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Table of Content

    15 December 2016, Volume 7 Issue 4
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    Review Article
    The state and future of emergency medicine in Macedonia
    Bret Nicks, Marko Spasov, Christopher Watkins
    2016, 7(4):  245-249.  doi:10.5847/wjem.j.1920-8642.2016.04.001
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    BACKGROUND: Macedonia has universal public health care coverage. Acute and emergency patient care is provided in different care environments based on the medical complaint and resource proximity. While emergency medicine and well organized emergency departments (EDs) are an essential component of any developed health care system, emergency medicine as a specialty is relatively non-existent in Macedonia.
    DATA RESOURCES: A system assessment regarding presence, availability and capacity of EDs was completed from 2013-2015, based upon assessments of 21 institutions providing emergency care and information provided by the Ministry of Health. This assessment establishes a benchmark from which to strategically identify, plan and implement the future of emergency medicine in Macedonia.
    RESULTS: In general, emergency departments - defined by offering acute care 24 hours per day, 7 days per week - were available at all general and university hospitals. However, care resources, emergency and acute care training, and patient care capacity vary greatly within the country. There is limited uniformity in acute care approach and methodology. Hospital EDs are not organized as separate divisions run by a head medical doctor, nor are they staffed by specialists trained in emergency medicine. The diagnostic and treatment capacities are insufficient or outdated by current international emergency medicine standards and frequently require patient transfer or admission prior to initiation.
    CONCLUSION: Most of the surveyed hospitals are capable of providing essential diagnostic tests, but very few are able to do so at the point or time of presentation. While emergency medical services (EMS) have improved system-wide, emergent care interventions by EMS and within all hospitals remain limited. Further system-wide acute and emergency care improvements are forthcoming.

    Amiodaron in atrial fibrillation: post coronary artery bypass graft
    Paria Habibollahi, Shahrzad Hashemi Jam, Samad Shams Vahdati, Hamidreza Morteza Baghi, Hassan Amiri
    2016, 7(4):  250-254.  doi:10.5847/wjem.j.1920-8642.2016.04.002
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    BACKGROUND: Atrial fibrilation (AF) is the most common complication following heart surgeries; it often occurs in patients after coronary artery bypass graft (CABG). The purpose of this review is to categorize prophylaxes or treatment by administration of Amiodaron in patients with CABG.
    DATA RESOURCES: We searched google scholar, pubmed, and Cochrane Library databases (the period 1970-2010) for articles on Amiodaron in CABG and cardiac surgery. A total of 1 561 articles were identified, and 30 articles met the criteria and were enrolled in this review.
    RESULTS: Most studies supported Amiodarone for prophylaxi purpose in patients who were performed with CABG; few papers supported Amiodaron as a drug for treating CABG. The prophylaxis can decrease the incidence rate of AF in CABG, but if it uses as a treatment, the side effect of Amiodaron will decrease because all of the patients will not get Amiodarone. In the other hand use of Amiodarone as a treatment does not influence the length of hospital stay significantly but these kinds of study are so few.
    CONCLUSION: No appropriate therapeutic method has been defined for AF. At present, the common way of treating AF following cardiac surgery is mainly based on prophylaxis in medical books and references.

    Original Articles
    Short lessons in basic life support improve self-assurance in performing cardiopulmonary resuscitation
    Mario Kobras, Sascha Langewand, Christina Murr, Christiane Neu, Jeannette Schmid
    2016, 7(4):  255-262.  doi:10.5847/wjem.j.1920-8642.2016.04.003
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    BACKGROUND: There are several reasons why resuscitation measures may lead to inferior results: difficulties in team building, delayed realization of the emergency and interruption of chest compression. This study investigated the outcome of a new form of in-hospital cardiopulmonary resuscitation (CPR) training with special focus on changes in self-assurance of potential helpers when faced with emergency situations.
    METHODS: Following a 12-month period of CPR training, questionnaires were distributed to participants and non-participants. Those non-participants who intended to undergo the training at a later date served as control group.
    RESULTS: The study showed that participants experienced a significant improvement in self-assurance, compared with their remembered self-assurance before the training. Their self-assurance also was significantly greater than that of the control group of non-participants.
    CONCLUSION: Short lessons in CPR have an impact on the self-assurance of medical and non-medical personnel.

    Is current training in basic and advanced cardiac life support (BLS & ACLS) effective? A study of BLS & ACLS knowledge amongst healthcare professionals of North-Kerala
    Madavan Nambiar, Nisanth Menon Nedungalaparambil, Ottapura Prabhakaran Aslesh
    2016, 7(4):  263-269.  doi:10.5847/wjem.j.1920-8642.2016.04.004
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    BACKGROUND: Healthcare professionals are expected to have knowledge of current basic and advanced cardiac life support (BLS/ACLS) guidelines to revive unresponsive patients.
    METHODS: A cross-sectional study was conducted to evaluate the current practices and knowledge of BLS/ACLS principles among healthcare professionals of North-Kerala using pretested self-administered structured questionnaire. Answers were validated in accordance with American Heart Association's BLS/ACLS teaching manual and the results were analysed.
    RESULTS: Among 461 healthcare professionals, 141 (30.6%) were practicing physicians, 268 (58.1%) were nurses and 52 (11.3%) supporting staff. The maximum achievable score was 20 (BLS 15/ ACLS 5). The mean score amongst all healthcare professionals was 8.9±4.7. The mean score among physicians, nurses and support staff were 8.6±3.4, 9±3.6 and 9±3.3 respectively. The majority of healthcare professionals scored ≤50% (237, 51.4%); 204 (44.3%) scored 51%-80% and 20 (4.34%) scored >80%. Mean scores decreased with age, male sex and across occupation. Nurses who underwent BLS/ACLS training previously had significantly higher mean scores (10.2±3.4) than untrained (8.2±3.6, P=0.001). Physicians with <5 years experience (P=0.002) and nurses in the private sector (P=0.003) had significantly higher scores. One hundred and sixty three (35.3%) healthcare professionals knew the correct airway opening manoeuvres like head tilt, chin lift and jaw thrust. Only 54 (11.7%) respondents were aware that atropine is not used in ACLS for cardiac arrest resuscitation and 79 (17.1%) correctly opted ventricular fibrillation and pulseless ventricular tachycardia as shockable rhythms. The majority of healthcare professionals (356, 77.2%) suggested that BLS/ACLS be included in academic curriculum.
    CONCLUSION: Inadequate knowledge of BLS/ACLS principles amongst healthcare professionals, especially physicians, illuminate lacunae in existing training systems and merit urgent redressal.

    Effects of a general practitioner cooperative co-located with an emergency department on patient throughput
    Michiel J. van Veelen, Crispijn L. van den Brand, Resi Reijnen, M. Christien van der Linden
    2016, 7(4):  270-273.  doi:10.5847/wjem.j.1920-8642.2016.04.005
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    BACKGROUND: In 2013 a General Practitioner Cooperative (GPC) was introduced at the Emergency Department (ED) of our hospital. One of the aims of this co-located GPC was to improve throughput of the remaining patients at the ED. To determine the change in patient flow, we assessed the number of self-referrals, redirection of self-referrals to the GPC and back to the ED, as well as ward and ICU admission rates and length of stay of the remaining ED population.
    METHODS: We conducted a four months' pre-post comparison before and after the implementation of a co-located GPC with an urban ED in the Netherlands.
    RESULTS: More than half of our ED patients were self-referrals. At triage, 54.5% of these self-referrals were redirected to the GPC. After assessment at the GPC, 8.5% of them were referred back to the ED. The number of patients treated at the ED declined with 20.3% after the introduction of the GPC. In the remaining ED population, there was a significant increase of highly urgent patients (P<0.001), regular admissions (P<0.001), and ICU admissions (P<0.001). Despite the decline of the number of patients at the ED, the total length of stay of patients treated at the ED increased from 14 682 hours in the two months' control period to 14 962 hours in the two months' intervention period, a total increase of 270 hours in two months (P<0.001).
    CONCLUSION: Introduction of a GPC led to efficient redirection of self-referrals but failed to improve throughput of the remaining patients at the ED.

    Acute Care/Trauma Surgeon's role in obstetrical/gynecologic emergencies (The OBCAT Alert)
    Seong K. Lee, Eddy H. Carrillo, Andrew Rosenthal, Rafael Sanchez, Chauniqua Kiffin, Dafney L. Davare
    2016, 7(4):  274-277.  doi:10.5847/wjem.j.1920-8642.2016.04.006
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    BACKGROUND: Overwhelming hemorrhage or other intra-abdominal complications may be associated with obstetrical or gynecologic (OB/GYN) procedures and may require the surgical training of an Acute Care/Trauma Surgeon. The OB Critical Assessment Team (OBCAT Alert) was developed at our institution to facilitate a multidisciplinary response to complex OB/GYN cases. We sought to review and characterize the Acute Care/Trauma Surgeon's role in these cases.
    METHODS: We conducted a retrospective review of all emergency consults during an OB/GYN case at our institution from 2008 to 2015. An OBCAT is a hospital based alert system designed to immediately notify OB/GYN, anesthesiology, Acute Care/Trauma, the intensive care unit (ICU), and the blood bank of a potential emergency during an OB/GYN case.
    RESULTS: There were 7±3 OBCAT alerts/year. Seventeen patients required Acute Care/Trauma surgery intervention for hemorrhage. Thirteen patients required damage control packing during their hospitalization. Blood loss averaged 6.8±5.5 L and patients received a total of 21±14 units during deliveries with hemorrhage. There were 17 other surgical interventions not related to hemorrhage; seven of these cases were related to adhesions or intestinal injury. Seven additional cases required evaluation post routine OB/GYN procedure; the most common reason was for severe wound complications. There were three deaths during this study period.
    CONCLUSION: Emergency OB/GYN cases are associated with high morbidity and may require damage control or other surgical techniques in cases of overwhelming hemorrhage. Acute Care/Trauma Surgeons have a key role in the treatment of these complex cases.

    The Buffering analysis to identify common geographical factors within the vicinity of severe injury related to motor vehicle crash in Malaysia
    Nik Hisamuddin Rahman, Ruslan Rainis, Syed Hatim Noor, Sharifah Mastura Syed Mohamad
    2016, 7(4):  278-284.  doi:10.5847/wjem.j.1920-8642.2016.04.007
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    BACKGROUND: The main objective was to identify common geographical buildup within the 100-meter buffer of severely injured based on injury severity score (ISS) among the motor vehicle crash (MVC) victims in Malaysia.
    METHODS: This was a prospective cohort study from July 2011 until June 2013 and involved all MVC patients attending emergency departments (ED) of two tertiary centers in a district in Malaysia. A set of digital maps was obtained from the Town Planning Unit of the district Municipal Office (local district map). Vector spaces were spanned over these maps using GIS software (ARCGIS 10.1 licensed to the study center), and data from the identified severe injured cases based on ISS of 16 or more were added. Buffer analysis was performed and included all events occurring within a 100 -meter perimeter around a reference point.
    RESULTS: A total of 439 cases were recruited over the ten-month data collection period. Fifty two (11%) of the cases were categorized as severe cased based on ISS scoring of 16 and more. Further buffer analysis looking at the buildup areas within the vicinity of the severely injured locations showed that most of the severe injuries occurred at locations on municipal roads (15, 29%), straight roads (16, 30%) and within villages buildup (suburban) areas (18, 35%).
    CONCLUSION: This study has successfully achieved its objective in identifying common geographical factors and buildup areas within the vicinity of severely injured road traffic cases.

    Prevention of aspiration of gastric contents during attempt in tracheal intubation in the semi-lateral and lateral positions
    Ichiro Takenaka, Kazuyoshi Aoyama
    2016, 7(4):  285-289.  doi:10.5847/wjem.j.1920-8642.2016.04.008
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    BACKGROUND: Pulmonary aspiration of gastric contents during tracheal intubation is a life-threatening complication in emergency patients. Rapid sequence intubation is commonly performed to prevent aspiration but is not associated with low risk of intubation related complications. Although it has been considered that aspiration can be prevented in the lateral position, few studies have evaluated the ability to prevent aspiration. Moreover, this position is not always a favorable position for tracheal intubation. If aspiration can be prevented in a clinically relevant semi-lateral position, it may be advantageous. We assessed the ability to prevent aspiration in the lateral position and various degrees of the semi-lateral position using a vomiting-regurgitation manikin model.
    METHODS: A manikin's head was placed in the neutral, simple extension, or sniffing position. The amount of aspirated saline into the bronchi during simulated vomiting was measured at semi-lateral position angles of 0º to 90º in 10º increments. The difference in the vertical height between the mouth corner and the inferior border of the vocal cord was measured radiologically at each semi-lateral position in the three head-neck positions.
    RESULTS: Pulmonary aspiration was prevented at the ≥70º, ≥80º, and 90º semi-lateral positions in the neutral, simple extension, and sniffing positions, respectively. The mouth was lower than the vocal cord in the semi-lateral position in which aspiration was prevented.
    CONCLUSION: The lateral or excessive semi-lateral position was necessary to protect the lung from aspiration in the head-neck positions commonly used for tracheal intubation. Prevention of aspiration was difficult within clinically relevant semi-lateral positions.

    Pattern of acute poisoning in Jimma University Specialized Hospital, South West Ethiopia
    Eyosias Teklemariam, Shibiru Tesema, Awol Jemal
    2016, 7(4):  290-293.  doi:10.5847/wjem.j.1920-8642.2016.04.009
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    BACKGROUND: Poisoning is a common cause of morbidity and mortality worldwide. People can be exposed to poisons either intentionally or accidentally. Designing appropriate treatment or prevention approaches depends on understanding of the nature and pattern of poisoning in a specific place. Information on the patterns of acute poisoning in Ethiopian hospitals is limited. This study was, therefore, conducted to evaluate the patterns of acute poisoning in Jimma University Specialized Hospital (JUSH), South West Ethiopia.
    METHODS: A record based retrospective analysis of acute poisoning cases presented to JUSH from January 1, 2012 to December 31, 2013 was conducted. The collected data was analyzed using SPSS version 16.
    RESULTS: Of the 103 patients, 49 (47.6%) were male and 54 (52.4%) were female. The highest prevalence of poisoning was observed in persons aged 12-20 years (70, 67.96%). Majority of the cases were intentional poisoning (52, 50.5%), and 28 (27.2%) of the cases were accidental. The common causes of poisoning were house hold cleansing agents (43, 41.7%), organophosphates (28, 27.2%) and drugs (13, 12.6%). Diarrhea and vomiting (49.5%), altered consciousness (16.5%) and epigastric pain (13.6%) were the common presenting symptoms.
    CONCLUSION: Majority of the victims of the acute poisoning in this study were aged 12-20 years. The most common mode of poisoning was intentional poisoning resulting from temporary quarrel. The common poisons used by the victims were found to be household cleansing agents.

    Enterogenous infection of Candida albicans in immunocompromised rats under severe acute pancreatitis
    Xiang-wang Zhao, Lei Yan, Dan Xu, Yu-hui Cui, Chun-hui Yang, Yan-jun Zhou, Jian-guo Tang
    2016, 7(4):  294-299.  doi:10.5847/wjem.j.1920-8642.2016.04.010
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    BACKGROUND: Opportunistic infection of Candida albicans (C. albicans) has become a serious problem in immunocompromised patients. The study aimed to explore the mechanism of enterogenous infection of C. albicans in immunocompromised rats under severe acute pancreatitis (SAP).
    METHODS: Sprague Dawley (SD) rats (n=100) were randomly assigned into 5 groups as the following: blank group, cyclophosphamide+ceftriaxone+SAP group, cyclophosphamide+ceftriaxone group, cyclophosphamide+SAP group, and cyclophosphamide group. The rats were sacrificed at 5 and 10 days, and their jejunum, colon, mesenteric lymph nodes, pancreas, intestinal content, and blood were quickly collected to detect C. albicans. A region of the 25S rRNA gene was chosen and amplified by polymerase chain reaction (PCR) to differentiate C. albicans genotypes. The amplified products were further sequenced and compared to judge their homology.
    RESULTS: Compared with the Cyclophosphamide group, the combination of immunosuppressants and broad-spectrum antibiotics significantly increased the colonization of C. albicans in intestine in 5 and 10 days. Pure SAP stress did not increase the opportunistic infection of C. albicans. The PCR products of C. albicans isolates all belonged to the genotype A family, and sequence alignment showed that the amplified fragments were homologous.
    CONCLUSION: The damage of immune system and broad-spectrum antimicrobial agents are important risk factors for opportunistic fungal infection. Intestinal tract is an important source for genotype-A C. albicans to translocate and invade into bloodstream.

    Letter to the editor
    Clinical characteristics of childhood cancer in emergency room in a tertiary hospital in Pakistan
    Amna Jawaid, Khubaib Arif, Nick Brown, Zehra Fadoo
    2016, 7(4):  300-302.  doi:10.5847/wjem.j.1920-8642.2016.04.011
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    Clinical Image
    Emergency department diagnosis of a concealed pleurocutaneous fistula in a 78-year-old man using point-of-care ultrasound
    Richard Amini, Albert Amini, Patrick Hollinger, Suzanne Michelle Rhodes, Charles Schmier
    2016, 7(4):  307-309.  doi:10.5847/wjem.j.1920-8642.2016.04.013
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    Stroke due to Bonzai use: two patients
    Baki Dogan, Hakan Dogru, Levent Gungor, Kemal Balci
    2016, 7(4):  310-312.  doi:10.5847/wjem.j.1920-8642.2016.04.014
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