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Table of Content

    15 March 2016, Volume 7 Issue 1
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    Review Article
    Airway foreign bodies: A critical review for a common pediatric emergency
    Alaaddin M Salih, Musab Alfaki, Dafalla M Alam-Elhuda
    2016, 7(1):  5-12.  doi:10.5847/wjem.j.1920-8642.2016.01.001
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    BACKGROUND: Airway foreign bodies (AFBs) is an interdisciplinary area between emergency medicine, pediatrics and otolaryngology. It is a life-threatening condition that is not infrequently seen; however, it is poorly covered in medical literature. Accidental aspiration of an element into airways is a widespread clinical scenario among children under 3 years, predominantly males. Moreover, it is the leading cause of infantile deaths and the fourth one among preschool children.
    DATA RESOURCES: A systemic search was conducted in July 2015 using PubMed/PubMed Central Database of The National Center for Biotechnology Information (NCBI) (http://www.ncbi.nlm.nih.gov/). A total of 1 767 articles were identified and most of them were meta-analyses, systematic reviews, and case series. Those thoroughly discussing assessment and management of AFBs were retrieved.
    RESULTS: AFBs episodes may be either witnessed or missed. Presence of a witness for the inhalation is diagnostic. The later usually present with persistent active cough. A classical triad of paroxysmal cough, wheezing, and dyspnoea/decreased air entry was reported, though many presentations have inconsistent findings. Hence, diagnosis requires high index of clinical suspicion. Flexible fibro-optic bronchoscopy is the gold standard of diagnosis, whereas inhaled objects are best retrieved by rigid bronchoscopes.
    CONCLUSIONS: Close supervision of pediatrics is the hallmark of prevention. Caregivers should ensure a safe surrounding milieu, including the toys their offspring play with. Immediate complications result from direct obstruction or injury by the inhaled object. Alternatively, prolonged lodging traps air and induces inflammatory response causing atelectesis and pneumonia, respectively.

    Original Articles
    End-tidal capnometry during emergency department procedural sedation and analgesia: a randomized, controlled study
    Samuel G. Campbell, Kirk D. Magee, Peter J. Zed, Patrick Froese, Glenn Etsell, Alan LaPierre, Donna Warren, Robert R. MacKinley, Michael B. Butler, George Kovacs, David A. Petrie
    2016, 7(1):  13-18.  doi:10.5847/wjem.j.1920-8642.2016.01.002
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    BACKGROUND: This prospective, randomized trial was undertaken to evaluate the utility of adding end-tidal capnometry (ETC) to pulse oximetry (PO) in patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED).
    METHODS: The patients were randomized to monitoring with or without ETC in addition to the current standard of care. Primary endpoints included respiratory adverse events, with secondary endpoints of level of sedation, hypotension, other PSA-related adverse events and patient satisfaction.
    RESULTS: Of 986 patients, 501 were randomized to usual care and 485 to additional ETC monitoring. In this series, 48% of the patients were female, with a mean age of 46 years. Orthopedic manipulations (71%), cardioversion (12%) and abscess incision and drainage (12%) were the most common procedures, and propofol and fentanyl were the sedative/analgesic combination used for most patients. There was no difference in patients experiencing de-saturation (SaO2<90%) between the two groups; however, patients in the ETC group were more likely to require airway repositioning (12.9% vs. 9.3%, P=0.003). Hypotension (SBP<100 mmHg or <85 mmHg if baseline <100 mmHg) was observed in 16 (3.3%) patients in the ETC group and 7 (1.4%) in the control group (P=0.048).
    CONCLUSIONS: The addition of ETC does not appear to change any clinically significant outcomes. We found an increased incidence of the use of airway repositioning maneuvers and hypotension in cases where ETC was used. We do not believe that ETC should be recommended as a standard of care for the monitoring of patients undergoing PSA.

    Intranasal ketamine for the treatment of patients with acute pain in the emergency department
    Roshana Shrestha, Samita Pant, Ashis Shrestha, Kabita Hada Batajoo, Rashmi Thapa, Sumana Vaidya
    2016, 7(1):  19-24.  doi:10.5847/wjem.j.1920-8642.2016.01.003
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    BACKGROUND: Pain in the emergency department (ED) is common but undertreated. The objective of this study was to examine the efficacy and safety of intranasal (IN) ketamine used as an analgesic for patients with acute injury with moderate to severe pain.
    METHODS: This study was a cross sectional, observational study of patients more than 8 years old experiencing moderate to severe pain [visual analog score (VAS) >50 mm]. The initial dose of IN ketamine was 0.7 mg/kg with an additional dose of 0.3 mg/kg if VAS was more than 50 mm after 15 minutes. Pain scores and vital signs were recorded at 0, 15, 30 and 60 minutes. Side-effects, sedation level and patient's satisfaction were also recorded. The primary outcome was the number of patients achieving ≥ 20 mm reductions in VAS at 15 minutes. Other secondary outcome measures were median reduction in VAS at 15, 30 and 60 minutes, changes of vital signs, adverse events, satisfaction of patients, and need for additional ketamine.
    RESULTS: Thirty-four patients with a median age of 29.5 years (IQR 17.5-38) were enrolled, and they had an initial median VAS of 80 mm (IQR 67-90). The VAS decreased more than 20 mm at 15 minutes in 27 (80%) patients. The reduction of VAS from baseline to 40 mm (IQR 20-40), 20 mm (IQR 14-20) and 20 mm (IQR 10-20) respectively at 15, 30 and 60 minutes (P<0.001). No critical changes of vital signs were noted and adverse effects were mild and transient.
    CONCLUSION: This study showed that IN ketamine is an analgesic choice for patients with acute injury in moderate to severe pain in an overcrowded and resource limited ED.

    Analgesic effect of paracetamol combined with low-dose morphine versus morphine alone on patients with biliary colic: a double blind, randomized controlled trial
    Mohammad Reza Farnia, Rasoul Babaei, Farzaneh Shirani, Mehdi Momeni, Majid Hajimaghsoudi, Elnaz Vahidi, Morteza Saeedi
    2016, 7(1):  25-29.  doi:10.5847/wjem.j.1920-8642.2016.01.004
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    BACKGROUND: Numerous drugs have been proposed to alleviate pain in patients with biliary colic, especially opioids, but still there is a tendency to use less narcotics because of their side effects and the unwillingness of some patients. The present study aimed to compare the analgesic effect of paracetamol combined with low-dose morphine versus morphine alone in patients with biliary colic.
    METHODS: A randomized double-blind controlled trial was performed in 98 patients with biliary colic, recruited from two emergency departments from August 2012 to August 2013. Eleven patients were excluded and the remaining were randomized into two groups: group A received 0.05 mg/kg morphine+1 000 mg paracetamol in 100 mL normal saline and group B received 0.1 mg/kg morphine+normal saline (100 mL) as placebo. Pain scores were recorded using visual analogue scale (VAS) at baseline and 15 and 30 minutes after drug administration. Adverse effects and the need for rescue medication (0.75 μg/kg intravenous fentanyl) were also reported within 60 minutes of drug administration.
    RESULTS: Before the infusion, the mean±SD VAS scores were 8.73±1.57 in group A and 8.53±1.99 in group B. At 15 minutes after drug administration, the mean±SD VAS scores were 2.16±1.90 in group A vs. 2.51±1.86 in group B; mean difference was -0.35, and 95%CI -1.15 to 0.45 (P=0.38). At 30 minutes the mean±SD VAS scores were 1.66±1.59 in group A vs. 2.14±1.79 in group B; mean difference was -0.48, and 95%CI -1.20 to 0.24 (P=0.19). The mean pain scores in the two groups at 15 and 30 minutes demonstrated no significant difference.
    CONCLUSION: Paracetamol combined with low-dose morphine may be effective for pain management in patients with biliary colic.

    Comparison of intravenous pantoprazole and ranitidine in patients with dyspepsia presented to the emergency department: a randomized, double blind, controlled trial
    Engin Senay, Cenker Eken, Murat Yildiz, Derya Yilmaz, Erhan Alkan, Mete Akin, Mustafa Serinken
    2016, 7(1):  30-34.  doi:10.5847/wjem.j.1920-8642.2016.01.005
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    BACKGROUND: This study aimed to compare pantoprazole, a proton-pomp inhibitors (PPIs), and ranitidine, a H2 receptor antagonists (H2RA), in ceasing dyspeptic symptoms in the emergency department (ED).
    METHODS: This randomized, double-blinded study compared the effectiveness of 50 mg ranitidine (Ulcuran®) and 40 mg pantoprazole (Pantpas®), given in a 100 mL saline solution by an intravenous rapid infusion within 2-4 minutes in patients with dyspepsia presented to the ED. Pain intensity was measured at baseline, 30 and 60 minutes after the drug administration.
    RESULTS: A total of 72 patients were eligible for the study. Of these patients, 2 were excluded from the study because the initial visual analogue scale (VAS) scores were under 20 mm and 4 were excluded from the statistical analysis because of being diagnosed as having other causes of epigastric pain despite being allocated to one of the study groups. Thirty-three patients in the pantoprazole group and 33 patients in the ranitidine group were analyzed ultimately. The mean age of the patients was 36.6±15 years, and 26 (39.4%) patients were male. Both of the groups reduced pain effectively at 30 [27.6±28 (18 to 37) vs. 28.3±23 (20 to 37), respectively] and 60 minutes [39.6±39 (26 to 53) vs. 42.3±25 (33 to 51), respectively]. There were 13 (39.4%) patients in the pantoprazole group and 8 (24.2%) patients in the ranitidine group who required additional drug at the end of the study (P=0.186).
    CONCLUSION: Intravenous pantoprazole and ranitidine are not superior to each other in ceasing dyspeptic symptoms at 30 and 60 minutes in the ED.

    Emergency department patients with small bowel obstruction: What is the anticipated clinical course?
    Sarah E Frasure, Amy Hildreth, Sukhjit Takhar, Michael B Stone
    2016, 7(1):  35-39.  doi:10.5847/wjem.j.1920-8642.2016.01.006
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    BACKGROUND: Emergency physicians (EPs) often care for patients with acute small bowel obstruction. While some patients require exploratory laparotomy, others are managed successfully with supportive care. We aimed to determine features that predict the need for operative management in emergency department (ED) patients with small bowel obstruction (SBO).
    METHODS: We performed a retrospective chart review of 370 consecutive patients admitted to a large urban academic teaching hospital with a diagnosis of SBO over a two-year period. We evaluated demographic characters (prior SBO, prior abdominal surgery, active malignancy) and clinical findings (leukocytosis and lactic acid) to determine features associated with the need for urgent operative intervention.
    RESULTS: Patients with a prior SBO were less likely to undergo operative intervention [20.3% (42/207)] compared to those without a prior SBO [35.2% (57/162)]. Abnormal bloodwork was not associated with need for operative intervention. 68% of patients with CT scan findings of both an SBO and a hernia, however, were operatively managed.
    CONCLUSIONS: Patients with a history of SBO were less likely to require operative intervention at any point during their hospitalization. Abnormal bloodwork was not associated with operative intervention. The CT finding of a hernia, however, predicted the need for operative intervention, while other findings (ascites, duodenal thickening) did not. Further research would be helpful to construct a prediction rule, which could help community EPs determine which patients may benefit from expedited transfer for operative management, and which patients could be safely managed conservatively as an initial treatment strategy.

    A correlation analysis of Broselow™ Pediatric Emergency Tape-determined pediatric weight with actual pediatric weight in India
    Deepak Geetaprasad Mishra, Tamorish Kole, Rahul Nagpal, Jeffery Paul Smith
    2016, 7(1):  40-43.  doi:10.5847/wjem.j.1920-8642.2016.01.007
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    BACKGROUND: The Broselow™ Pediatric Emergency Tape indicates standardized, pre-calculated medication doses, dose delivery volumes, and equipment sizes using color-coded zones based on height-weight correlations. The present study attempted to provide more evidence on the effectiveness of the Broselow™ Pediatric Emergency Tape by comparing the tape-estimated weights with actual weights. We hypothesized that the Broselow™ Pediatric Emergency Tape would overestimate weights in Indian children aged<10 years, leading to inaccurate dosing and equipment sizing in the emergency setting.
    METHODS: This prospective study of pediatric patients aged <10 years who were divided into three groups based on actual body weight: <10 kg, 10-18 kg, and >18 kg. We calculated the percentage difference between the Broselow-predicted weight and the measured weight as a measure of tape bias. Concordant results were those with a mean percent difference within 3%. Standard deviation was measured to determine precision. Accuracy was determined as color-coded zone prediction and measured weight concordance, including the percentage overestimation by 1-2 zones.
    RESULTS: The male-to-female ratio of the patients was 1.3:1. Total agreement between color-coding was 63.18% (κ=0.582). The Broselow™ color-coded zone agreement was 74.8% in the <10 kg group, 61.24% in the 10-18 kg group, and 53.42% in the >18 kg group.
    CONCLUSIONS: The Broselow™ Pediatric Emergency Tape showed good evidence for being more reliable in children of the <10 kg and 10-18 kg groups. However, as pediatric weight increased, predictive reliability decreased. This raises concerns over the use of the Broselow™ Pediatric Emergency Tape in Indian children because body weight was overestimated in those weighing >18 kg.

    Assessment of a predictive score for pulmonary complications in cancer patients after esophagectomy
    Xue-zhong Xing, Yong Gao, Hai-jun Wang, Shi-ning Qu, Chu-lin Huang, Hao Zhang, Hao Wang, Quan-hui Yang
    2016, 7(1):  44-49.  doi:10.5847/wjem.j.1920-8642.2016.01.008
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    BACKGROUND: Esophagectomy is a very important method for the treatment of resectable esophageal cancer, which carries a high rate of morbidity and mortality. This study was undertaken to assess the predictive score proposed by Ferguson et al for pulmonary complications after esophagectomy for patients with cancer.
    METHODS: The data of patients who admitted to the intensive care unit after transthoracic esophagectomy at Cancer Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College between September 2008 and October 2010 were retrospectively reviewed.
    RESULTS: Two hundred and seventeen patients were analyzed and 129 (59.4%) of them had postoperative pulmonary complications. Risk scores varied from 0 to 12 in all patients. The risk scores of patients with postoperative pulmonary complications were higher than those of patients without postoperative pulmonary complications (7.27±2.50 vs. 6.82±2.67; P=0.203). There was no significant difference in the incidence of postoperative pulmonary complications as well as in the increase of risk scores (χ 2=5.477, P=0.242). The area under the curve of predictive score was 0.539±0.040 (95%CI 0.461 to 0.618; P=0.324) in predicting the risk of pulmonary complications in patients after esophagectomy.
    CONCLUSION: In this study, the predictive power of the risk score proposed by Ferguson et al was poor in discriminating whether there were postoperative pulmonary complications after esophagectomy for cancer patients.

    Periplaneta americana extract used in patients with systemic inflammatory response syndrome
    Hong-wei Zhang, Li-you Wei, Gang Zhao, Ya-jing Yang, Shu-zheng Liu, Zhen-yu Zhang, Zhang Jing, Yan-ling Hu
    2016, 7(1):  50-54.  doi:10.5847/wjem.j.1920-8642.2016.01.009
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    BACKGROUND: Periplaneta americana extract is recognized to have a positive effect on gastrointestinal mucosa. This study aimed to investigate the effects of periplaneta americana extract on immune function, nutrition status and gastrointestinal complications of early enteral nutrition patients with systemic inflammatory response syndrome (SIRS).
    METHODS: Patients with SIRS were randomly divided into two groups: treatment and control groups. All patients in the two groups received conventional therapy including enteral nutrition, but periplaneta americana extract, an additional Chinese medicine, was given to the patients in the treatment group. At the beginning of treatment (0 day) and 1, 3, and 7 days after treatment, the levels of immunoglobulin (IgA), total lymphocyte count (TLC), total protein (TP) and prealbumin (PA) were respectively tested in patients' venous blood. The incidences of bloating, diarrhea, aspiration pneumonia and high blood sugar at 7 days after treatment were recorded. The mortality of the patients in 28 days was recorded.
    RESULTS:At 3 and 7 days after treatment, the levels of IgA and TLC in the treatment group were higher than those in the control group (P<0.05). At 7 days after treatment, the levels of TP and PA in the treatment group were higher than those in the control group (P<0.05). The incidences of bloating and diarrhea in the treatment group were lower than those in the control group, the differences were significant (P<0.05). The mortality of treatment group was lower than that of the control group (P>0.05).
    CONCLUSION: Periplaneta americana extract could reduce gastrointestinal complications and improve immune function and nutritional status in patients with systemic inflammatory response syndrome.

    Chest X-rays in detecting injuries caused by blunt trauma
    Kadir Agladioglu, Mustafa Serinken, Onur Dal, Halil Beydilli, Cenker Eken, Ozgur Karcioglu
    2016, 7(1):  55-58.  doi:10.5847/wjem.j.1920-8642.2016.01.010
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    BACKGROUND: The appropriate sequence of different imagings and indications of thoracic computed tomography (TCT) in evaluating chest trauma have not yet been clarified at present. The current study was undertaken to determine the value of chest X-ray (CXR) in detecting chest injuries in patients with blunt trauma.
    METHODS: A total of 447 patients with blunt thoracic trauma who had been admitted to the emergency department (ED) in the period of 2009-2013 were retrospectively reviewed. The patients met inclusion criteria (age>8 years, blunt injury to the chest, hemodynamically stable, and neurologically intact) and underwent both TCT and upright CXR in the ED. Radiological imagings were re-interpreted after they were collected from the hospital database by two skilled radiologists.
    RESULTS: Of the 447 patients, 309 (69.1%) were male. The mean age of the 447 patients was 39.5±19.2 (range 9 and 87 years). 158 (35.3%) patients were injured in motor vehicle accidents (MVA). CXR showed the highest sensitivity in detecting clavicle fractures [95%CI 78.3 (63.6-89)] but the lowest in pneuomediastinum [95%CI 11.8 (1.5-36.4)]. The specificity of CXR was close to 100% in detecting a wide array of entities.
    CONCLUSION: CXR remains to be the first choice in hemodynamically unstable patients with blunt chest trauma. Moreover, stable patients with normal CXR are candidates who should undergo TCT if significant injury has not been ruled out.

    Critical care nurses' attitude towards life-sustaining treatments in South East Iran
    Farideh Razban, Sedigheh Iranmanesh, Hasan Eslami Aliabadi, Mansooreh Azzizadeh Forouzi
    2016, 7(1):  59-64.  doi:10.5847/wjem.j.1920-8642.2016.01.011
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    BACKGROUND: Life-sustaining treatments (LSTs) may prolong life but greatly decrease the quality of death. One factor influencing decision-making about withholding and withdrawing these treatments is the attitude of nurses. This study aimed to evaluate the attitude of critical care nurses towards life-sustaining treatments in South East Iran.
    METHODS: In this cross-sectional study, "Ethnicity and Attitudes towards Advance Care Directives Questionnaire" was used to investigate the attitude of 104 critical care nurses towards life-sustaining treatments in three hospitals affiliated to Kerman University of Medical Sciences.
    RESULTS:The findings of this study indicated that although a majority of critical care nurses (77%) did not have personal desire for use of LSTs including CPR and mechanical ventilation, they had moderately negative to neutral attitude towards general use of LSTs (2.95 of 5).
    CONCLUSIONS:These findings suggest that nurses' attitude towards LSTs can be changed by inclusion of specific courses about death, palliative care and life-sustaining treatments in undergraduate and postgraduate nursing curricula. Educating Muslim nurses about religious aspects of LSTs may also improve their attitudes.

    Case Reports
    The Chikungunya virus: An emerging US pathogen
    Thomas M. Nappe, Craig M. Chuhran, Steven A. Johnson
    2016, 7(1):  65-67.  doi:10.5847/wjem.j.1920-8642.2016.01.012
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    BACKGROUND: The Chikungunya (CHIK) virus was recently reported by the CDC to have spread to the United States. We report an early documented case of CHIK from the state of Pennsylvania after a patient recently returned from Haiti in June of 2014.
    METHODS: A 39-year-old man presented to the emergency department complaining of fever, fatigue, polyarthralgias and a diffuse rash for two days. Four days before, he returned from a mission trip to Haiti and reported that four of his accompanying friends had also become ill. A CHIK antibody titer was obtained and it was found to be positive. During his hospital stay, he responded well to supportive care, including anti-inflammatories, intravenous hydration and anti-emetics.
    RESULTS: His condition improved within two days and he was ultimately discharged home.
    CONCLUSIONS: Manifestations of CHIK can be similar to Dengue fever, which is transmitted by the same species of mosquito, and occasionally as a co-infection. Clinicians should include Chikungunya virus in their differential diagnosis of patients who present with fever, polyarthralgia and rash with a recent history of travel to endemic areas, including those within the United States.

    Invasive group B streptococcal infection in a patient with post splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension
    Tomoya Okazaki, Toru Hifumi, Arisa Manabe, Hikari Matsumura, Satoshi Egawa, Hideyuki Hamaya, Nastuyo Shinohara, Koshiro Takano, Hajime Shishido, Yuko Abe, Kenya Kawakita, Masanobu Hagiike, Yasuhiro Kuroda
    2016, 7(1):  68-70.  doi:10.5847/wjem.j.1920-8642.2016.01.013
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    BACKGROUND: Splenectomy in patients with liver cirrhosis (LC) is expected to become more common owing to its efficacy on portal hemodynamics. In this report we describe an alarming case of group B streptococcus (GBS) infection after splenectomy in a patient with LC.
    METHODS: A 72-year-old woman with a history of LC was admitted to our emergency department because of respiratory failure. The patient had received left lateral segmentectomy of the liver and splenectomy three months before admission. Pulmonary examination revealed significant wheezing during inspiration and expiration, but no crackles and stridor. Chest radiography and CT showed no infiltrates. A presumptive diagnosis of bronchial asthma caused by upper respiratory infection was made. Four days after admission, GBS infection was confirmed by blood culture and penicillin G was administered. Antibiotics were given intravenously for a total of 12 days.
    RESULTS: The patient was discharged on the 12th day after admission.
    CONCLUSIONS: Although efficacy of splenectomy in patients with LC has been reported, immune status should be evaluated for a longer period. Patients who have undergone splenectomy are highly susceptible to bacteria; moreover, LC itself is an independent risk factor for mortality in patients with sepsis. Since prophylaxis against GBS has not been established, immediate action should be taken. Emergency physicians should be aware of invasive GBS infection in the context of the critical risk factors related to splenectomy and LC, particularly the expected increase of splenectomy performed in LC patients.

    Generalized seizure, the only manifestation of a small ischemic atherothrombotic infarction
    Assadollahi Marjan, Ramezani Mahtab, Karimialavijeh Ehsan, Mirfazaelian Hadi
    2016, 7(1):  71-73.  doi:10.5847/wjem.j.1920-8642.2016.01.014
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    BACKGROUND: According to the literature, generalized seizure as a presenting sign of stroke is rare, and in the reported cases it was accompanied by a focal neurological deficit. Presentation of a small ischemic atherothrombotic brain infarction with convulsive generalized seizure is very rare.
    METHODS: We reported a patient with acute small ischemic atherothrombotic infarction associated with an episode of generalized tonic-clonic seizure, a rare clinical manifestation in this type of stroke. The patient was treated with anti-epileptic therapy after admission.
    RESULTS: The patient was discharged with oral administration of phenytoin 100 mg TDS, aspirin 80 mg daily, and atorvastatin 40 mg daily.
    CONCLUSION:Small ischemic atherothrombotic infarction can present only with a seizure without any focal neurological deficit.

    Clinical Images
    Ultrasound diagnosis of diverticulitis
    Michael E. Abboud, Sarah E. Frasure, Michael B. Stone
    2016, 7(1):  74-76.  doi:10.5847/wjem.j.1920-8642.2016.01.015
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    Instructions for Authors
    Instructions for Authors
    2016, 7(1):  77-80. 
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