporal trending, aiming to guide the ambulance providers to provide service efficiently and hence improve the early care of trauma in a resource-limited setting. The study centers utilized the hospital-based Anglo-American model of ambulance services.

Methods: All ambulance dispatch cases for road traffic incidents (RTIs) from two tertiary centers in the District of Kota Bharu, Malaysia, were included. Data collection was carried out for 10 months commencing January 2023. The digital map consisted of layers of borough boundaries, and the road network was obtained from the local municipal office. The x and y GIS coordinates for each RTI location were recorded from the automated vehicle location (AVL) mapping system installed in the dispatch center that was linked to each of the ambulance units. Cases were included for all ambulance dispatch cases related to RTIs. Self-referrals, other modes of emergency department attendances, and missing GIS coordinates were excluded from analysis. The data were transferred into the Excel format, which in turn underwent GIS analysis by using ArcGIS (10.1). The GIS clustering analysis involved mapping of RTI cases based on borough and road network digital layers by using inverse distance weighting (IDW) analysis. Other secondary data were obtained from ambulance services records from both hospitals.

Results: A total of 439 RTI cases were recruited over the 10-month data collection period. Temporal analysis showed that there were obvious peaked RTI incidences (37% of all cases) in the late morning and early evening. Thirty percent of cases of RTI occurred during the weekend, with a slight surge on Saturdays. Urban area was the most common location for RTI (n = 247; 59.9%). Clustering analyses had shown two boroughs, namely Boroughs Demit and Binjai, with hotspot and high-severity injured cases, respectively.

Conclusion: The study identified two boroughs with hotspots for RTI that peaked in the early morning and during the weekend. Geographical information system findings had given insight to PHC providers for future planning in ambulance resource allocation in the area of interest based on location and time that needed the most.

Background: Stroke is a major cause of critical illness in resource-limited, conflict-affected regions, yet ICU-based data remain scarce. This study characterizes the epidemiology, temporal trends, and mortality predictors among patients with stroke admitted to the largest tertiary ICU in southern Yemen.

Patients and Methods: We conducted a retrospective cohort study of adult ICU admissions from October 2019 to September 2021. Stroke cases were identified using ICD-10 codes and classified by subtype (ischemic or hemorrhagic) via neuroimaging and the clinical records. Seasonal trend decomposition (STL) was used to analyze seasonal patterns, and multivariable logistic regression was performed to identify mortality predictors, adjusted for age, sex, and comorbidities.

Results: Among 1244 ICU admissions, 456 (36.7%) were patients with stroke, with a mean monthly admission rate of 19.0 ± 4.2 cases. Ischemic strokes predominated (82.0%; n = 374) over hemorrhagic strokes (18.0%; n = 82), with the proportion of ischemic strokes increasing from 80.0% to 85.3% (P = 0.08). STL analysis revealed significant seasonal variation, including an October peak (amplitude ±3.8 cases; P = 0.003) and an upward trend peaking in March 2021 (+4.2 cases/month; P = 0.017). Stroke admissions accounted for 14.6% to 59.4% of monthly ICU occupancy. Overall mortality was 19.1%, higher in hemorrhagic strokes (23.2%) than in ischemic strokes (18.2%; P = 0.03). Propensity-matched analysis confirmed increased 30-day mortality in hemorrhagic strokes (26.8% vs. 18.3%; standardized mean difference = 0.21). Multivariable analysis identified hemorrhagic subtype (adjusted OR, 1.82 [95% CI, 1.03–3.21]) and age (adjusted OR, 1.15 per 5-year increase [95% CI, 1.02–1.30]) as independent mortality predictors. Conversely, longer ICU stays were protective (adjusted OR, 0.95 per day [95% CI, 0.91–0.99]).

Conclusion: Stroke accounts for over one-third of ICU admissions in this setting, with hemorrhagic strokes conferring a significantly higher mortality risk. The observed seasonal peak and identified mortality predictors underscore the need for targeted surveillance and management protocols in resource-constrained ICUs.

Background: Treatment of agitation in the intensive care unit is constantly evolving. Currently, antipsychotics and benzodiazepines are commonly used to treat agitation. Dronabinol is an active cannabinoid that produces psychological effects similar to tetrahydrocannabinol.

Objective: The pilot study aimed to determine the efficacy of dronabinol for agitation in a Shock Trauma Intensive Care Unit (STICU) at a Tertiary Academic Medical Center in the United States.

Methods: This was a single-center, retrospective observational study of adult patients receiving dronabinol for agitation in the STICU unit from January 1, 2020, to June 1, 2024. Patients were excluded if they were prisoners, received dronabinol for an indication other than agitation, or received invasive mechanical ventilation or dexmedetomidine within 48 hours before or during dronabinol initiation. The primary outcome was the difference in cumulative morphine milligram equivalents (MME) 48 hours before and after dronabinol initiation.

Results: The charts of 110 patients were reviewed, and 25 patients were selected for inclusion. Patients had an average age of 42.28 ± 15.6 years. Out of 25 patients, 48% tested positive for cannabinoids, and 9% had a traumatic brain injury upon admission. The primary outcome was not statistically different between before and after dronabinol initiation (143.36 MME vs. 132.71 MME; P = 0.834). There was also no statistically significant decrease in the number of antipsychotic administrations (0.25 vs. 0.50; P = 0.497) or benzodiazepines and barbiturates (1.28 vs 0.91; P = 0.279).

Conclusion: Based on the findings from our study, which included a limited number of non-intubated patients admitted to a STICU, the addition of dronabinol did not statistically decrease the cumulative MME or the need for benzodiazepines, barbiturates, or anti-psychotics. Further studies are warranted to address the effects of dronabinol in intubated patients.

Background: Non-invasive ventilation (NIV), including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP), is essential in managing acute respiratory failure (ARF). The XVENT™ CMV20 Frontliner is a locally developed, dual-mode NIV device tailored for resource-limited settings. This study evaluated its performance and patient tolerance in CPAP and BiPAP modes.

Methods: In this single-center, randomized, equivalence trial (July–October 2020), adult patients with acute hypoxemic respiratory failure (SpO₂ <93%, respiratory rate >28/min) and no risk of hypercapnia were randomly assigned (1:1) to receive either CPAP or BiPAP via XVENT™. Outcomes included oxygen saturation, respiratory rate, blood pressure, heart rate, and comfort over 54 hours.

Results: Twenty patients were enrolled. Both CPAP and BiPAP significantly improved SpO₂ (>95%) within 3 hours (P < 0.0001), with concurrent reductions in respiratory rate, heart rate, and blood pressure. No significant differences were found between groups in these physiological parameters. However, comfort scores improved more in the CPAP group (P = 0.0006). The device operated stably, delivering consistent pressures with minor, non-clinically significant deviations from set values.

Conclusion: The XVENT™ CMV20 Frontliner effectively delivers CPAP and BiPAP therapy in ARF. Both modes improved oxygenation and reduced respiratory distress. CPAP was better tolerated, suggesting it may be the preferred mode in hypoxemic patients without hypercapnia, especially in resource-limited settings.

Clinical Trial Registry: ISRCTN68812324

Background: The present study aimed to evaluate the ease and success of placement of the i-gel, laryngeal mask airway (LMA) Protector, and Ambu AuraGain in relation to the operator’s experience.

Material and Methods: This prospective randomized study included 90 patients of either sex aged 18–60 years, classified as American Society of Anesthesiologists (ASA) physical status I or II, with 30 patients allotted to each of the three groups (groups A, B, and C). In groups A, B, and C, the airway was secured using the i-gel, LMA Protector, and Ambu AuraGain, respectively. The primary objective of the study was to evaluate the ease and success rate of placement of these three supraglottic airway devices (SADs), while the secondary objective was to compare their placement with respect to operator’s experience.

Results: The insertion time of the SAD was 14.12 ± 6.82, 19.17 ± 9.07, and 14.86 ± 6.42 s in groups A, B, and C, respectively. Statistically significant differences were observed between the i-gel and LMA Protector (p = 0.011) and between the Ambu AuraGain and LMA Protector (p = 0.029). The first-attempt success rate for placement was higher in group C (93.33%) compared with groups A and B (both 86.67%). The i-gel can be inserted quickly and easily, even by residents with limited airway management experience; however, placement of the LMA Protector was more difficult for residents with <20 SAD placements.

Conclusion: The current study concludes that the i-gel can be placed more swiftly without additional attempts by less experienced residents compared with the Ambu AuraGain and the LMA Protector.

Background: Malaysia’s prehospital care system, historically led by Assistant Medical Officers, is facing increasing complexity due to emerging trauma patterns, remote operations, and industrial emergencies. While the Advanced Diploma in Emergency Care subspecialisation in Prehospital Care (ADEC-PHC) serves as the national benchmark for training, its alignment with industrial requirements remains underexplored. This study aims to critically assess the congruence between expert expectations and the ADEC-PHC curriculum and to identify training gaps requiring pedagogical reform.

Methods: This qualitative, cross-sectional study employed a two-phase methodology: (1) nine semi-structured interviews with purposively sampled experts across government, private, and industrial sectors; and (2) analysis of three official ADEC-PHC curriculum documents. Data were thematically analysed using Braun and Clarke’s six-step framework, with cross-comparison of expert insights and curriculum content.

Results: Three thematic domains emerged: (1) clinical preparedness and procedural competency strongly aligned with curriculum; (2) non-technical and administrative competencies, including leadership, communication, and decision-making, largely absent from formal training; and (3) system-level and contextual readiness, including remote care, digital literacy, and medicolegal awareness, insufficiently addressed. Experts called for greater emphasis on critical thinking, reflective practice, and interdisciplinary management.

Conclusion: Despite strengths in technical training, the ADEC-PHC curriculum lacks structured development in non-technical and contextual competencies vital for modern prehospital care. These findings offer an empirically grounded framework for curriculum reform aligned with international standards, supporting the evolution of Malaysia’s prehospital care workforce into future-ready, autonomous providers.

Background: Chest trauma patients often require chest tube insertion to re-expand their lungs. While routine chest X-rays are commonly performed after tube removal to detect complications, their necessity is debated due to concerns about unnecessary radiation, costs, and prolonged hospitalization.

Objective: This study aimed to evaluate the necessity of routine chest radiographs following chest tube removal in patients with traumatic pneumothorax by examining the incidence of abnormal post-removal findings and their clinical relevance.

Materials and Methods: The medical records of traumatic patients at Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, from June 2020 to May 2023 were retrospectively reviewed. We enrolled patients who underwent chest tube insertion. Exclusion criteria included transfer to another hospital, death during admission, persistent mechanical ventilation at the time of tube removal, or Glasgow Coma Scale (GCS) score <8.

Results: Among the 207 patients analyzed, 82.1% were male, with a mean age of 43.4 years. Blunt trauma was the predominant mechanism of injury (94.7%), most often resulting in multiple organ injuries (52.7%). The median duration of chest tube placement was 6 days. Abnormal chest radiographs following chest tube removal were observed in 6.3% of patients. Among these, 69.2% presented symptoms such as chest pain, dyspnea, or hypoxemia. Overall, chest tube reinsertion was required in only 1.4% of all patients (n = 3), all of whom were both symptomatic and had abnormal radiographic findings. Clinical symptoms were the only independent predictor of both abnormal chest X-ray findings and chest tube reinsertion (P < 0.001).

Conclusion: Routine imaging after chest tube removal may be unnecessary in asymptomatic trauma patients. A symptom-guided approach appears safe and effective, reducing unnecessary imaging and resource use without compromising patient safety. These findings should be interpreted with caution, given the study’s limitations.

Background: Surgical site infections (SSIs) remain a significant concern in Cesarean sections (CS), with evidence-based intraoperative practices playing a central role in prevention. However, adherence to protocols often varies, requiring actions to minimize their impact on patients’ outcomes.

Aim: To improve compliance with intraoperative SSI prevention practices during Cesarean deliveries from 80% in August 2024 to 90% by January 2025.

Methods: A prospective before-and-after study using the Plan-Do-Study-Act (PDSA) model was conducted from August 2024 to January 2025 in a community hospital. Baseline data were collected 4 weeks prior. A checklist monitored key practices, including hand hygiene, timely administration of antibiotic prophylaxis, glove changes, operating room traffic, and normothermia. Observations were paired with staff education, reminders, and regular feedback to staff and leaders. Compliance and SSI rates were analyzed using descriptive statistics.

Results: One hundred and eighty-six procedures were observed (25 baseline, 161 intervention). Overall compliance improved from 52% to 100% by week 9. Surgical hand hygiene compliance increased from 76% to >80%. Compliance with the timely administration of antibiotic prophylaxis improved, particularly in emergency CS. Operating room traffic decreased significantly. Only one SSI occurred during the intervention (0.6%), compared to one during the baseline (4.0%).

Conclusion: Targeted quality improvement strategies improved compliance with key intraoperative SSI prevention practices and were associated with reduced infection rates. Education, real-time observation, and feedback were effective in promoting behavior change. Sustained improvement requires routine integration of monitoring into surgical workflows and ongoing analysis of practice adherence indicators.

Background: The STOP-BANG (SB) questionnaire is a validated screening tool for obstructive sleep apnea screening and may also serve as a predictor of difficult airway management. However, existing evidence linking SB scores to airway difficulty remains limited and inconsistent. This study addresses this gap by assessing the usefulness of the SB score as a simple, non-invasive preoperative predictor of difficult airway management.

Method: A qualitative observational study was conducted involving 250 patients aged 25–65 years (American Society of Anesthesiologists [ASA] physical status I–III) undergoing elective surgery under general anesthesia with endotracheal intubation. Each patient’s SB score was recorded preoperatively. Patients were then divided into two groups: Group I (SB score <3) and Group II (SB score ≥3). After induction of anesthesia, airway parameters were assessed, including mask ventilation grade, Cormack–Lehane (CL) laryngoscopic view, and the intubation difficulty scale (IDS) score.

Results: The mean age was 42.4 ± 13.9 years. In Group I, the mean weight and height were 60.9 ± 8.9 kg and 1.58 ± 0.07 m, respectively, while in Group II, they were 73.1 ± 8.9 kg and 1.61 ± 0.10 m, respectively (p < 0.05). Mask ventilation was easier in Group I, with 54.2% of patients exhibiting grade 1 ventilation, whereas 48.9% of patients in Group II had grade 3 ventilation. Slight intubation difficulty (IDS 1–5) was more frequent in Group II. Higher SB scores were also associated with poorer CL grades.

Conclusion: An SB score ≥3 effectively predicts difficult airway management, being associated with higher rates of difficult mask ventilation, poorer laryngoscopic views, and increased IDS. As a quick, reliable, and non-invasive tool, SB can help anesthesiologists anticipate airway challenges and enhance perioperative safety.

Background: Sepsis and septic shock are conditions characterized by systemic infection and tissue hypoperfusion. Septic shock is defined by the requirement for vasopressor to maintain a mean arterial pressure ≥65 mmHg, or the presence of hyperlactatemia (lactate >2 mmol/L) in the absence of hypovolemia. These patients face a markedly higher risk of death, and the Sequential Organ Failure Assessment (SOFA) scale serves as a valuable tool for quantifying this risk. Due to its medical complexity and associated mortality rates, numerous clinical and laboratory variables have been proposed to predict mortality outcomes. Among these variables, gasometric parameters—such as lactate and base excess—accurately reflect the degree of tissue hypoperfusion and, consequently, the severity of shock.

Methods: This retrospective observational study included patients admitted to Hospital Universitario San Ignacio between January 1, 2017, and December 31, 2019. Receiving operating characteristic curves and the Youden Index were used to identify new cut-off values for lactate and base excess in predicting mortality. Sensitivity and specificity for lactate and base excess were then calculated, with 28-day in-hospital mortality as the outcome.

Results: The average lactate level was 3 mmol/L with a base excess of -6.1 mmol/L, indicative of tissue hypoperfusion. Lactate levels were significantly higher in patients who died compared to survivors, highlighting their prognostic value. Similarly, base excess levels showed a significant trend towards more negative values in non-survivors compared to survivors. Lactate levels >3.5 mmol/L and base excess values <−7.5 mmol/L were associated with increased 28-day mortality rates.

Conclusion: Patients with septic shock had an average lactate level of 3 mmol/L and a base excess of −6.1 mmol/L on admission, indicating a higher risk of hemodynamic instability requiring vasopressor support. Elevated blood lactate levels >3.5 mmol/L and base excess levels <−7.5 mmol/L were strongly associated with increased in-hospital mortality rates.

Background: Extubation failure is a common and clinically significant complication in critically ill patients requiring invasive mechanical ventilation, particularly among those with coronavirus disease 2019 (COVID-19). This study aimed to characterize patients with COVID-19 who experienced extubation failure.

Methods: We conducted a retrospective cohort study using the institutional COVID-19 registry (RECOVID). The study included patients aged ≥18 years with confirmed COVID-19 who received invasive mechanical ventilation and were extubated in the intensive care unit (ICU) or Emergency Department. Extubation failure was defined as reintubation within 48 hours. Bivariate analyses were performed to assess the associations between clinical variables and extubation outcomes, followed by multivariable logistic regression to identify independent predictors.

Results: Among 492 intubated patients, 10.4% experienced extubation failure. Patients with extubation failure were more likely to be female (57% vs. 38%, p = 0.009) and to have a history of cardiac disease (45% vs. 10%, p < 0.001), malignancy (12% vs. 5%, p = 0.03), or immunosuppression (18% vs. 5%, p = 0.004). Extubation failure was associated with longer durations of mechanical ventilation [median 17 days, interquartile range (IQR): 12–29 vs. 8 days, IQR: 6–12; p < 0.001], prolonged ICU stay [median 24 days, IQR: 17–35 vs. 13 days, IQR: 9–19; p < 0.001], extended hospital stay [median 42 days, IQR: 24–55 vs. 21 days, IQR: 14–30; p < 0.001], and higher in-hospital mortality (20% vs. 10%, p = 0.037). Multivariate analysis identified cardiac disease, prolonged mechanical ventilation, and immunosuppression as independent risk factors for extubation failure.

Conclusion: Extubation failure occurred in 10% of ventilated COVID-19 patients and was strongly associated with preexisting cardiac disease, immunosuppression, and prolonged mechanical ventilation, leading to longer ICU and hospital stays and higher mortality. These findings highlight the importance of individualized weaning strategies in critically ill COVID-19 patients.