Frontiers in Emergency Medicine

Comparison of infusion of dexmedetomedine and magnesium sulfate on the stability of hemodynamic status during emergency orthopedic surgery: a randomized double-blind clinical trial

Mohammad Irajian — 2024-08-12

Objective: Preparing patients for emergency surgeries requires accurate consideration of their clinical condition and medical history to avoid potential hemodynamic instability and compromise the immune system. This study aims to compare the effects of dexmedetomidine and magnesium sulfate infusions in maintaining stable hemodynamics during emergency orthopedic surgery. Methods: The present study was conducted as a randomized and double-blind clinical trial with the participation of 80 patients who were candidates for an emergency orthopedic surgery during 2021. Magnesium sulfate was administered as an intravenous bolus at a loading dose of 50 mg/kg over 10 minutes, followed by a continuous infusion at a rate of 15-20 mg/kg/hour. Dexmedetomidine was administered as an intravenous bolus at a loading dose of 1 mcg/kg over 10 minutes, followed by a continuous infusion at a rate of 0.2-0.7 mcg/kg/hour, depending on patient response. These infusions were initiated 15 minutes before induction of anesthesia and continued until the end of surgery. All drugs (dexmedetomidine and magnesium sulfate) were diluted in a 50-cc syringe and infused. The hemodynamic status (diastolic blood pressure (DBP), systolic blood pressure (SBP) mean arterial pressure (MAP) and heart rate (HR)) of the patients between the two groups was recorded and finally compared with each other. Results: The hemodynamic status (DBP, SBP, MAP and HR) between the two groups at all (perioperative time) times were without significant statistical differences (P˃0.05). Conclusion: Both dexmedetomidine and magnesium sulfate are effective and safe options for achieving hemodynamic stability during emergency orthopedic surgery.

Effects of altitude on biceps brachii and erector spinae muscles oxygen saturation during basic cardiopulmonary resuscitation: a simulation study

Sonia Piñero-Saez — 2024-09-19

Objective: To assess biceps brachii and erector spinae muscular oxygen saturation (SmO₂) by near infrared spectroscopy (NIRS), during 10 minutes of resuscitation at simulated altitudes of 600, 3000 and 5000 m before and after carrying out a simulation program for adaptation to hypoxia. Performing and maintaining a good-quality cardiopulmonary resuscitation (CPR) at higher altitudes may pose a significant challenge to resuscitators due tom decrease in arterial oxygen saturation. This fact adversely effects the quality of resuscitation. Methods: Participants performed 10 minutes of CPR on a mannequin in the laboratory in environments that simulated altitudes. Subsequently, a standardized altitude conditioning protocol was carried out using intermittent hypoxia. The participants performed CPR again under the conditions and altitudes previously referred to. Results: Initial heart rate (HR) at 5000 > 3000 m, and both > 600 m. HR at each altitude was higher conditioning at the end of CPR. The SmO₂ of both muscles showed no differences at the beginning and at the end of CPR and was higher in both muscles after the conditioning program before and at the end of CPR. In both muscles, SmO₂ values before and after conditioning show a slightly increasing trend during CPR. Conclusion: NIRS use allows developing an optimum training plan. The rescuer will know his limits and optimize his performance. The improvement in physical performance and recovery capacity induced by intermittent hypoxia conditioning programs increases the quality of CPR in prolonged cardiac arrests and in adverse conditions, such as at high altitudes.

Road traffic accidents and injuries, 2018: a multi-centric epidemiological study from India

Yogita Sharma — 2024-10-07

Objective: Road traffic injuries (RTIs) have been recognized globally as an important public health problem. Effective road safety initiatives should address the traffic system as a whole to find a solution and look at the traffic system as a collective to discuss interactions between vehicles, road users and road infrastructure. Therefore, epidemiological data from different geographies of the country should be available. Hence, an electronic-based comprehensive and integrated RTI surveillance system was established in five centres located across the country to assess the burden of RTIs, including the outcome. Methods: This paper is a cross-sectional multi-centric study conducted using an electronic-based comprehensive and integrated RTI surveillance system. Results: A total of 15,319 participants were enrolled under the surveillance of road traffic events for a period of one year. Self-fall/skid was the most common (34.87%) type of accident, followed by a crash between two vehicles (25.77%) and a crash with a pedestrian (16.59%). Among them, 88.94% were the injured, who were alive with or without rehabilitation, and 673 (4.43%) were dead. Mostly, two-wheelers (geared or non-geared) were involved in the accident as they shared a significant portion (75.54%) of the total accidents. Conclusion: The study highlights the epidemiological issues related to road accidents and RTIs that need to be addressed in order to find appropriate solutions for reducing the RTI burden. It gives an understanding of the manner of trauma, the pattern of injuries, and the outcome of road traffic accidents required to adopt efficient preventive and comprehensive trauma care.

Incidence and predictors of delirium among the intensive care unit patients at Jimma Medical Center, Southwest Ethiopia

Asaminew Habtamu — 2024-10-16

Objective: Delirium is characterized by impaired attention and awareness, accompanied by cognitive deficits. It develops rapidly and poses a considerable burden on healthcare systems. Patients in the intensive care unit (ICU) are particularly vulnerable to developing delirium. This study aims to determine the incidence and predictors of delirium among ICU patients at Jimma Medical Center in southwest Ethiopia in 2023. Methods: A prospective observational cohort study was conducted on 403 patients aged≥18 years admitted to emergency, surgical, and medical ICUs at Jimma Medical Center in southwest Ethiopia. Patients were assessed twice daily for delirium using the Richmond agitation sedation scale (RASS) and confusion assessment method (CAM). The association between independent variables and delirium incidence was analyzed using Cox proportional hazards (PH) regression. A univariate Cox PH model screened variables at a 0.25 significance level, followed by a multivariable Cox PH model for significant variables. Variables with a P-value≤0.05 were considered significantly associated with delirium incidence among ICU patients. Results: The findings of this study revealed that the overall occurrence of delirium among critically ill ICU patients was 118 (29.3%) (95% CI: 25%,34%), and the rest, 70.7% of the participants, were censored (95% CI: 66,75). The incidence rate of delirium among intensive care unit patients was 21.2 (95% CI: 17.8,25.4) per 1000 person-days of observation. Chronic obstructive pulmonary disease (AHR: 1.94; 95% CI: 1.23,3.56), stroke (AHR: 1.8; 95%CI: 1.98,3.73), Oxygen Saturation less than 90% (AHR:1.61; 95% CI: 1.11,2.34) and Obesity (AHR: 0.35; 95%CI: 0.13,0.84) were independent predictors of delirium among ICU patients. conclusion: This study found that, with an incidence rate of 21.2 occurrences per 1000 person-days of observation, delirium greatly affects the outcome of intensive care unit patients in the Jimma Medical Center. The study identifies several factors that independently predict the occurrence of delirium in ICU patients, including obesity, stroke, low oxygen saturation levels, and COPD. Interestingly, our findings suggest that admission for heart failure may have a protective effect against delirium. Therefore, health professionals ought to give special attention to patients with identified predictors.

case of faecopneumothorax resulting from a delayed diagnosis of traumatic diaphragmatic injury

Ali Yamini — 2024-10-22

Diaphragmatic hernia is a rare condition that can result from blunt or penetrating trauma. It is often asymptomatic for years, making diagnosis challenging. In fact, up to 66% of diaphragmatic ruptures can go unnoticed at the time of trauma. Delayed diagnosis can lead to complications, including faecopneumothorax. We report the case of a 15-year-old Iranian female who had a history of a motor vehicle accident 1 year prior to being referred to our center. She presented with tension faecopneumothorax, which occurred due to the incarceration and strangulation of the large bowel in the thoracic cavity. the patient was urgently transferred to the operating room for exploratory surgery. In patients presenting with symptoms of pulmonary or intestinal obstruction and a history of thoracoabdominal injury, the clinician should consider diaphragmatic hernia as a potential diagnosis. Prompt recognition of this condition is crucial as complications can significantly increase morbidity and mortality rates.

Love protects us; we should take care of it

Mohammad Eftekhari — 2024-10-22

Five years of work as emergency physician (EP) in some of the busiest hospitals in a developing country has never been an exhausting experience for me. In fact, my immense passion for this job has brought me happiness even amidst the most challenging shifts. There has been, however, instances of extraordinary difficulty, which have long stuck in my mind. One of those occasions was the time when, at the end of an already tough shift, my middle-aged patient died despite our team’s efforts. At that very moment, I assumed that it would not be possible for me to survive from my terrible feelings this time. Nevertheless, just in a couple of days, I was prepared for my next shift. I wondered what helped me recover so early. I knew that loving my job had rescued me. However, many questions engaged my mind. What was the origin of this passion?

I have had the privilege of working with passionate, responsible physicians whose primary goal in life was caring for patients. This experience encouraged me to take pleasure in my struggle to improve my clinical practice. I should also humbly admit that plenty of medical students have gained the same attitude and insight from working with me.

The reputation of the experience of “love transmission” augmented somewhat the hypothesis of its origin. But what will be the consequences of that? Will the resilience and hardiness remain in the future or cause dropping out of my job earlier than normal?

A rapid review of the medical literature revealed only a few papers dealing with the role of love in medicine, none specifically pertaining to the realm of emergency medicine. Some studies investigated love in terms of biology. Tobias et al. evaluated central nervous system activity in response to love. They showed that love could activate the limbic structure which could in turn result in reduction of stress and improving health, well-being and productivity. Dr. Marcum defined the concept of “prudent love” by a philosophical analysis method in 2011. He maintains that wisdom in combination with the emotion of love can work synergistically and result in a better outcome. In other words, a physician with prudent love tries constantly with pleasure to gain more and the best knowledge and skill for caring of patients (i.e., more wisdom). A positive cycle will exist among the experience in mind and the pleasure in heart. This pleasure could heal a tired healer. Such physicians with prudent love not only will treat more effectively their patients, but will also feel more long-term wellness in their career, and perhaps even more longevity.

In summary, I believe EPs deserve a quality of life better than what is achieved through just struggling with difficulties and fighting against burnout. An EP who loves his job, has a different perception of inevitable occupational stresses, because love can create a mindset that views sad events and even failures as opportunities which motivates him instead of causing disappointment and tiredness. However, we are human beings and unwanted stress will inevitably occur. In these circumstances, such EPs will find out the best coping strategy to react to them properly in a way that would prevent from entrapment in the vicious cycle of burnout. I acknowledge that, at present, these remarks remain vague, poetic, and non-pragmatic. They need to be operationalized in the form of transferrable skills. Therefore, I think the topic of love in this context is an untouched area that merits further research, preferably in cooperation with psychologists and psychiatrists. I sincerely hope that in future we will see more powerful, self-healing physicians, who care for their patients with pleasure.