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Original/Research Article

The Effects of Air Pollution on Cardiovascular and Respiratory Causes of Emergency Admission

Ali Mohammad Shahi, Ali Omraninava, Mitra Goli, Hamid Reza Soheilarezoomand, Nader Mirzaei

EMERGENCY , Vol. 2 No. 3 (2014), 3 August 2014, Page pp. 107-114

Introduction: Today, air pollution is one of the critical problems in metropolitans and necessary preparations are needed for confronting with this crisis. The present study was based on the goal of determining the relation of air pollutant levels with the rate of emergency admission for respiratory and cardiovascular patients. Methods: In the present retrospective cross- sectional study, all respiratory and cardiovascular patients, referred to emergency department during 2012, was assessed. The meteorological and pollution data were collected. Information of the numbers and dates (month, day) of daily admission of respiratory and cardiovascular diseases was achieved from hospital's electronic registration system. The relation of air pollution and respiratory and cardiovascular admissions were analyzed by Generalize additive model (GAM). Results: Totally 5922 patients were assessed included 4048 (68.36%) cardiovascular and 1874 (31.64%) respiratory disease. Carbon monoxide (CO) level was independent risk factor of cardiovascular disease on the same day (RR=1.49; 95% CI: 1.25- 1.77; P<0.001), the last day (RR=1.22; 95% CI: 1.02- 1.45; P=0.03), and the two last days (RR=1.3; 95% CI: 1.09- 1.54; P<0.001). The same process was similarly repeated for ozone (O3). In addition, the O3 level in the same day (RR=1.49; 95% CI: 1.25- 1.77; P<0.001), the last day (RR=1.22; 95% CI: 1.02- 1.45; P=0.03), the two last days (RR=1.3; 95% CI: 1.09- 1.54; P<0.001), and the last weak (RR=1.004; 95% CI: 1.0007-1.008; P=0.02) were independent risk factors of respiratory admissions. The increased level of particulate matter less than 2.5 micrometers in diameter (PM2.5) like O3 led to grow the admissions in emergency department with respiratory causes. Conclusion: The findings of the present study suggested that rising the levels of CO and O3 during two days leads to a significant increase in cardiovascular admission in the third day. Furthermore, increase the O3, PM2.5, nitrogen oxides (NO2), and CO levels causes to rising respiratory admissions in emergency department.

Introduction: Burns can be very destructive, and severely endanger the health and lives of humans. It maybe cause disability and even psychological trauma in individuals. . Such an event can also lead to economic burden on victim’s families and society. The aim of our study is to evaluate epidemiology and outcome of burn patients referring to emergency department. Methods: This is a cross-sectional study was conducted by evaluation of patients’ files and forensic reports of burned patients’ referred to the emergency department (ED) of Akdeniz hospital, Turkey, 2008. Demographic data, the season, place, reason, anatomical sites, total body surface area, degrees, proceeding treatment, and admission time were recorded. Multinomial logistic regression was used to compare frequencies’ differences among single categorized variables. Stepwise logistic regression was applied to develop a predictive model for hospitalization. P<0.05 was defined as a significant level. Results: Two hundred thirty patients were enrolled (53.9% female). The mean of patients' ages was 25.3 ± 22.3 years. The most prevalence of burn were in the 0-6 age group and most of which was hot liquid scalding (71.3%). The most affected parts of the body were the left and right upper extremities. With increasing the severity of triage level (OR=2.2; 95% CI: 1.02-4.66; p=0.046), intentional burn (OR=4.7; 95% CI: 1.03-21.8; p=0.047), referring from other hospitals or clinics (OR=3.4; 95% CI: 1.7-6.6; p=0.001), and percentage of burn (OR=18.1; 95% CI: 5.42-62.6; p<0.001) were independent predictive factor for hospitalization. In addition, odds of hospitalization was lower in patients older than 15 years (OR=0.7; 95% CI: 0.5-0.91; p=0.035). Conclusion: This study revealed the most frequent burns are encountered in the age group of 0-6 years, percentage of <10%, second degree, upper extremities, indoor, and scalding from hot liquids. Increasing ESI severity, intentional burn, referring from other hospitals or clinics, and the percentage of burn were independent predictive factors for hospitalization.

Diagnostic Accuracy of Ultrasound in Detection of Traumatic Lens Dislocation

Seyed Hossein Ojaghi Haghighi, Hamid Reza Morteza Begi, Raana Sorkhabi, Mohammad Kazem Tarzamani, Golshan Kamali Zonouz, Akram Mikaeilpour, Farzad Rahmani

EMERGENCY , Vol. 2 No. 3 (2014), 3 August 2014, Page pp. 121-124

Introduction: Traumatic eye injuries (TEI) involved about 3% of cases referred to the emergency departments of developing countries. Lens dislocation is one of the critical cases of ophthalmic emergencies. The present study was aimed to evaluate the diagnostic accuracy of ultrasonography in detection of traumatic lens dislocation. Methods: In this cross-sectional study the findings of ultrasonography and orbital computed tomography (OCT) of head and face trauma patients, referred to Imam Reza hospital, Tabriz, Iran, from July 2013 to June 2014, have been compared. The sensitivity, specificity, positive and negative likelihood ratio, positive and negative predictive value, and accuracy of ultrasonography were calculated. Cohen's kappa coefficient was presented to assess the agreement of ultrasonography with OCT findings. Results: One hundred thirty patients with the mean age of 35.4±18.0 were evaluated (75.4% male). Sensitivity and specificity of ultrasonography were 84.6% (95% Cl: 53.7-97.3) and 98.3% (95% Cl: 93.3- 99.7), respectively. Also, positive and negative likelihood ratio were calculated 49.5 (95% Cl: 12.3-199.4) and 0.15 (95% Cl: 0.04- 0.56), respectively. Cohen's kappa coefficient of 0.83 (95% Cl: 0.66-1.0; p<0.0001) was representative of excellent agreement of these two tests. Conclusion: The finding of this project was representative of 84.6% sensitivity, 98.3% specificity, and 96.9% accuracy of ultrasonography in detection of traumatic lens dislocation. It seems that in cases which OCT is not possible, ultrasonography could be an acceptable option to assess traumatic eye injuries.

Outcome of Patients Underwent Emergency Department Thoracotomy and Its Predictive Factors

Shahram Paydar, Abdoshahid Moghaninasab, Elham Asiaei, Golnar Sabetian Fard Jahromi, Shahram Bolandparvaz, Hamidreza Abbasi

EMERGENCY , Vol. 2 No. 3 (2014), 3 August 2014, Page pp. 125-129

Introduction: Emergency department thoracotomy (EDT) may serve as the last survival chance for patients who arrive at hospital in extremis. It is considered as an effective tool for improvement of traumatic patients’ outcome. The present study was done with the goal of assessing the outcome of patients who underwent EDT and its predictive factors. Methods: In the present study, medical charts of 50 retrospective and 8 prospective cases underwent emergency department thoracotomy (EDT) were reviewed during November 2011 to June 2013. Comparisons between survived and died patients were performed by Mann-Whitney U test and the predictive factors of EDT outcome were measured using multivariate logistic regression analysis. P < 0.05 considered statistically significant. Results: Fifty eight cases of EDT were enrolled (86.2% male). The mean age of patients was 43.27±19.85 years with the range of 18-85. The mean time duration of CPR was recorded as 37.12±12.49 minutes. Eleven cases (19%) were alive to be transported to OR (defined as ED survived). The mean time of survival in ED survived patients was 223.5±450.8 hours. More than 24 hours survival rate (late survived) was 6.9% (4 cases). Only one case (1.7%) survived to discharge from hospital (mortality rate=98.3%). There were only a significant relation between ED survival and SBP, GCS, CPR duration, and chest trauma (p=0.04). The results demonstrated that initial SBP lower than 80 mmHg (OR=1.03, 95% CI: 1.001-1.05, p=0.04) and presence of chest trauma (OR=2.6, 95% CI: 1.75-3.16, p=0.02) were independent predictive factors of EDT mortality. Conclusion: The findings of the present study showed that the survival rate of trauma patients underwent EDT was 1.7%. In addition, it was defined that falling systolic blood pressure below 80 mmHg and blunt trauma of chest are independent factors that along with poor outcome.

An Audit of Emergency Department Accreditation Based on Joint Commission International Standards (JCI)

Behrooz Hashemi, Maryam Motamedi, Mania Etemad, Farhad Rahmati, Mohammad Mehdi Forouzanfar, Fatemeh Kaghazchi

EMERGENCY , Vol. 2 No. 3 (2014), 3 August 2014, Page pp. 130-133

Introduction: Despite thousands of years from creation of medical knowledge, it not much passes from founding the health care systems. Accreditation is an effective mechanism for performance evaluation, quality enhancement, and the safety of health care systems. This study was conducted to assess the results of emergency department (ED) accreditation in Shohadaye Tajrish Hospital, Tehran, Iran, 2013 in terms of domesticated standards of joint commission international (JCI) standards. Methods: This is a cohort study with a four months follow up which was conducted in the ED of Shohadaye Tajrish hospital in December 2013. The standard evaluation check list of Iran hospitals (based on JCI standards) included 24 heading and 337 subheading was used for this purpose. The effective possible causes of weak spots were found and their solutions considered. After correction, assessment of accreditation were repeated again. Finally, the achieved results of two periods were analyzed using SPSS version 20. Results: Quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities had the score of below 50%. The mean of total score for accreditation in ED in the first period was 60.4±30.15 percent and in the second period 68.9±22.9 (p=0.005). Strategic plans, head of department, head nurse, resident physician, responsible nurse for the shift, and personnel file achieved the score of 100%. Of total headings below 50% in the first period just in two cases, collection and analysis of data with growth of 40% as well as competency and capability test for staffs with growth of 17%, were reached to more than 50%. Conclusion: Based on findings of the present study, the ED of Shohadaye Tajrish hospital reached the score of below 50% in six heading of quality improvement, admission in department and patient assessment, competency and capability test for staffs, collection and analysis of data, training of patients, and facilities. While, the given score in strategic plans, head of department, head nurse, resident physician, responsible nurse for the shifts, and personnel file was 100%.

Quality of Life in Emergency Medicine Specialists of Teaching Hospitals

Afshin Amini, Mohammad Reza Munesan, Ali Arhami Dolatabadi, Hamid Kariman, Hamid Reza Hatamabadi, Ali Shahrami, Majid Shojaee

EMERGENCY , Vol. 2 No. 3 (2014), 3 August 2014, Page pp. 134-137

Introduction: Quality of life (QOL) of emergency medicine specialists can be effective in providing services to patients. The aim of the present study was evaluating the lifestyle of emergency medicine practitioners, understanding their problems, and addressing the solutions to enhance and improve their lifestyles, in teaching hospitals in Iran. Method: This descriptive cross-sectional study was conducted on emergency medicine physicians in 10 teaching hospitals of Iran in 2011. Emergency physicians with at least three years of experience who interested in the study, were enrolled in the project. All participants filled out the consent form and QOL questionnaires, then underwent physical examinations and some medical laboratory tests. Categorical variables were reported as percentages, while continuous variables expressed as means and standard deviations. p <0.05 was considered statistically significant. Results: Totally, 100 subjects participated in the study, of whom 48 were male. The mean and standard deviation of the physicians’ age were 38.7±5.1 years. 43% of physicians had an average QOL, while 37% good. 96% of studied physicians had a good condition regarding habitual history, while 93% of them had a poor condition in performing screening tests. Exercise program and personal health in individuals with normal BMI were correlated with higher levels of QOL. BMI was higher in 40-50 years old subjects than youngers. Hypertension was present in five cases (5%), hypercholesterolemia in six (6%), hypertriglyceridemia in six (6%), increased LDL in four (4%), low HDL in four (4%), and impaired FBS in 4 (4%). Conclusion: The findings showed that 63% of studied emergency physicians had an average level of QOL and other ones good. The majority of physicians had undesirable situation regarding the performance of screening tests.

Brief Report

Diagnostic Accuracy of Ascites Fluid Gross Appearance in Detection of Spontaneous Bacterial Peritonitis

Hamed Aminiahidashti, Seyed Mohammad Hosseininejad, Hosein Montazer, Farzad Bozorgi, Iraj Goli khatir, Fateme Jahanian, Behnaz Raee

EMERGENCY , Vol. 2 No. 3 (2014), 3 August 2014, Page pp. 138-140

Introduction: Spontaneous bacterial peritonitis (SBP) as a monomicrobial infection of ascites fluid is one of the most important causes of morbidity and mortality in cirrhotic patients. This study was aimed to determine the diagnostic accuracy of ascites fluid color in detection of SBP in cirrhotic cases referred to the emergency department. Methods: Cirrhotic patients referred to the ED for the paracentesis of ascites fluid were enrolled. For all studied patients, the results of laboratory analysis and gross appearance of ascites fluid registered and reviewed by two emergency medicine specialists. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ration of the ascites fluid gross appearance in detection of SBP were measured with 95% confidence interval. Results: The present project was performed in 80 cirrhotic patients with ascites (52.5 female). The mean of the subjects’ age was 56.25±12.21 years (35-81). Laboratory findings revealed SBP in 23 (29%) cases. Fifty nine (73%) cases had transparent ascites fluid appearance of whom 17 (29%) ones suffered from SBP. From 21 (26%) cases with opaque ascites appearance, 15 (71%) had SBP. The sensitivity and specificity of the ascites fluid appearance in detection of SBP were 46.88% (Cl: 30.87-63.55) and 87.50% (95% Cl: 75.3-94.14), respectively. Conclusion: It seems that the gross appearance of ascites fluid had poor diagnostic accuracy in detection of SBP and considering its low sensitivity, it could not be used as a good screening tool for this propose.

Case Report

Gastric Perforation and Phlegmon Formation by Foreign Body Ingestion

Albert Alejandro Avila Alvarez, Jose Fernando Parra, Diego Andres Buitrago, Fernando Rodriguez, Atilio Moreno

EMERGENCY , Vol. 2 No. 3 (2014), 3 August 2014, Page pp. 141-143

This is a case report of foreign body ingestion in a suicide attempt resulting in gastric perforation and phlegmon formation during a subsequent 6 month period that eventually required surgical intervention. The patient had a prolonged course because she did not report a history of foreign body ingestion and the initial evaluating physicians had no suspicion about possible foreign body ingestion and may have missed important findings on physical examination. Gastric perforation by a foreign object  may have a slow course rather than presenting acute abdomen. The realization of a proper physical examination in the emergency department is key to an accurate diagnosis.

Hashimoto Encephalopathy in Case of Progressive Cognitive Impairment; a Case Report

Abbas Tafakhori, Bahaadin Siroos, Mojdeh Ghabaii, Mohammad Hossein Harirchain, Masih Tajdini, Sushil Kumar Garg

EMERGENCY , Vol. 2 No. 3 (2014), 3 August 2014, Page pp. 144-146

Hashimoto's encephalopathy (HE) is a rare condition characterized by atypical psychiatric and heterogeneous neurological manifestations such as acute cerebral ischemia, seizure, tremors, myoclonus, psychosis, depression, cognitive disorders, and fluctuating loss of consciousness. Here, a case of 28 year-old man was reported who referred to the emergency department (ED) with different acute neurologic disorders and final diagnose of HE.

Photo Quiz

Worsened Dysrhythmia after Chemical Cardioversion with Digoxin; a Case of Malpractice

Behrooz Hashemi, Mehdi Pishgahi, Marzieh Maleki

EMERGENCY , Vol. 2 No. 3 (2014), 3 August 2014, Page pp. 147-149

The patient was a 23-year-old man referred to the emergency department (ED) with the chief complaint of palpitation. The patient experienced dizziness, cold sweating, and lightheadedness after getting up which started spontaneously. He had four episodes of the same problems in seven months ago that felt better after taking 10 mg propranolol. But, in the current episode his problem was not solved by the same medication. He had no history of smoking, substance abuse, medication use, congenital heart disease, syncope, previous surgery, chest trauma, or any other known medical problems. As well, he had no any positive history of the same problems in his family. The patients’ on-arrival vital signs were as follow: systolic blood pressure (SBP): 90 mmHg, pulse rate (PR): 150/minute, respiratory rate (RR): 14/minute, oral temperature: 37◦C, oxygen saturation 96% with nasal cannula and 100% oxygen, Glasgow coma scale (GCS) 15/15. He was not experienced any other concomitant problems such as ischemic chest discomfort, shortness of breathing, or sign of circulatory shock such as paleness, mottling, etc. On general physical examination the patients’ lung and heart sounds, four limbs pulses, and capillary refile were normal. As well, focused neurological and abdominal examinations did not have any positive finding. The patient underwent close cardiac, vital sign monitoring and electrocardiography (ECG). Figure 1 shows the on-arrival patients’ ECG. Atrial fibrillation (AF) was diagnosed by the corresponding physician and digoxin (!?) prescribed that led to severe lethargy, weakness, sweating, and bradycardia. Figure 2 shows the post mediation ECG of patient.