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.

Comparison of intranasal versus intravenous dexmedetomidine in postoperative pain control in traumatic mandibular fractures surgery: a randomized clinical trial

Tannaz Pourlak — 2024-11-11

Objective: Effective pain management in mandibular fractures is crucial due to the complications associated with opioids, such as respiratory depression and re-intubation. Non-opioid methods are therefore important. This study aims to compare the effectiveness, safety, and efficiency of intranasal (IN) versus intravenous (IV) dexmedetomidine (Dex) for reducing acute pain following mandibular surgery. Methods: This study was a randomized, double-blind clinical trial. All patients underwent general anesthesia, laryngoscopy, and intubation in a standardized manner. For the IN administration group, Dex was prescribed at a dose of 0.2 µ/kg (in the form of drops) half an hour before the start of anesthesia. For the IV administration group, Dex was administered at a dose of 0.5 µ/kg intravenously over ten minutes, half an hour before anesthesia. During the first 24 hours after surgery, pain intensity and the total amount of opioid medication (measured in mg of pethidine) were recorded for each patient. Results: There was no significant difference in pain intensity between the two groups in the post-anesthesia care unit (P=0.898), one hour (P=0.052) and 24 hours post-surgery (P=0.898). However, pain intensity was significantly lower in the IN Dex group at the second (P=0.044), fourth (P=0.041), sixth (P=0.048), and twelfth (P=0.025) hours. Total pethidine injected in the IN Dex group was significantly lower than in the IV Dex group (P=0.041). Conclusion: This study underscores the efficacy of IN Dex as a viable alternative for postoperative pain management in traumatic mandibular fracture surgeries.

Kounis syndrome in the era of COVID-19: pathophysiology, clinical challenges, and therapeutic approaches

Abinavi Balaji — 2024-11-15

Kounis syndrome, first described in 1991, refers to allergic or hypersensitive reactions that result in acute coronary syndrome (ACS). In addition to SARS-CoV-2, this disease has enhanced our comprehension of viral infections, inflammatory reactions, and cardiovascular repercussions. The COVID-19 pandemic has exposed the occurrence of cardiac damage, arrhythmias, and thrombotic events that are associated to the SARS-CoV-2 virus, thereby making the understanding of their development more complex. This research explores the complex correlation between Kounis syndrome and COVID-19, encompassing the phenomena of cytokine storms and endothelial dysfunction. Diagnosing Kounis syndrome in the context of COVID-19 presents challenges, nevertheless, it is imperative to distinguish it from other cardiovascular disorders. The identification of risk factors and predisposing situations that can exacerbate Kounis syndrome in COVID-19 patients is highlighted, with a particular focus on patient assessment. The care of Kounis syndrome in COVID-19 necessitates a multidisciplinary strategy that involves collaboration among cardiologists, allergists, and other specialists. Possible therapies encompass epinephrine, antihistamines, corticosteroids, cardiovascular interventions, as well as long-term surveillance and measures to reduce risk. Additional investigation should include epidemiological enquiries, experimental frameworks, and advancements in diagnostic and therapeutic approaches. Comprehending the connection between viral infections and coronary syndromes caused by allergies is crucial for clinical practice and the well-being of patients. This review explores the neurobiological similarities and clinical implications of Kounis syndrome and COVID-19, aiming to enhance comprehension and treatment of this intricate clinical scenario.

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.

A 67-year-old man with cardiac air tamponade: a case report

Somayeh Mirbagheri — 2024-11-11

Pneumopericardium is a rare entity, primarily described as a result of causes such as penetrating/blunt trauma and procedures, aspergillosis, and diaphragmatic hernia. Malignancy history has also emerged as a new cause. A 67-year-old man with a history of active cancer presented to the emergency department with the chief complaint of shortness of breath and hemoptysis. He had low blood pressure and tachycardia along with hypoxia. The thoracic computed tomography (CT) imaging revealed a right pulmonary mass, central necrosis, and anterior pneumopericardium and gas adjacent to the right pericardial border.Patients with small, stable, asymptomatic pneumopericardium may be treated conservatively with close monitoring to prevent escalation to cardiac tamponade. Prompt decompression is advised if there are progressive symptoms, a concurrent pneumothorax, or cardiac tamponade.

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.

Utilizing Design Thinking in the Administration of Emergency Departments

Saeed Aqavil-Jahromi — 2024-11-12

Emergency Departments (EDs) are the primary access point of medical resources for patients who need urgent care. These departments face numerous administrative obstacles and challenges, such as managing large patient populations, providing timely access to treatment availability, and coordinating various medical and non-medical staff. Our ED is in a tertiary-care referral hospital with more than 70,000 visits annually. Despite moving the ED to a space of about 4000 square meters and doubling the number of beds in the past two years, the overcrowding problem still exists and has even worsened. Solutions that have been proposed to reduce this problem, such as reducing the length of stay of patients by increasing the discharge of patients by emergency specialists or other specialists responsible for patients, limiting the number of emergency beds to reduce the workload of nurses, interacting with hospital outpatient clinics for visiting patients with lower acuity. However, these efforts have not been successful and have increased the dissatisfaction of patients, nursing staff, and physicians. Therefore, it seems that there is a need for innovation in providing solutions to solve the problems. While traditional administrative methods may not help address these issues comprehensively, design thinking (DT), a human-centered approach to innovation, offers a talented alternative. This method focuses on understanding what users need, redefining problems in a human-centric way, and creating innovative solutions. It can significantly improve patient care and ED efficiency. DT entails five steps:

Empathy (understanding patient and staff needs): Administrators can use interviews, patient and staff observations, or surveys to understand the experiences of both patients and staff in their facility. This stage is crucial for understanding the 'true problem' and creating user-centric solutions.
Definition (problem identification): Identify the core problem(s) by analyzing insights, looking for trends, or combining prominent issues.
Ideation (brainstorming solutions): In this step, multidisciplinary teams organize to generate numerous and different ideas, often through workshops involving healthcare professionals, administrative staff, and patients.
Prototyping (developing solutions): Promising ideas are transformed into prototypes. These models are typically low-fidelity and inexpensive for easy testing and iteration.
Testing (pilot testing and continuous modification): Feedback is collected from users in real-world settings to test the prototype to determine how well it achieves its goal. The Discovery workshop is an ongoing process rather than a one-time event. Solutions are continuously adjusted based on current and future ED staff input. One of the principles behind DT is that it evolves with time, which means it develops and improves according to needs.

Empathy and user-centered design of emergency departments can create responsive and cooperative spaces for patients while reducing overall stress. If bottlenecks and inefficiencies are recognized, they can be resolved to streamline processes, resulting in reduced wait times and increased efficiency. A culture of creativity and teamwork can be established by including staff in the brainstorming and initial design steps. This leads to greater job satisfaction and reduced turnover. The solutions created through DT are likely to be more scalable and generalizable across other departments or hospitals, thus driving broader systemic change.

While DT has many benefits, its application in EDs is challenging. This refers to any change that is challenging for an organization to implement. It requires significant time and money and can be particularly difficult because it involves integrating long-standing solutions with new capabilities. Solutions to these challenges will require strong leadership, ongoing capacity building, and a dedication to progressive change.

DT in ED management holds great promise for improving patient care and efficiency. While hospitals will never operate like startups, prioritizing human-centered design approaches outside of the ED can result in solutions that enable us to address the meaningful and unique challenges faced within them. These solutions often lead to improved patient care, reduced disagreement, and a more satisfying work environment for the staff. Assessing its long-term effects through longitudinal studies and evaluating its impact on populations within real-world contexts will enrich our understanding of this area.