Table of Content

15 June 2017, Volume 8 Issue 2

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Original Articles

Improving hospital-based trauma care for road traffic injuries in Malawi

Linda Chokotho, Wakisa Mulwafu, Isaac Singini, Yasin Njalale, Kathryn H. Jacobsen

2017, 8(2):  85-90.  doi:10.5847/wjem.j.1920-8642.2017.02.001

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BACKGROUND: The mortality rate from road traffic injuries has increased in sub-Saharan Africa as the number of motor vehicles increase. This study examined the capacity of hospitals along Malawi's main north-south highway to provide emergency trauma care.

METHODS: Structured interviews and checklists were used to evaluate the infrastructure, personnel, supplies, and equipment at all four of Malawi's central hospitals, ten district hospitals, and one mission hospital in 2014. Most of these facilities are along the main north-south highway that spans the country.

RESULTS: Between July 2013 and March 2014, more than 9 200 road traffic injuries (RTIs) and 100 RTI deaths were recorded by the participating hospitals. All of the hospitals reported staff shortages, especially during nights and weekends. Few clinicians had completed formal training in emergency trauma management, and healthcare workers reported gaps in knowledge and skills, especially at district hospitals. Most central hospitals had access to the critical supplies and medications necessary for trauma care, but district hospitals lacked some of the supplies and equipment needed for diagnosis, treatment, and personal protection.

CONCLUSION: The mortality and disability burden from road traffic injuries in Malawi (and other low-income countries in sub-Saharan Africa) can be reduced by ensuring that every central and district hospital has a dedicated trauma unit with qualified staff who have completed primary trauma care courses and have access to the equipment necessary to save lives.

Patient tracking in earthquake emergency response in Iran: A qualitative study

Nahid Tavakoli, Mohammad H Yarmohammadian, Reza Safdari, Mahmoud Keyvanara

2017, 8(2):  91-98.  doi:10.5847/wjem.j.1920-8642.2017.02.002

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BACKGROUND: After a disaster, all victims have to be rapidly and accurately identified for locating, tracking and regulating them. The purpose of this study was to summarize people’s experiences that how the patients were tracked in past earthquake disasters in Iran.

METHODS: A qualitative study was carried out in 2015. This was an interview-based qualitative study using content analysis. The interviewed people included physicians, nurses, emergency medical technicians, disaster managers, Red Crescent Society' first responders and managers. Participants were identi?ed using a snow ball sampling method. Interviews were audiotaped, transcribed, coded, and entered into MAXQDA (version 10) for coding and content analysis.

RESULTS: Three main themes and seven categories including content (recoding data), function (identification of victims, identification of the deceased, informing the patients' relatives, patients’ evacuation and transfer, and statistical reporting), technology (the state of using technology) were identified that showed the patient tracking status in past earthquakes in Iran.

CONCLUSION: Participants believed that to identify and register the data related to patients or the dead, no consistent action plan was available. So developing a consistent patient tracking system could overcome this issue and improve patient safety.

Prediction of motor recovery after ischemic stroke using diffusion tensor imaging: A meta-analysis

Jing-fen Jin, Zhi-ting Guo, Yu-ping Zhang, Yuan-yuan Chen

2017, 8(2):  99-105.  doi:10.5847/wjem.j.1920-8642.2017.02.003

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BACKGROUND: This systematic review aims to investigate the prediction value of diffusion tensor imaging for motor function recovery of ischemic stroke patients.

METHODS: Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 9), PubMed, Embase, Clarivate Analytics, Scopus, CINAHL, Chinese Biomedical Literature Database, China National Knowledge Infrastructure and Google Scholar were searched for either motor recovery or corticospinal tract integrity by diffusion tensor imaging in different stroke phase from January 1, 1970, to October 31, 2016. The study design and participants were subjected to metrological analysis. Correlation coefficient (r) was used for evaluating the relationship between fractional anisotropy (FA) and motor function outcome. Correlation coefficient values were extracted from each study, and 95% confidence intervals (CIs) were calculated by Fisher's z transformation. Meta-analysis was conducted by STATA software.

RESULTS: Fifteen studies with a total of 414 patients were included. Meta-analysis showed that FA in the subacute phase had the significant correlation with motor function outcome (ES=0.75, 95%CI 0.62-0.87), which showed moderate quality based on GRADE system. The weight correlation coefficient revealed that an effect size (ES) of FA in acute phase and chronic phase was 0.51 (95%CI 0.33-0.68) and 0.62 (95%CI 0.47-0.77) respectively.

CONCLUSION: This meta-analysis reveals that FA in the subacute phase after ischemic stroke is a good predictor for functional motor recovery, which shows moderate quality based on the GRADE system.

Fibrinogen degradation product levels on arrival for trauma patients requiring a transfusion even without head injury

Youichi Yanagawa, Kouhei Ishikawa, Kei Jitsuiki, Toshihiko Yoshizawa, Yasumasa Oode, Kazuhiko Omori, Hiromichi Ohsaka

2017, 8(2):  106-109.  doi:10.5847/wjem.j.1920-8642.2017.02.004

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BACKGROUND: There have been few reports on the clinical significance of the fibrinogen degradation product (FDP) level in trauma patients with and without head injury. We retrospectively analyzed trauma patients with or without head injury to investigate the clinical significance of the FDP level.

METHODS: From April 2013 to June 2015, a medical chart review was retrospectively performed for all patients with trauma. The exclusion criteria included patients who did not receive a transfusion. The patients were divided into two groups: a FDP>100 group, which included patients who had an FDP level on arrival over 100 ng/mL, and a FDP≤100 group.

RESULTS: The ratio of open fractures and the prothrombin ratio in the FDP>100 group were significantly smaller than those observed in the FDP≤100 group. The average age, ratio of blunt injury, Injury Severity Score (ISS), volume of transfusion and mortality ratio in the FDP>100 group were significantly greater than those in the FDP≤100 group. There was a weakly positive correlation between the FDP level and ISS (R=0.35, P=0.002), but it was not associated with the transfusion volume. The results of an analysis excluding patients with head injury showed a similar tendency.

CONCLUSION: The FDP levels may be a useful biochemical parameter for the initial evaluation of the severity of trauma and mortality even in blunt traumatized patients without head injury or with stable vital signs.

Potential impact of early physiotherapy in the emergency department for non-traumatic neck and back pain

Pothiawala Sohil, Pua Yong Hao, Leong Mark

2017, 8(2):  110-115.  doi:10.5847/wjem.j.1920-8642.2017.02.005

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BACKGROUND: Musculoskeletal complaints, especially non-traumatic neck and back pain, are routinely encountered in the emergency department (ED) and lead to ED overcrowding, a burgeoning wait time for physiotherapy and outpatient orthopedic reviews. The study aimed to evaluate the impact of early physiotherapy evaluation and treatment (EPET) vs. standard care (SC) on clinical outcomes for patients presenting to the ED with non-traumatic neck and back pain.

METHODS: A retrospective observational study of 125 patients who presented to the ED with non-traumatic neck and back pain with/without peripheral symptoms from July 2010 to February 2011. Neck Disability Index (NDI), Modified Oswestry Low Back Pain Disability Questionnaire (MODI) and 11-point Numeric Pain Rating Scale were used as outcome measures and compared between groups at a mean of 34 days from their initial ED visit.

RESULTS: We identified a total of 125 patients. EPET group comprised 62 patients (mean age, 45 years; men, 63%) and SC group comprised 63 patients (mean age, 45 years; men, 43%). The EPET and SC groups received physiotherapy at a median of 4 and 34 days respectively from their first ED visit. EPET patients had significantly lower levels of disability (9.0% vs. 33.4%, Welch t-test, P<0.001) and pain (median value, 1 vs. 4 points, Mann-Whitney U-test, P<0.001) compared with SC patients.

CONCLUSION: Early access to physiotherapy in ED was associated with reduced pain and disability levels. EPET protocol can potentially decrease the demand on outpatient orthopedic services, thereby freeing up available resources to treat patients who are more likely to benefit from it.

Trend of blood lactate level in acute aluminum phosphide poisoning

Peyman Erfantalab, Kambiz Soltaninejad, Shahin Shadnia, Nasim Zamani, Hossein Hassanian-Moghaddam, Arezou Mahdavinejad, Behrooz Hashemi Damaneh

2017, 8(2):  116-120.  doi:10.5847/wjem.j.1920-8642.2017.02.006

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BACKGROUND: Aluminum phosphide (AlP) poisoning is common in the developing countries. There is no specific antidote for the treatment of acute AlP poisoning. Early diagnosis of poisoning and outcome predictors may facilitate treatment decisions. The objective of this study was to determine the trend of blood lactate level in acute AlP poisoning to evaluate its role as a prognostic factor.

METHODS: This was a prospective study on acute AlP intoxicated patients during one year. Demographic data, clinical and laboratory data on admission, and outcome were recorded in a self-made questionnaire. Blood lactate levels were analyzed every two hours for 24 hours.

RESULTS: Thirty-nine (27 male, 12 female) patients were included in the study. The mortality rate was 38.5%. The mean blood pressure, pulse rate, blood pH and serum bicarbonate level were significantly different between the survivors and non-survivors groups. Blood lactate level was significantly higher in the non-survivors group during 8 to 16 hours post ingestion.

CONCLUSION: Blood lactate level could be used as an index of severity of acute AlP poisoning.

Infected aortic and iliac aneurysms: Clinical manifestations in the emergency departments of two hospitals in southern Taiwan, China

Chang-Chih Tsai, Chien-Chin Hsu, Kuo-Tai Chen

2017, 8(2):  121-125.  doi:10.5847/wjem.j.1920-8642.2017.02.007

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BACKGROUND: Accurate diagnosis of infected aortic and iliac aneurysms is often delayed, hampering timely treatment and potentially resulting in a fatal consequence. The aim of this study was to discover useful clinical features that can help physicians to identify these patients.

METHODS: We reviewed the discharge notes from two hospitals and identified all patients who had a diagnosis of infected aneurysms of the thoracoabdominal aorta and iliac arteries between July 2009 and December 2013. Eighteen patients, aged from 41 to 93, were reviewed. Only 6 patients were diagnosed accurately in their first visit to our ED.

RESULTS: Most patients had at least one underlying illness, and it took 1 to 30 (9.9±6.5) days for physicians to diagnose their infected aneurysm. Localized pain and fever were the two most commonly presented symptoms. The majority (92%) of isolated microorganisms were gram-negative bacilli, including Salmonella spp, Klebsiella pneumoniae, and Escherichia coli. Two of the 3 patients who underwent non-operative therapy died, and all of the patients who underwent a combination of medical and operative therapies survived.

CONCLUSION: We suggest that physicians liberally use computed tomography scans on patients with unknown causes of pain and inflammatory processes. A combination of surgical and medical treatments is indicated for all patients with infected aortic and iliac aneurysms.

The RAMA Ped Card: Does it work for actual weight estimation in child patients at the emergency department

Thavinee Trainarongsakul, Pitsucha Sanguanwit, Supawan Rojcharoenchai, Kittisak Sawanyawisuth, Yuwares Sittichanbuncha

2017, 8(2):  126-130.  doi:10.5847/wjem.j.1920-8642.2017.02.008

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BACKGROUND: In emergency conditions, the actual weight of infants and young children are essential for treatments. The RAMATHIBODI Pediatric Emergency Drug Card or RAMA Ped Card has also been developed to estimate actual weight of the subjects. This study aimed to validate the RAMA Ped Card in correctly identifying the actual weight of infants and young adults.

METHODS: This study was a prospective study. We enrolled all consecutive patients under 15 years of age who visited the emergency department (ED). All eligible patients' actual weight and height were measured at the screening point of the ED. The weight of each patient was also measured using the unlabeled RAMA Ped Card. The Cohen's kappa values and agreement percentages were calculated.

RESULTS: During the study period, there were 345 eligible patients. The RAMA Ped Card had a 61.16% agreement with the actual weight with a kappa of 0.54 (P<0.01), while the agreement with the actual height had a kappa of 0.90 and 91.59% agreement. Sub-group analysis found kappa scores with good range in two categories: in cases of accidents and in the infant group (kappa of 0.68 and 0.65, respectively).

CONCLUSION: The RAMA Ped Card had a fair correlation with the actual weight in child patients presenting at the ED. Weight estimation in infant patients and children who presented with accidents were more accurate.

Knowledge, attitude and anxiety pertaining to basic life support and medical emergencies among dental interns in Mangalore City, India

Vinej Somaraj, Rekha P Shenoy, Ganesh Shenoy Panchmal, Praveen S Jodalli, Laxminarayan Sonde, Ravichandra Karkal

2017, 8(2):  131-135.  doi:10.5847/wjem.j.1920-8642.2017.02.009

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BACKGROUND: This cross-sectional study aimed to assess the knowledge, attitude and anxiety pertaining to basic life support (BLS) and medical emergencies among interns in dental colleges of Mangalore city, Karnataka, India.

METHODS: The study subjects comprised of interns who volunteered from the four dental colleges. The knowledge and attitude of interns were assessed using a 30-item questionnaire prepared based on the Basic Life Support Manual from American Heart Association and the anxiety of interns pertaining to BLS and medical emergencies were assessed using a State-Trait Anxiety Inventory (STAI) Questionnaire. Chi-square test was performed on SPSS 21.0 (IBM Statistics, 2012) to determine statistically significant differences (P<0.05) between assessed knowledge and anxiety.

RESULTS: Out of 183 interns, 39.89% had below average knowledge. A total of 123 (67.21%) reported unavailability of professional training. The majority (180, 98.36%) felt the urgent need of training in basic life support procedures. Assessment of stress showed a total of 27.1% participants to be above high-stress level. Comparison of assessed knowledge and stress was found to be insignificant (P=0.983).

CONCLUSION: There was an evident lack of knowledge pertaining to the management of medical emergencies among the interns. As oral health care providers moving out to the society, a focus should be placed on the training of dental interns with respect to Basic Life Support procedures.

Effect of metronome rates on the quality of bag-mask ventilation during metronome-guided 30:2 cardiopulmonary resuscitation: A randomized simulation study

Ji Ung Na, Sang Kuk Han, Pil Cho Choi, Dong Hyuk Shin

2017, 8(2):  136-140.  doi:10.5847/wjem.j.1920-8642.2017.02.010

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BACKGROUND: Metronome guidance is a feasible and effective feedback technique to improve the quality of cardiopulmonary resuscitation (CPR). The rate of the metronome should be set between 100 to 120 ticks/minute and the speed of ventilation may have crucial effect on the quality of ventilation. We compared three different metronome rates (100, 110, 120 ticks/minute) to investigate its effect on the quality of ventilation during metronome-guided 30:2 CPR.

METHODS: This is a prospective, randomized, crossover observational study using a RespiTrainer○ ^r. To simulate 30 chest compressions, one investigator counted from 1 to 30 in cadence with the metronome rate (1 count for every 1 tick), and the participant performed 2 consecutive ventilations immediately following the counting of 30. Thirty physicians performed 5 sets of 2 consecutive (total 10) bag-mask ventilations for each metronome rate. Participants were instructed to squeeze the bag over 2 ticks (1.0 to 1.2 seconds depending on the rate of metronome) and deflate the bag over 2 ticks. The sequence of three different metronome rates was randomized.

RESULTS: Mean tidal volume significantly decreased as the metronome rate was increased from 110 ticks/minute to 120 ticks/minute (343±84 mL vs. 294±90 mL, P=0.004). Peak airway pressure significantly increased as metronome rate increased from 100 ticks/minute to 110 ticks/minute (18.7 vs. 21.6 mmHg, P=0.006).

CONCLUSION: In metronome-guided 30:2 CPR, a higher metronome rate may adversely affect the quality of bag-mask ventilations. In cases of cardiac arrest where adequate ventilation support is necessary, 100 ticks/minute may be better than 110 or 120 ticks/minute to deliver adequate tidal volume during audio tone guided 30:2 CPR.

Diverse coagulopathies in a rabbit model with different abdominal injuries

Ruo Wu, Luo-gen Peng, Hui-min Zhao

2017, 8(2):  141-147.  doi:10.5847/wjem.j.1920-8642.2017.02.011

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BACKGROUND: Although coagulopathy can be very common in severe traumatic shock patients, the exact incidence and mechanism remain unclear. In this study, a traumatic shock rabbit model with special abdomen injuries was developed and evaluated by examining indicators of clotting and fibrinolysis.

METHODS: Forty New Zealand white rabbits were randomly divided into four groups: group 1 (sham), group 2 (hemorrhage), group 3 (hemorrhage-liver injury), and group 4 (hemorrhage-liver injury/intestinal injury-peritonitis). Coagulation was detected by thromboelastography before trauma (T₀), at 1 hour (T₁) and 4 hours (T₂) after trauma.

RESULTS: Rabbits that suffered from hemorrhage alone did not differ in coagulation capacity compared with the sham group. The clot initiations (R times) of group 3 at T₁ and T₂ were both shorter than those of groups 1, 2, and 4 (P<0.05). In group 4, clot strength was decreased at T₁ and T₂ compared with those in groups 1, 2, and 3 (P<0.05), whereas the R time and clot polymerization were increased at T₂ (P<0.05). The clotting angle significantly decreased in group 4 compared with groups 2 and 3 at T₂ (P<0.05).

CONCLUSION: This study suggests that different abdominal traumatic shock show diverse coagulopathy in the early phase. Isolated hemorrhagic shock shows no obvious effect on coagulation. In contrast, blunt hepatic injury with hemorrhage shows hypercoagulability, whereas blunt hepatic injury with hemorrhage coupled with peritonitis caused by a ruptured intestine shows a tendency toward hypocoagulability.

Letter to the editors

An unusual case of renal calculi leading to myocardial infarction and cardiogenic shock

Vanessa Santos, James Espinosa, Alan Lucerna, Andrew Caravello

2017, 8(2):  148-150.  doi:10.5847/wjem.j.1920-8642.2017.02.012

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Bacteremia or pseudobacteremia? Review of pseudomonas fluorescens infections

Takeshi Nishimura, Kenji Hattori, Akihiko Inoue, Taiji Ishii, Tetsuya Yumoto, Kohei Tsukahara, Astunori Nakao, Satoshi Ishihara, Shinichi Nakayama

2017, 8(2):  151-154.  doi:10.5847/wjem.j.1920-8642.2017.02.013

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Acute airway emergency caused by an organic foreign body located in the laryngeal mucosa

Freya Droege, Anke Schlueter, Stefan Hansen, Stephan Lang, Nina Dominas

2017, 8(2):  155-156.  doi:10.5847/wjem.j.1920-8642.2017.02.014

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Instructions for Authors

Instructions for Authors

2017, 8(2):  157-160. 

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