Original/Research Article

Occupational Exposure to Sharp Tools in Emergency Medical Service Staff; an Epidemiologic Study

Hamidreza Aghababaeian, Seyed Ahmad Moosavi, Maryam Dastorpoor, Nasim Kamyar, Mina Farrokhiyan, Behzad Mosaffa, Ehsan Bahrampour, Sadegh Ahmadi Mazhin

Iranian Journal of Emergency Medicine, Vol. 4 No. 4 (2017), 8 October 2017, Page 152-146

Introduction: Sharp tools are among the major risk factors for transmission of blood borne infections. Therefore, the present study was carried out with the aim of determining epidemiologic aspects of occupational exposure and injury with sharp tools in emergency medical service (EMS) of Dezfoul, Iran, in 2014-2015. Methods: This cross-sectional study was carried out on 140 EMS staff who met the inclusion criteria, using census method. The tool used for data gathering was a questionnaire prepared by the researcher including demographic and personal health data, prevalence and cause of injury with sharp tools, knowledge, mental state, reporting exposure, measures taken, and follow-ups. Data were analyzed using statistical tests such as chi square. Results: Overall, 75% of the participants had been exposed to sharp tools at least once in the past year. Most injuries had occurred during venipuncture of the patient (41.09%). 54.2% of all exposures had happened during transfer. In addition, sadly, 63.9% of the exposures of the staff to patients’ infected secretions were not reported. 63% of injuries with sharp objects had occurred in the night shift. There was a correlation between working experience and frequency of exposure (p=0.02, r=0.19). Conclusion: The results of the present study are indicative of the high occupational exposure to sharp tools among staff of the studied EMS, a significant number of which had not been reported. 

Prevalence of Tachydysrhythmia in Patients with Chronic Obstructive Pulmonary Disorder Exacerbation in Emergency Department; a Cross-Sectional Study

Seyed Abouzar Fakhr Mousavi, Seyed Mehdi Zia Ziabari, Soroush Felezi Nasiri, Javaneh Jafarshad

Iranian Journal of Emergency Medicine, Vol. 4 No. 4 (2017), 8 October 2017, Page 157-153

Introduction: Patients with chronic obstructive pulmonary disorder (COPD) are at risk of developing tahcydysrhythmia due to various reasons such as hypoxia, hypercapnia, respiratory acidosis, respiratory and metabolic alkalosis, hypokalemia, ischemic cardiac diseases, and cor-pulmonale as well as using drugs such as theophylline and beta-agonists. The present study was designed with the aim of evaluating the prevalence of various types of tachydysrhythmia in acute exacerbation of COPD. Methods: In this cross-sectional study, patients presenting to emergency department (ED) who were diagnosed with acute COPD exacerbation were evaluated regarding tachydysrhythmia prevalence in their electrocardiogram (ECG) on admission and its distribution based on age, sex, history of underlying illness, history of addiction or smoking, previous hospitalization, and mortality. Data were analyzed using SPSS 21 statistical software and p < 0.05 was considered as significance level. Results: 292 patients with the mean age of 67.35 ± 12.11 years were evaluated (72.6% male). Prevalence of dysrhythmia was 138 patients (47.3%). Normal sinuous rhythm and sinus tachycardia were the most common underlying rhythms with 52.7% and 35.6% prevalence, respectively. Prevalence of tachydysrhythmia was significantly higher in patients with a history of drug abuse (p = 0.049), smokers (p = 0.011), and those with an underlying disease (p = 0.017).  Yet, no difference was detected based on age (p = 0.240), sex (p = 0.062) and previous hospitalization (p = 0.159) in this regard. Finally, 268 (93.7%) patients were discharged from ED and 18 (6.3%) died. Prevalence of tachydysrhythmia in those who died was 77.78% compared with 44.78% in those who were discharged (p = 0.007). Conclusion: Based on the findings, overall prevalence of tachydysrhythmia in patients with COPD was 47.3% in the current study. The most common tachydysrhythmias were sinuous tachycardia, atrial fibrillation, multifocal atrial tachycardia, and idiojunctional rhythm. The prevalence of tachydysrhythmia was significantly higher in those who died, had a history of smoking and drug abuse, and those with an underlying disease. 

The Extent of Maintaining the Privacy of Patients Hospitalized in Emergency Departments of Hospitals Affiliated with Arak University of Medical Sciences; a Cross-sectional Study

Mahdi Harorani, Abdol Ghader Pakniyat, Ali Jadidi, Hajar Sadeghi, Pouran Varvanifarahani, Mohammad Golitaleb, Masoud Basati, Mahdi Safarabadi

Iranian Journal of Emergency Medicine, Vol. 4 No. 4 (2017), 8 October 2017, Page 163-158

Introduction: Today, from the viewpoint of nursing ethics, maintaining the privacy of patients as a part of patient rights is the base and foundation of caring for the patient. Therefore, the present study was done with the aim of evaluating the extent to which the privacy of patients hospitalized in emergency department (ED) is maintained. Methods: This cross-sectional study was carried out in EDs of educational hospitals in Arak, Iran. Convenience sampling was used to include patients hospitalized in ED. The tool used for data gathering was a valid and reliable questionnaire that consisted of demographic data as well as 25 questions to assess the physical, informational and mental-social aspects of patient privacy. Gathered data were analyzed with SPSS software version 16. Results: In the end, data extracted from 300 patients with the mean age of 41 ± 7.22 years were evaluated (60% male). Among the studied patients 62.2% of the participants rated the maintenance of their privacy as poor and only a few (1.7%) of them rated their privacy maintenance as good. In the present study, maintaining the privacy of the patients had a significant correlation with age (p = 0.04), marital status (p = 0.04), and level of education (p = 0.03). Conclusion: Based on the results of the present study, it seems that from the patients’ point of view, maintenance of their privacy by the staff is poor in the studied centers. 

Comparison of Kocher and Modified Hippocratic Methods in Reduction of Anterior Shoulder Dislocation; a Quasi Experimental Study

Iraj Golikhatir, Seyed Mohammad Hosseininejad, Zahra Noori Gharansaraii, Farzad Bozorgi, Fatemeh Jahanian, Hamed Aminiahidashti, Seyed Hossein Montazer

Iranian Journal of Emergency Medicine, Vol. 4 No. 4 (2017), 8 October 2017, Page 168-164

Introduction: Various methods have been designed for shoulder reduction and Kocher method (flexion, adduction and external rotation) and traction counter-traction are introduced as the oldest methods. Therefore, the present study was designed aiming to compare these two methods in reduction of anterior shoulder dislocation. Methods: This quasi experimental study was conducted on 16 to 60 year-old patients presenting to emergency department following anterior shoulder dislocation during 1 year. Patients underwent reduction via Kocher or traction counter-traction methods and were compared regarding reduction time, pain relief rate, success rate and neurological vascular complications. Results: 150 patients with the mean age of 32.11 ± 11.3 years were randomly divided into 2 groups of traction counter-traction (67 individuals) and Kocher (83 individuals) (86.7% male). The 2 groups were similar regarding age (p = 0.52) and sex (p = 0.679). There was no significant difference regarding pain relief after reduction between the 2 groups (p > 0.05). Mean reduction time was 72.27 ± 15.08 seconds in the traction group and 62.34 ± 24.35 seconds in the rotation group (p < 0.0001). In addition, duration of hospitalization was 3.00 ± 0.48 hours in traction group versus 3.08 ± 0.61 hours in the other group (p = 0.382). The frequency of failure in reduction cases was 1 (1.49%) in the traction group and 6 (7.22%) in the rotation group (p = 0.129). Finally, 2 (2.40%) cases of mild injury of brachial plexus in the ulnar nerve path occurred in the rotation group and no neurological complication was seen in the traction group. Conclusion: According to the results of the present study, Kocher and traction counter-traction methods were similar regarding pain relief after reduction and total duration of hospitalization, but reduction time was shorter in Kocher method and treatment failure rate was reported to be higher in this method. 

Antibiotic Prophylaxis Prescription in Simple Traumatic Wounds Treated in Emergency Department

Hamed Basir Ghafouri, Nader Tavakoli, Mohammad-Reza Yasinzadeh, Niloofar Abazarian, Amir Noyani, Mehdi Azarmnia

Iranian Journal of Emergency Medicine, Vol. 4 No. 4 (2017), 8 October 2017, Page 173-169

Introduction: Currently, considering the advances made in management of traumatic wounds, preventing secondary infections following these accidents is considered a serious challenge. Although using antibiotics for prophylaxis to reduce infection has become less popular, it is still discussed as a method of reducing infection. The aim of the present study is to evaluate the rate and route of antibiotic prophylaxis prescription in traumatic wounds treated in emergency department (ED) and compare it with international standards. Methods: This cross-sectional study was carried out in the ED of Shohadaye-Hafte-Tir Hospital, Tehran, Iran. Patients with simple traumatic wounds were included via easy non-probability method. Before wound healing, the researcher evaluated the patient’s wound regarding appearance, site, cause of injury, length and depth of the wound, time since occurrence of injury, and presence or absence of evident contamination, and determined presence or absence of indication for prescribing antibiotics based on recommendations of approved references in emergency medicine. The researcher asked the patients questions regarding receiving or not receiving antibiotic prophylaxis and its duration after the healing of the wound. Data were analyzed using SPSS-21 after gathering. Results: Overall, 296 patients with the mean age of 31.56 ± 14.74 years were evaluated, 816% of which were male. For 268 (90.5%) of the studied patients, antibiotics was prescribed. However, only 58 (19.6%) had indications for prophylaxis prescription. All of the patients who had indications for receiving antibiotics had received antibiotic prophylaxis. According to the results of this study, antibiotic prophylaxis was prescribed without indications in 210 (71%) of the patients. There was a significant difference (p=0.0001) between the duration of antibiotic prophylaxis prescription in this study and the standard duration recommended for simple wounds. Duration of antibiotics prescription was more than 3 days regarding wounds with evident contamination (p=0.018) and wounds with indication of antibiotic prescription (p=0.007). Sex of the patients, wound type, and anatomic site of injury did not have a significant effect on the mean duration of antibiotics prescription compared to the recommended rate (p > 0.05). Conclusion: Based on the results of the present study, for 71% of the patients with simple traumatic wounds, antibiotic prophylaxis was prescribed without presence of indications and the duration of antibiotic prophylaxis prescription was longer than the standard recommendations. 

Airway Management via Insertion of Laryngeal Tube versus Combitube into a Manikin by Emergency Medicine Residents

Hamidreza Morteza Bagi, Amir Ghafarzad, Malak Sadat Naeimi

Iranian Journal of Emergency Medicine, Vol. 4 No. 4 (2017), 8 October 2017, Page 179-174

Introduction: Laryngeal tube (LT) and combitube (CT) are among devices used for establishing the airway in patients. This study was done with the purpose of comparing the success rate and duration of intubation when emergency medicine (EM) residents used LT or CT. Methods: In this cross sectional study, carried out in Tabriz, Iran, in 2016, all EM residents of Tabriz University of Medical Sciences were included. Number of attempts and time required for successful intubation via LT and CT and airway management were evaluated for each participant using a manikin. Results: A total of 52 EM residents in three groups (First Year: 17, Second Year: 16, and Third Year: 19) with the mean age of 36.24 ± 9.21 years participated in this study (61.53% male). All the residents were successful in inserting LT and CT on the first attempt. Mean duration of CT and LT placement in third year residents (7.5 ± 2.01, 6.39 ± 1.21, respectively) was significantly shorter than second year residents (9.25 ± 2.87, 8.06 ± 2.24, respectively) and first year residents (13.06 ± 3.54, 11.76 ± 2.43, respectively). Mean duration of CT placement (9.9 ± 3.15) was significantly greater than LT placement (8.71 ± 2.88) (p<0.05). Conclusion: Based on the results obtained in the present study, EM residents were successful in LT and CT placement into a manikin on the first attempt. However, time required for placement of LT was shorter than CT. 

Letter to Editor

The Necessity of Evaluating the Stability of Pre-Hospital Emergency Service Drugs in Different Climates

Hamidreza Aghababaeian, Mohammad Maniey, Sadegh Ahmadi Mazhin

Iranian Journal of Emergency Medicine, Vol. 4 No. 4 (2017), 8 October 2017, Page 142-140

One of the indices of development in a society is providing the necessary healthcare for all people. One of the most important pillars of healthcare is emergency care, especially the pre-hospital type. Pre-hospital emergency care starts on the patient’s bedside and ends in the emergency service of a hospital. Emergency organizations train 4 groups for providing emergency service and pre-hospital care: 1) first responder; 2) emergency medical technician (EMT)-Basic; 3) EMT-Intermediate; 4) EMT-Paramedic. Prescribing drugs for the patients in need is one of the many responsibilities of the last 2 groups (EMT-Intermediate and EMT-Paramedic) that treat many patients each year. Proper and timely use of drugs can minimize threats to patients’ lives and keep them from dying. It is obvious that those who use drugs for treating patients need to have a safe deposit of drugs in addition to accurate and correct information to be able to take the first step of treatment correctly and safely. Currently, all emergency drugs in pre-hospital emergency care of Iran are kept in a box with no insulation and in an environment with temperature changes. Although some drug companies do not consider little changes in temperature as a cause of change in drug effectiveness, the conditions in medical emergencies are very different and harder than laboratory environments. In some countries including Iran, the temperature of the ambulance cabin may vary from -30°C in winter in Ardebil to +65°C in summer in Khouzestan. However, world health organization (WHO) suggests storing drugs in a dry environment between 15°C and 25°C and based on the climate of the region up to a maximum of 30°C. Little data exists regarding the stability of drugs in changing temperatures. Johansen et al. carried out a study in this regard on atropine, naloxone, and lidocaine in Utah in 1992 and reported that no considerable change was found in the concentration of drugs. In 2005, Priston et al. carried out a study in the UK on 11 drugs in -15°C and found that some of the drugs have relatively lower stability if frozen. In addition, in the drug instructions of some drugs including atropine, calcium, and morphine the highest storing temperature is indicated to be 30°C and nebulized albuterol should also be stored in 25°C. Obviously, drug treatment is very important in pre-hospital emergency services, which in turn is the first line of treatment in medical emergencies, accidents and disasters and sometimes an injection of atropine or adrenaline can save someone’s life at the onset of a problem. Therefore, the effect of extreme climates of some provinces in Iran on the effectiveness and safety of the drugs used in pre-hospital emergency services should be studied and evaluated. The authors have decided to point out the importance of drug stability in pre-hospital emergency service in various climates hoping that researchers who have the ability and equipment for doing this research evaluate this topic so that the obtained results are shared with managers and any possible corrective measures needed are taken. 

Measuring Fibrinogen Level in Patients with Pelvic Trauma

Mehrdad Esmailian, Davood Mohammadi, Mehdi Nasr Esfahani, Majid Zamani

Iranian Journal of Emergency Medicine, Vol. 4 No. 4 (2017), 8 October 2017, Page 145-143

Pelvic fracture is the second most common cause of death in trauma patients after head trauma; and the major reason for death in these patients is hemorrhage and its resulting hypovolemic shock. Rapid and proper diagnosis and treatment can improve the outcome of these patients. The main treatment consists of fixation of the pelvis and resuscitation of patient’s hemodynamic using isotonic liquids and blood products until the condition is favorable for surgery or angiography. New findings show that fibrinogen plays a vital role in reaching and maintaining homeostasis, especially in patients that have lost a significant amount of blood. It seems that concentration of plasma fibrinogen, which is a key glycoprotein in the coagulation cascade, is independently related to hemorrhage and prophylaxis infusion of fibrinogen concentrate can decrease bleeding. Fibrinogen level has been introduced as a determining factor in prediction of 28-day mortality of patients with heavy traumatic bleeding. Compared to fresh frozen plasma (FFP), injection of fibrinogen concentrate has had better results in improvement of outcome and has decreased need for other blood components and has led to an increased probability of survival without increasing the risk of venous thromboembolism. A study in 2015 showed that 19.2% of the patients with severe hemorrhage due to trauma had a fibrinogen level less than 2gr/L.

Writers of the current letter evaluated 60 patients with traumatic pelvic fracture with the mean age of 51.12 ± 20.30 years (11-85) (58.30% male). 42 (70.0%) cases had presented with 1-sided or double sided ramus fracture, 17 (28.3%) cases with iliac wing fracture and 1 (1.7%) case with acetabulum fracture. 16.7% of the patients had a hemoglobin level less than 10 mg/dL and 21.7% had systolic blood pressure less than 90 mmHg on admission to emergency department. Mean blood level of fibrinogen in this group of patients was 261.85 ± 40.24 mg/dL (200-368). In other words, considering the normal range described for the kit used for this study (Mahsa Yaran Company, Iran) none of the patients were in the hypofibrinogenemia zone (< 200 mg/dL). It seems that variables such as trauma severity, racial characteristics, underlying illnesses, hemorrhage severity, type of fracture, and … might also affect the level of plasma fibrinogen and its decrease following hemorrhage. Overall, a final decision regarding the effect of fibrinogen injection instead of products such as FFP requires further studies with higher accuracy and considering other factors affecting the outcome of such patients. However, considering the studies that affirm the role of fibrinogen in improving the outcome of patients with severe hemorrhage, it seems that measuring plasma fibrinogen level and injecting it for patients with hypofibrinogenemia is a wise solution in management of this type of patients.