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Table of Content

    15 December 2018, Volume 9 Issue 4
    Original Articles
    Social attitude and willingness to attend cardiopulmonary resuscitation training and perform resuscitation in the Crimea
    Alexei Birkun, Yekaterina Kosova
    2018, 9(4):  237-248.  doi:10.5847/wjem.j.1920-8642.2018.04.001
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    BACKGROUND: To promote potentially life-saving bystander cardiopulmonary resuscitation (CPR), the proportion of CPR-trained general public and their attitude toward CPR should be assessed, which is yet to be done in the former Soviet Union countries. As a case study, the survey is aimed to investigate the prevalence of CPR training, CPR knowledge, attitude and willingness to attend training and attempt CPR in the general population of the Crimea.
    METHODS: A personal interview survey was done from November 2017 to January 2018 with quota sampling reflecting age, gender and territorial distribution of the Crimean population.
    RESULTS: Out of 384 persons surveyed, 53% were trained in CPR. Of trained, 24% passed training within the last year, 44% attended a single course. Among the non-trained, 51% never thought about the need to attend training. Knowledge of CPR is generally poor. About 52% wish to learn CPR, 79% and 91% are willing to attempt CPR on a stranger or a loved one, respectively. Lack of knowledge is the strongest barrier to attempt CPR. People aged ≥60, those with educational level lower than high school, widowed and retired are mostly untrained and unwilling to learn CPR. Females and unemployed are mostly untrained, but willing to be educated.
    CONCLUSION: There is a need for increasing CPR training and retraining, and improving awareness and motivation to learn CPR in the Crimean population, targeting the least trained groups. The results could be used as a reference point for future studies in the former USSR countries, utilising the same methodology.

    Sub-dissociative dose ketamine administration for managing pain in the emergency department
    Sergey Motov, Jefferson Drapkin, Antonios Likourezos, Joshua Doros, Ralph Monfort, John Marshall
    2018, 9(4):  249-255.  doi:10.5847/wjem.j.1920-8642.2018.04.002
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    BACKGROUND: We describe our experience of utilizing sub-dissociative dose ketamine (SDK) in managing a variety of acute and chronic painful conditions in the emergency department (ED).
    METHODS: A descriptive study was conducted in our ED over a period of seven years (2010-2016) by retrospectively reviewing charts of patients aged 18 and older presenting to the ED with painful complaints and receiving SDK analgesia. Primary data analyses included type of SDK administration (intravenous push [IVP], short-infusion [SI] or continuous infusion [CI]), dosing, rates of analgesic utilization before and after SDK administration, and adverse effects.
    RESULTS: Three hundred sixty-two patients were enrolled in the study. Mean ketamine doses given by IVP, SI and CI were 26.3 mg, 23.4 mg, and 11.3 mg. The mean duration of CI was 135.87 minutes. The percentage of patients not requiring post-SDK analgesia increased by 16%, 18%, and 37% in IVP, SI and CI groups. Adverse effects were recorded for 13% of patients.
    CONCLUSION: SDK administered by IVP, SI, and CI in the ED for a variety of painful conditions is a feasible analgesic modality in the ED that is associated with a decrease in overall requirements of post-ketamine analgesia and opioid sparing.

    Effect of sedative agent selection on morbidity, mortality and length of stay in patients with increase in intracranial pressure
    Brian G. Cornelius, Elizabeth Webb, Angela Cornelius, Kenneth W.G. Smith, Srdan Ristic, Jay Jain, Urska Cvek, Marjan Trutschl
    2018, 9(4):  256-261.  doi:10.5847/wjem.j.1920-8642.2018.04.003
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    BACKGROUND: To identify the effects of sedative agent selection on morbidity, mortality, and length of stay in patients with suspected increase in intracranial pressure. Recent trends and developments have resulted in changes to medications that were previously utilized as pharmacological adjuncts in the sedation and intubation of patients with suspected increases in intracranial pressure. Medications that were previously considered contraindicated are now being used with increasing regularity without demonstrated safety and effectiveness. The primary objective of this study is to evaluate and compare the use of Ketamine as an induction agent for patients with increased intracranial pressure. The secondary objective was to evaluate and compare the use of Etomidate, Midazolam, and Ketamine in patients with increased intracranial pressure.
    METHODS: We conducted a retrospective chart review of patients transported to our facility with evidence of intracranial hypertension that were intubated before trauma center arrival. Patients were identified during a 22-month period from January 2014 to October 2015. Goals were to evaluate the impact of sedative agent selection on morbidity, mortality, and length of stay.
    RESULTS: During the review 148 patients were identified as meeting inclusion criteria, 52 were excluded due to incomplete data. Of those the patients primarily received; Etomidate, Ketamine, and Midazolam. Patients in the Ketamine group were found to have a lower mortality rate after injury stratification.
    CONCLUSION: Patients with intracranial hypertension should not be excluded from receiving Ketamine during intubation out of concern for worsening outcomes.

    Utility of point-of-care musculoskeletal ultrasound in the evaluation of emergency department musculoskeletal pathology
    Elaine Situ-LaCasse, Ryan W. Grieger, Stephen Crabbe, Anna L. Waterbrook, Lucas Friedman, Srikar Adhikari
    2018, 9(4):  262-266.  doi:10.5847/wjem.j.1920-8642.2018.04.004
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    BACKGROUND: To evaluate the utilization of point-of-care ultrasound (POCUS) for the assessment of emergency department (ED) patients with musculoskeletal symptoms and the impact of musculoskeletal POCUS on medical decision-making and patient management in the ED.
    METHODS: This was a retrospective review of ED patients presenting with musculoskeletal symptoms who received a POCUS over a 3.5-year period. An ED POCUS database was reviewed for musculoskeletal POCUS examinations used for medical decision-making. Electronic medical records were then reviewed for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of musculoskeletal POCUS on patient management in ED.
    RESULTS: A total of 264 subjects (92 females, 172 males) and 292 musculoskeletal POCUS examinations were included in the final analysis. Most common symptomatic sites were knee (31.8%) and ankle (16.3%). Joint effusion was the most common finding on musculoskeletal POCUS, noted in 33.7% of the patients, and subcutaneous edema/cobblestoning was found in 10.2% of the patients. Muscle or tendon rupture was found in 2.3% of the patients, and 1.9% of the patients had joint dislocation. Bursitis or bursa fluid was found in 3.4% of patients, and tendonitis/tendinopathy was found in 2.3%. Twenty percent of them were ultrasound-guided musculoskeletal procedures, and most of them (73.3%) were arthrocentesis. Of the included studies, all except three either changed or helped guide patient management as documented in the patients’ medical records.
    CONCLUSION: Our study findings illustrate the utility of POCUS in the evaluation of a variety of musculoskeletal pathologies in the ED.

    Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department
    Sarah E. Frasure, Amy F. Hildreth, Raghu Seethala, Heidi H. Kimberly
    2018, 9(4):  267-271.  doi:10.5847/wjem.j.1920-8642.2018.04.005
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    BACKGROUND: Emergency physicians frequently encounter patients with acute small bowel obstructions (SBO). Although computed tomography (CT) imaging is the current gold standard in the assessment of patients with suspected SBO in the emergency department, a few studies have examined the use of ultrasound as an alternative imaging technique.
    METHODS: We evaluated the accuracy of ultrasound performed in the ED by a variety of providers (physicians with various levels of training, physician assistants) compared to CT imaging in 47 patients with suspected SBOs.
    RESULTS: Our data demonstrated a sensitivity of 93.8% and a specificity of 93.3% when compared to abdominal CT, and a sensitivity of 94.3% and specificity of 95.2% using a composite endpoint of abdominal CT and discharge diagnosis.
    CONCLUSION: Ultrasound can play an important role in the identification of small bowel obstructions in ED patients.

    Ultrasonographic assessment of paediatric ocular emergencies: A tertiary eye hospital based observation
    Amar Pujari, Deepa R Swamy, Rashmi Singh, Ritika Mukhija, Rohan Chawla, Pradeep Sharma
    2018, 9(4):  272-275.  doi:10.5847/wjem.j.1920-8642.2018.04.006
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    BACKGROUND: The purpose of this study is to assess the utility of ocular ultrasound B scan in the emergency at the first point of care for detecting posterior segment and orbital pathologies in cases of paediatric ocular emergencies.
    METHODS: A prospective observational study involving 122 paediatric patients presenting to eye emergency over a period of ninety days were assessed with ultrasonography for the posterior segment as well as orbital pathology whenever indicated. The ocular ultrasound was performed gently over closed eyelids.
    RESULTS: Posttraumatic globe injuries were the most common indication for posterior segment evaluation, which constituted 80 (65.57%) eyes. Among these 52 patients had an anechoic posterior segment and 28 patients had variable findings such as vitreous haemorrhage (8.19%), retinal detachment (6.55%), choroidal detachment (4.91%), posteriorly dislocated clear lens (0.81%) and retained intraocular foreign body (5.73%). Non-traumatic cases constituted around 42 (34.42%) eyes, which included corneal ulcer (7.37%), retinoblastoma (6.55%), endophthalmitis (4.91%), extra-ocular muscle cysticercosis (4.91%), orbital cellulitis (4.09%), periocular haemorrhage (2.45%), proptosis(1.63%), paediatric cataract (1.63%) and cryptophthalmos (0.81%). No adverse events of performing the ultrasound was noted.
    CONCLUSION: First point ultrasonography in paediatric ocular emergencies is a cheap, portable and an effective tool in the assertion of significant posterior segment and orbital diseases.

    Estimating the weight of children in Nepal by Broselow, PAWPER XL and Mercy method
    Karun Shrestha, Prakriti Subedi, Oshna Pandey, Likhita Shakya, Kailash Chhetri, Darlene R. House
    2018, 9(4):  276-281.  doi:10.5847/wjem.j.1920-8642.2018.04.007
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    BACKGROUND: Resuscitation of a critically-ill child requires an accurate weight for fluids and medication dosing; however, weighing children on a scale while critically ill is not always practical. The objective of this study is to determine the accuracy of three different weight estimation methods (Broselow, PAWPER XL and Mercy tape) of children presenting to Patan Hospital, Nepal.
    METHODS: This was a prospective, cross-sectional study that included children presenting to the emergency department and under-fourteen outpatient clinic at Patan Hospital. Measured weight was compared to estimated weight of Broselow, PAWPER XL, and Mercy tapes. The mean percentage error and percentage of estimated weights that were within 10% (PW10) and 20% (PW20) of actual weight were calculated. Acceptable accuracy was determined as a PW10>70% and PW20>95%. A Bland-Altman analysis was done to determine agreement between each weight estimation method and actual weight.
    RESULTS: The study included 813 children. The mean age was 4.2 years (ranging from 4 days to 14 years) with 60% male. The mean percentage error (MPE) for Broselow, PAWPER XL and Mercy were -1.0% (SD 11.8), 0.7% (10.5) and 4.2% (11.9) respectively. The predicted weight within 10% was highest for the PAWPER XL (71.5%) followed by Broselow (63.2%) and Mercy (58.1%). The predicted weight within 20% of actual weight was 95.2%, 91.5% and 91.3% for PAWPER XL, Broselow and Mercy respectively.
    CONCLUSION: The PAWPER XL tape was the only method found to be accurate in estimating the weight of Nepalese children.

    Comparison of exogenous melatonin versus placebo on sleep efficiency in emergency medicine residents working night shifts: A randomized trial
    Shervin Farahmand, Masoume Vafaeian, Elnaz Vahidi, Atefeh Abdollahi, Shahram Bagheri-Hariri, Ahmad Reza Dehpour
    2018, 9(4):  282-287.  doi:10.5847/wjem.j.1920-8642.2018.04.008
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    BACKGROUND: Sleep deprivation resulting from night shifts, is a major cause of burnout among physicians. Exogenous melatonin may improve sleep quality in night-shift workers. The study aims to compare the effectiveness of melatonin versus placebo on sleep efficiency in emergency medicine (EM) residents.
    METHODS: A randomized, double-blind, replicated crossover trial was performed on EM residents. This study consisted of 4 phases within a month with intervention periods of 2 nights and washouts of 6 days. In our study, EM residents had nine-hour shifts on 6 consecutive days, 2 mornings, 2 evenings and 2 nights and then 2 days off. At the end of shifts’ cycle, 24 EM residents were given 3 mg melatonin or placebo (12 in each arm of the study) for 2 consecutive nights after the second night shift with crossover to the other arm after a six-day off drug. This crossover intervention was repeated for two more another time. Finally, we created 48 cases and comparisons in each arm. Different items related to sleep quality were assessed and compared both within the same group and between the two groups.
    RESULTS: In the melatonin group, daytime sleepiness (calculated by Karolinska Sleep Scale) had a significant reduction after taking the second dose of drug (P=0.003) but the same result was not observed when comparing the 2 groups. Mood status (calculated by Profile of Mood States) showed no remarkable difference between the 2 groups.
    CONCLUSION: Melatonin might have a limited benefit on sleep quality in EM residents working night shifts.

    Case Letters
    A case of thyroid emergency with cardiac arrest supported by extracorporeal membrane oxygenation
    Gan-nan Wang, Xu-feng Chen, Gang Zhang, Yong Mei, Zhe Wang, Qin Zhang, Jin-song Zhang
    2018, 9(4):  288-290.  doi:10.5847/wjem.j.1920-8642.2018.04.009
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    Emergency department diagnosis of an ovarian inguinal hernia in an 11-year-old female using point-of-care ultrasound
    Richard Amini, Nicola Baker, Dale P. Woolridge, Angela B. Echeverria, Albert Amini, Srikar Adhikari
    2018, 9(4):  291-293.  doi:10.5847/wjem.j.1920-8642.2018.04.010
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    A rare cause of foot drop: Tired bullet
    Egemen Küçük, Eser Gümüş, Veli Emre Türkmen
    2018, 9(4):  294-296.  doi:10.5847/wjem.j.1920-8642.2018.04.011
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    Author index WJEM 2018
    Author index WJEM 2018
    2018, 9(4):  297-297. 
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    Subject index WJEM 2018
    Subject index WJEM 2018
    2018, 9(4):  298-300. 
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    Instructions for Authors
    Instructions for Authors
    2018, 9(4):  301-304. 
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