World Journal of Emergency Medicine

Emergency department electric scooter injuries after the introduction of shared e-scooter services: A retrospective review of 3,331 cases

Ittai Shichman, Or Shaked, Shai Factor, Ahuva Weiss-Meilik, Amal Khoury

2022, 13(1): 5-10. doi:10.5847/wjem.j.1920-8642.2022.002

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BACKGROUND: To determine the frequency, characteristics, and use of resources related to electric scooter (e-scooter) injuries in the emergency department (ED) of a major metropolitan area hospital.
METHODS: We performed a retrospective review of all ED presentations related to e-scooter injuries at a level I trauma center between May 2017 and February 2020. We identified ED presentation data, injury-related data, patients’ clinical course after evaluation, injury diagnosis, surgical procedures, and ED readmissions.
RESULTS: A total of 3,331 patients with e-scooter injuries presented to the ED over a 34-month period. There was a 6-fold increase in e-scooter-related injuries presenting to the ED, from an average of 26.9 injuries per month before the introduction of shared e-scooter services in August 2018 to an average of 152.6 injuries per month after its introduction. The average injury rate during weekdays was 3.27 per day, with the majority of injuries occurring in the afternoon. The most common mechanism of injury was rider fall (79.1%). There were a total of 2,637 orthopedic injuries, of which 599 (22.7%) were fractures. A total of 296 (8.9%) patients were hospitalized following the initial ED admission, and 462 surgeries were performed within 7 days of ED arrival.
CONCLUSIONS: The introduction of the shared e-scooter services is associated with a dramatic increase in e-scooter injuries presenting to the ED. E-scooter use carries considerably underestimated injury risks of high-energy trauma and misunderstood mechanisms of injuries. These injuries challenge the healthcare system, with a major impact on both EDs and surgical departments.

Tranexamic acid for major trauma patients in Ireland

Kieran Walsh, Francis O’Keeffe, Louise Brent, Biswadev Mitra

2022, 13(1): 11-17. doi:10.5847/wjem.j.1920-8642.2022.003

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BACKGROUND: The Clinical Randomisation of an Anti-fibrinolytic in Significant Hemorrhage-2 (CRASH-2) is the largest randomized control trial (RCT) examining circulatory resuscitation for trauma patients to date and concluded a statistically significant reduction in all-cause mortality in patients administered tranexamic acid (TXA) within 3 hours of injury. Since the publication of CRASH-2, significant geographical variance in the use of TXA for trauma patients exists. This study aims to assess TXA use for major trauma patients with hemorrhagic shock in Ireland after the publication of CRASH-2.
METHODS: A retrospective cohort study was conducted using data derived from the Trauma Audit and Research Network (TARN). All injured patients in Ireland between January 2013 and December 2018 who had evidence of hemorrhagic shock on presentation (as defined by systolic blood pressure [SBP] <100 mmHg [1 mmHg=0.133 kPa] and administration of blood products) were eligible for inclusion. Death at hospital discharge was the primary outcome.
RESULTS: During the study period, a total of 234 patients met the inclusion criteria. Among injured patients presenting with hemorrhagic shock, 133 (56.8%; 95% confidence interval [CI] 50.2%-63.3%) received TXA. Of patients that received TXA, a higher proportion of patients presented with shock index >1 (70.68% vs.57.43%) and higher Injury Severity Score (ISS >25; 49.62% vs. 23.76%). Administration of TXA was not associated with mortality at hospital discharge (odds ratio [OR] 0.86, 95% CI 0.31-2.38).
CONCLUSIONS: Among injured Irish patients presenting with hemorrhagic shock, TXA was administered to 56.8% of patients. Patients administered with TXA were on average more severely injured. However, a mortality benefit could not be demonstrated.

A cadaveric model for transesophageal echocardiography transducer placement training: A pilot study

Ryan W. Horton, Kian R. Niknam, Viveta Lobo, Kathryn H. Pade, Drew Jones, Kenton L. Anderson

2022, 13(1): 18-22. doi:10.5847/wjem.j.1920-8642.2022.005

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BACKGROUND: Transesophageal echocardiography (TEE) is used in the emergency department to guide resuscitation during cardiac arrest. Insertion of a TEE transducer requires manual skill and experience, yet in some residency programs cardiac arrest is uncommon, so some physicians may lack the means to acquire the manual skills to perform TEE in clinical practice. For other infrequently performed procedural skills, simulation models are used. However, there is currently no model that adequately simulates TEE transducer insertion. The aim of this study is to evaluate the feasibility and efficacy of using a cadaveric model to teach TEE transducer placement among novice users.
METHODS: A convenience sample of emergency medicine residents was enrolled during a procedure education session using cadavers as tissue models. A pre-session assessment was used to determine prior knowledge and confidence regarding TEE manipulation. Participants subsequently attended a didactic and hands-on education session on TEE placement. All participants practised placing the TEE transducer until they were able to pass a standardized assessment of technical skill (SATS). After the educational session, participants completed a post-session assessment.
RESULTS: Twenty-five residents participated in the training session. Mean assessment of knowledge improved from 6.2/10 to 8.7/10 (95% confidence interval [CI] of knowledge difference 1.6-3.2, P<0.001) and confidence improved from 1.6/5 to 3.1/5 (95% CI of confidence difference 1.1-2.0, P<0.001). There was no relationship between training level and the delta in knowledge or confidence.
CONCLUSIONS: In this pilot study, the use of a cadaveric model to teach TEE transducer placement methods among novice users is feasible and improves both TEE manipulation knowledge and confidence levels.

Development of an intensive simulating training program in emergency medicine for medical students in China

Xin Lu, Shi Feng, Shi-gong Guo, Mu-bing Qin, Xiang-ning Liu, Shi-yuan Yu, Li-na Zhao, Zeng-zheng Ge, Jing-jing Chai, Sheng-yong Xu, Di Shi, Ji-hai Liu, Hua-dong Zhu, Yi Li

2022, 13(1): 23-26. doi:10.5847/wjem.j.1920-8642.2022.004

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BACKGROUND: A national standardized emergency medicine (EM) curriculum for medical students, including specific competencies in procedural skills, are absent in many countries. The development of an intensive simulating training program in EM, based on a tight schedule, is anticipated to enhance the competency of medical students.
METHODS: A 3-day intensive EM training program, consisting of four procedural skills and 8-hour case-based learning (CBL), was developed by experienced physicians from the EM department in Peking Union Medical College Hospital (PUMCH). Medical students from Peking Union Medical College (PUMC) and Tsinghua University (THU) participated in the training. Three written tests were cautiously designed to examine the short-term (immediately after the program) and long-term (6 months after the program) efficacy of the training. After completion of the training program, an online personal appraisal questionnaire was distributed to the students on WeChat (a mobile messaging App commonly used in China) to achieve anonymous self-evaluation.
RESULTS: Ninety-seven out of 101 students completed the intensive training and took all required tests. There was a significant increase in the average score after the intensive simulating training program (pre-training 13.84 vs. 15.57 post-training, P<0.001). Compared with the pre-training test, 63 (64.9%) students made progress. There was no significant difference in scores between the tests taken immediately after the program and 6 months later (15.57±2.22 vs. 15.38±2.37, P=0.157). Students rated a higher score in all diseases and procedural skills, and felt that their learning was fruitful.
CONCLUSIONS: The introduction of a standardized intensive training program in EM focusing on key competencies can improve clinical confidence, knowledge, and skills of medical students toward the specialty. In addition, having such a program can also enhance student’s interest in EM as a career choice which may enhance recruitment into the specialty and workplace planning.

Changes and significance of serum troponin in trauma patients: A retrospective study in a level I trauma center

Li-wen Dou, Zhe Du, Ji-hong Zhu, Tian-bing Wang

2022, 13(1): 27-31. doi:10.5847/wjem.j.1920-8642.2022.016

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BACKGROUND: Elevated troponin I (TnI) is common among trauma patients. TnI is an indicator of myocardial injury, but clinical diagnosis of blunt cardiac injury cannot be based solely on an increase in TnI. Therefore, this study aims to explore the changes and clinical significance of serum TnI in trauma patients.
METHODS: The clinical data of consecutive trauma patients admitted to our trauma center between July 1, 2017 and July 31, 2020 were retrospectively analyzed. According to TnI levels within 24 hours of admission, patients were divided into the elevated and normal TnI groups. According to the TnI levels after 7 days of admission, a graph depicting a change in trend was drawn and then analyzed whether TnI was related to in-hospital mortality.
RESULTS: A total of 166 patients (69 and 97 cases with elevated and normal TnI, respectively) were included in this study. The average hospital stay, intensive care time, mechanical ventilation time, and in-hospital mortality were higher in the elevated TnI group than in the normal TnI group (P<0.05). The TnI level of trauma patients gradually increased after admission and peaked at 48 hours (7.804±1.537 ng/mL). Subsequently, it decreased, and then recovered to normal within 7 days. However, 13 patients did not recover. Logistic regression analysis revealed that abnormal TnI at 7 days was independently related to in-hospital mortality.
CONCLUSIONS: Trauma patients with elevated TnI levels may have a worse prognosis. Monitoring the changes in serum TnI is important, which can reflect the prognosis better than the TnI measured immediately after admission.

Anemia and risk of periprocedural cerebral injury detected by diffusion-weighted magnetic resonance imaging in patients undergoing transcatheter aortic valve replacement

Stella Ng, Qi-feng Zhu, Ju-bo Jiang, Chun-hui Liu, Jia-qi Fan, Ye-ming Xu, Xian-bao Liu, Jian-an Wang

2022, 13(1): 32-39. doi:10.5847/wjem.j.1920-8642.2022.025

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BACKGROUND: Anemia is prevalent in patients undergoing transcatheter aortic valve replacement (TAVR) and has been linked to impaired outcomes after the procedure. Few studies have evaluated the impact of anemia and new ischemic lesions post TAVR.
METHODS: We prospectively enrolled 158 patients who received TAVR in our center. Anemia was defined according to the World Health Organization criteria as hemoglobin <12 g/dL in women and <13 g/dL in men. All patients underwent diffusion-weighted magnetic resonance imaging (DW-MRI) procedure before and within 4-7 days after TAVR.
RESULTS: Anemia was present in 85 (53.8%) patients who underwent TAVR, and 126 (79.7%) patients had 718 new DW-MRI positive lesions with a mean of 4.54±5.26 lesions per patient. The incidence of new ischemic lesions was 81.2% in patients with anemia versus 78.1% in patients without anemia (P=0.629). Moreover, anemic patients had bigger total volume/lesions in the anterior cerebral artery/middle cerebral artery (ACA/MCA) and MCA regions compared to the non-anemic patients (31.89±55.78 mm ³ vs. 17.08±37.39 mm³, P=0.049; and 54.54±74.72 mm ³ vs. 33.75±46.03 mm³, P=0.034). Anemia was independently associated with the volume/lesion in the ACA/MCA (β=16.796, 95% confidence interval [95% CI] 2.001 to 31.591, P=0.026) and in the MCA zone (β=0.020, 95% CI 0.001 to 0.040, P=0.041).
CONCLUSIONS: Patients with pre-procedural anemia may have bigger total volume/lesions in the ACA/MCA and MCA regions compared to the non-anemic patients. Whether the consequences of bigger total volume/lesions impact neurological and cognitive outcomes remains to be investigated.

Effects of Maxingloushi decoction on immune inflammation and programmed death markers in mice with chronic obstructive pulmonary disease

Li Li, Jun Yan, Lin-qin Ma, Wei Bi, Cai-jun Wu

2022, 13(1): 40-45. doi:10.5847/wjem.j.1920-8642.2022.023

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BACKGROUND: To investigate effects of Maxingloushi decoction on lung inflammation and programmed death markers (programmed death-1 [PD-1], programmed death-ligand 1 [PD-L1]) in the lung tissue, peripheral blood, and bronchoalveolar lavage fluid (BLF) in a mouse model of chronic obstructive pulmonary disease (COPD).
METHODS: Thirty-six mature male BALB/C mice were randomly divided into normal group (group A, n=6), COPD model group (group B, n=10), Maxingloushi decoction + COPD group (group C, n=10), and PD-1 inhibitor + COPD group (group D, n=10). The COPD model was established by smoke inhalation combined with lipopolysaccharide (LPS). Levels of PD-1 and PD-L1 in plasma and BLF were measured by enzyme-linked immunosorbent assay (ELISA). Histopathological techniques were used to semi-quantitatively analyze the immuno-fluorescence optical density (IOD) value of the lung tissue.
RESULTS: In plasma and BLF, the expression of PD-1 in the group B was higher than that in the group A, and the expression of PD-L1 was lower than that in the group A. The expression of PD-1 and PD-L1 in the lung tissue was normalized in the group C in comparison with the group B (P<0.05) and the group D (P<0.05), and inflammatory cell infiltration in the lung tissue was also improved.
CONCLUSIONS: These findings reveal that COPD causes an immune imbalance in the peripheral blood and lung tissue, and that both Maxingloushi decoction and PD-1 inhibitor treatment can mitigate lung inflammation in COPD by reducing PD-1 expression and increasing PD-L1 expression. The treatment effect of Maxingloushi decoction may be superior to that of PD-1 inhibitor.

Protective effect of mesenchymal stem cell-derived exosomal treatment of hippocampal neurons against oxygen-glucose deprivation/reperfusion-induced injury

Xiao-fang Guo, Shuang-shuang Gu, Jun Wang, Hao Sun, Yu-juan Zhang, Peng-fei Yu, Jin-song Zhang, Lei Jiang

2022, 13(1): 46-53. doi:10.5847/wjem.j.1920-8642.2022.015

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BACKGROUND: Individuals who survive a cardiac arrest often sustain cognitive impairments due to ischemia-reperfusion injury. Mesenchymal stem cell (MSC) transplantation is used to reduce tissue damage, but exosomes are more stable and highly conserved than MSCs. This study was conducted to investigate the therapeutic effects of MSC-derived exosomes (MSC-Exo) on cerebral ischemia-reperfusion injury in an in vitro model of oxygen-glucose deprivation/reperfusion (OGD/R), and to explore the underlying mechanisms.
METHODS: Primary hippocampal neurons obtained from 18-day Sprague-Dawley rat embryos were subjected to OGD/R treatment, with or without MSC-Exo treatment. Exosomal integration, cell viability, mitochondrial membrane potential, and generation of reactive oxygen species (ROS) were examined. Terminal deoxynucleotidyl transferase-mediated 2’-deoxyuridine 5’-triphosphate nick-end labeling (TUNEL) staining was performed to detect neuronal apoptosis. Moreover, mitochondrial function-associated gene expression, Nrf2 translocation, and expression of downstream antioxidant proteins were determined.
RESULTS: MSC-Exo attenuated OGD/R-induced neuronal apoptosis and decreased ROS generation (P<0.05). The exosomes reduced OGD/R-induced Nrf2 translocation into the nucleus (2.14±0.65 vs. 5.48±1.09, P<0.01) and increased the intracellular expression of antioxidative proteins, including superoxide dismutase and glutathione peroxidase (17.18±0.97 vs. 14.40±0.62, and 20.65±2.23 vs. 16.44±2.05, respectively; P<0.05 for both). OGD/R significantly impaired the mitochondrial membrane potential and modulated the expression of mitochondrial function-associated genes, such as PINK, DJ1, LRRK2, Mfn-1, Mfn-2, and OPA1. The abovementioned changes were partially reversed by exosomal treatment of the hippocampal neurons.
CONCLUSIONS: MSC-Exo treatment can alleviate OGD/R-induced oxidative stress and dysregulation of mitochondrial function-associated genes in hippocampal neurons. Therefore, MSC-Exo might be a potential therapeutic strategy to prevent OGD/R-induced neuronal injury.