Bulletin of Emergency And Trauma
Volume:7 Issue: 1, jan 2019

  To perform a systematic review and meta-analysis of self-immolation epidemiology and characteristics in Iran. This was a systematic review and meta-analysis study. PubMed, Scopus, Web of science and Science Direct were searched for English literature and SID and Magiran for Persian in the time period of 2000 to 2016. The retrieved studies were screened and reviewed then quality assessed. Random Effect model was applied for meta-analysis. The qualitative data were analyzed by content analysis method. After literature screening, 39 studies included in the analysis. Women were subject to self-immolation more than men. The rate of self-immolation estimated to be 4.5 cases in every 100,000 populations and it was the reason of 16% of hospitalized burns. The average length of hospital stay calculated to be 12.24 (95% CI: 8.85-15.59) days. The total burnt surface area was 65.3% (95% CI: 56.71-73.89). Death due to self-immolation was 62.1%. The major risk factors of self-immolation were having mental health issues, family problems and characteristics and problems in relation/communication with spouses. Despite the low rate of self-immolation in Iran, it comprises one sixth of the hospitalized burns. The mortality rate of self-immolation also is high and this highlights the importance of providing special care. Psychological consultations and mental health screening in the primary health care would help to prevent the self-immolation

  To perform a systematic review of the properties and results of the studies that their approaches are lean management in emergency departments and the factors which influence on their performance. The necessary information in the first stage was collected by searching these keywords: "Lean principles" “Lean Six Sigma", "Lean Process", “Lean thinking”, “Lean Methodology”, “Toyota Production System lean processing”, "lean techniques", "emergency department”, “emergency medicine”, “emergency room” and “emergency care”. And in the next stage the keywords such as “lean management” and “emergency” was collected from SID, Medlib, IranDoc, Google Scholar, MagIran, IranMedex data bases. For extracting the data data-extracting forms was prepared. The information we got from the forms was organized in information-extracting forms and was analyzed manually. The diagrams were drawn in Excel: 2010. Finally, 26 essays have been included. Most of the studies were accomplished in Canada and U.S.A. only in one of the cases, the authors used the control group. Each of these terms, “lean techniques” and “lean principals”, with five times repetitions had the highest frequency. The most important team of implementation of lean management included: hospital management team or the manager of Emergency department, physicians, nurses, staffs and external counselors. Generally, 51 indicators were studied which among them the length of stay and the timing had the most frequency. After implementation of lean management, almost all studied indicators have significantly improved. 14 barriers, 14 facilitators and 10 effective factors were recognized in implementing the lean management. According to the studies, responsibility of organization’s senior management and his/her supports; increasing the knowledge of the characteristics and dimension of lean among the providers of health service; and decreasing the resistance and consulting with external counselors can have great effect on the success of lean management.

Endotracheal intubation is a lifesaving procedure that is performed in various settings within the hospital or even in the pre-hospital field. However, it can result in serious hemodynamic complications, such as post-intubation hypotension (PIH) and cardiac arrest. The most promising predictor of such complications is the shock index (SI), which holds great prognostic value for multiple disorders. On the other hand, most of the studies that have assessed the predictability of the pre-intubation SI have been small and were limited to a particular setting of a single center; thus, the results were not generalizable, and the predictive value vary according to the setting. This review comprehensively assessed the utility of the pre-intubation SI for predicting PIH and post-intubation cardiac arrest by classifying and comparing evidence compiled from various settings, such as pre-hospital settings, emergency departments (EDs), intensive care units (ICUs), and operating rooms (ORs). The vast majority of these studies, conducted in ED and ICU settings, which revealed a significant correlation between an elevated SI and PIH or post-intubation cardiac arrest. The reliability and simplicity of obtaining a pre-intubation SI value are important considerations that encourage the extension of its use to all in-hospital intubations. Further studies are required to assess the predictive value of the SI in the pre-hospital setting.

  To assess the effect of locally administered verapamil on transected peripheral nerve regeneration and functional recovery. Sixty male healthy white Wistar rats were divided into four experimental groups (n=15), randomly: In transected group (TC), left sciatic nerve was transected and stumps were fixed in the adjacent muscle. In treatment group defect was bridged using chitosan tube (CHIT/Verapamil) filled with 10 µL verapamil (100ng/mL). In chitosan conduit group (CHIT), the tube was filled with phosphate-buffered saline alone. In sham-operated group (SHAM), sciatic nerve was exposed and manipulated. The repair trend was examined based on behavioral and performance tests as well as the variations of the gastrocnemius muscle, morphometric indices, and immunohistochemical indices. Sciatic nerve functional study, muscle mass and morphometric indices confirmed faster recovery of regenerated axons in CHIT/Verapamil than CHIT group (P=0.001). When loaded in a chitosan tube verapamil accelerated and improved functional recovery and morphometric indices of sciatic nerve. Immunohistochemical analysis revealed the S-100 protein was vastly present in the transverse nerve sections and the myelin sheath. In the treatment group (chit/verapamil), the immunohistochemical susceptibility of the axons being repaired and the axons in the myelin sheath to S-100 protein was higher than the other groups. The present study demonstrated that a single local application of verapamil could accelerate functional recovery after transection of sciatic nerve

  To evaluate effects of pyrroloquinoline quinone (PQQ) on ischemia-reperfusion injury using a rat ovary model. Thirty healthy female Wistar rats with 250g were randomized into five experimental groups (n = 6): Group SHAM: The rats underwent only laparotomy. Group Ischemia: A 3- hour ischemia only. Group I/R: A 3-hour ischemia and a 3-hour reperfusion. 30 min before termination of reperfusion 20 µL soybeen oil (Solvent of PQQ) was administered. Group I/PQQ: A 3-hour ischemia only and 20 µL (10 mg/kg) intraperitoneal administration (IP) of PQQ 2.5 hours after induction of ischemia. Group I/R/PQQ: A 3-hour ischemia, a 3-hour reperfusion and 20 µL (10 mg/kg) IP of PQQ 2.5 hours after induction of ischemia. Animals treated with PQQ showed significantly ameliorated development of ischemia and reperfusion tissue injury compared to those of other groups (p=0.001). The significant higher values of SOD, GPO and GST were observed in I/R/PQQ animals compared to those of other groups (p=0.001). Damage indicator (MDA) was significantly lower in I/R/PQQ animal compared to those of other groups (p=0.001). Intraperitoneal administration of PQQ could be helpful in minimizing ischemia-reperfusion injury in ovarian tissue exposed to ischemia.

  To evaluate the effect of imbibed fibrinogen gauze on survival, bleeding and healing in liver trauma. This animal experimental study was conducted on 20 adult male Sprague-Dawley rats; with a mean weight of 300±50 gram; divided into two groups. Grade IV injury was induced to the subjects’ liver. Then, the bleeding site was packed with simple gauze in the control group, and imbibed fibrinogen gauze in the experimental group. All animals were re-evaluated for liver hemostasis 48 hours after the initial injury. Bleeding in the intra peritoneal cavity was measured using Tuberculosis Syringe in the first and second operations. Subjects were followed-up for 14 days. Eventually, the rats were sacrificed and their livers were sent to a lab for stereological assessment. Statistical comparisons were performed via Mann–Whitney U-test using SPSS. P-Values less than 0.05 were considered to be statistically significant. Half of the rats in the control group died, while all the rats in the imbibed fibrinogen gauze group survived after two weeks (p= 0.032). Bleeding in the imbibed fibrinogen gauze was significantly less than control group, 48 hours’ post-surgery (p<0.001). According to the stereological results, granulation tissue in the imbibed fibrinogen gauze group were more than the control group (P= 0.032). Also, fibrosis in the imbibed fibrinogen gauze group were more than the control group (P= 0.014). Our study indicated that imbibed fibrinogen gauze can potentially control liver bleeding and improve survival through increasing granulation tissue and fibrosis in injured liver.

  To evaluate the safety and effectiveness of NOM (nonoperative management) in the treatment of blunt liver trauma, following a standardized treatment protocol. All the hemodynamically stable patients with computed tomography (CT) diagnosis of blunt liver trauma underwent NOM. It included strict clinical and laboratory observation, 48-72h contrast enhanced ultrasonography (CEUS) or CT follow-up, a primary angioembolization in case of admission CT evidence of vascular injuries and a secondary angioembolization in presence of vascular injuries signs at follow-up CEUS. 181 patients (85.4%) [55 (30.4%) women and 126 (69.6%) men, median age 39 (range 14–71)] were included. Of these, 63 patients (34.8%) had grade I, 48 patients (26.5%) grade II, 39 patients (21.5%) grade III, 21 patients (11.6%) grade IV and 10 patients (5.5%) grade V liver injuries. The overall success rate of NOM was 96.7% (175/181). There was not significant difference in the success rate between the patients with different liver injuries grade. Morbidity rate was 7.4% (13/175). Major complications (2 bilomas, 1 liver hematoma and 2 liver abscesses) were successfully treated by CEUS or CT guided drainage. Eighteen (18/181) patients (9.9%) underwent angioembolization with successful results. Nonoperative management of blunt liver trauma represents a safe and effective treatment for both minor and severe injuries, achieving an high success rate and an acceptable morbidity rate. The angiographic study with embolization, although required only in selected cases of vascular injuries, represents a fundamental therapeutic option in a significant percentage of patients.

  To investigate the role of red cell distribution width (RDW) in comparison with Trauma-Associated Severe Hemorrhage (TASH) system in predicting the mortality of multiple trauma patients, referred to the hospital emergency department. This follow-up study was conducted on multiple trauma patients (age ≥ 18 years) with Injury Severity Scores (ISS) of ≥ 16, who were referred to the emergency department from March 1, 2017, to December 1, 2017. First, all patients were evaluated based on the Advanced Trauma Life Support (ATLS) guidelines, and then, their blood samples were sent for RDW measurements at baseline and 24 hours after admission. The ISS, Revised Trauma Score (RTS), and TASH were measured in the follow-ups and recorded by third-year emergency medicine residents. Hospital mortality was considered as the outcome of the study. In this study, 200 out of 535 multiple trauma patients were recruited. The frequency of hospital mortality was 19 (9.5%). In the univariate analysis, there was no significant relationship between hospital mortality and RDW at baseline, RDW on the first day, and ΔRDW (RDW at baseline - RDW on the first day), unlike ISS, RTS, TASH (p=0.97, P= 0.28, and p=0.24, respectively). On the other hand, in the multivariate analysis, ISS, RTS, and TASH showed a significant relationship with hospital mortality. The greatest area under the ROC curve (AUC) was attributed to TASH and RTS systems (0.94 and 0.93, respectively). TASH scoring system, which was mainly designed to predict the need for massive transfusion, may be of prognostic value for hospital mortality in multiple trauma patients, similar to ISS and RTS scoring systems.

To determine the prevalence and socio-economic disparity among victims with disabilities caused by RTAs in Iran as country with a high rate of accidents. The source of data was the Iranian Multiple Indicator Demographic and Health Survey, a nationwide cross-sectional study. The sampling framework was based on the population and housing census for Iran in 2006. Provincial samples ranged from 400 to 6,400 households. The target sample was 3,096 clusters consisting of 2,187 urban and 909 rural clusters. In the present study, all but a few indicators are reported at provincial levels. Mortality indicators, accident and disability rates, low birth weight rate and young age at marriage rates are presented at the national level only. Logistic regression was performed to investigate the individual and family factors influencing RTAs that lead to disability in Iran. The period prevalence (12 months) of road traffic accident disabilities (RTADs) in the total population of 111415 was 30.52 (95% CI: 21.13.41.64) per 100,000 individuals. Among those who had been injured during the year leading up to the study, the proportion of disabilities caused by RTAs was 31.67 (95% CI; 8.51.54.97) per 1000 pedestrians, 20.99 (95% CI: 13.37.30.75) per 1000 motorcyclists, 18.64 (95% CI: 7.71.29.57) per 1000 vehicle drivers. Multivariate logistic regression analysis showed that the risk of RTADs differed significantly in relation to age (AOR 50-59 vs. 0-9=10. 78, p-value:0.05); activity status (AOR unemployed vs. employed=4.72, p-value:0.001) and family income (AOR q2 vs. q1=0.37, p-value:0.048) of the victim. In addition to the risks associated with socio-economic groups, particularly vulnerable groups, RTADs have consequences which can lead to further marginalization of individuals, can affect their quality of life and damage the community as a whole.

Sepsis and septic shock remain a major cause of morbidity and mortality globally. In septic patient’s bedside physical examination can often be unhelpful in helping to identify the source of infection and, therefore, decide upon appropriate management. Protocols for point-of-care-ultrasound (POCUS) in critically-ill patients who present with shock or trauma have been described elsewhere including rapid ultrasound in shock (RUSH), focused assessment with sonography for trauma (FAST), and focused cardiac ultrasound (FOCUS). Although the use of POCUS in sepsis has been reported in existing literature, there is not an algorithm for when POCUS is indicated in septic patients. We describe the case of a 70-year-old woman who presented to the emergency department (ED) with a 1-week history of diarrhoea and vomiting. The initial diagnosis in ED was viral gastroenteritis with prerenal acute kidney injury and she was initially referred to the medial team. However, the patient remained hypotensive and oliguric after 2 litters of IV fluids. A point-of-case-ultrasound (POCUS) showed a right kidney with moderate hydronephrosis. Urology team was immediately contacted with a CT that confirmed an obstructive stone causing moderate kidney hydronephrosis. Emergency nephrostomy was performed and the patient was discharged and has remained asymptomatic.

Retroperitoneal and horseshoe abscesses are particularly important because of the anatomic characteristics and the clinical differences between treatment approaches. There are several challenges in treating perirectal and retroperitoneal abscess, the most important of which are partial recovery, high recurrence rates, and continence problems. A 65-yearold male patient underwent laparotomy at an external center with a diagnosis of ileus. Although no intraoperative pathology was detected, ileus persisted postoperatively, and the patient was referred to our clinic where he was diagnosed with a complicated horseshoe abscess, 9 cm in diameter and displaying retroperitoneal extension. Perirectal abscess drainage was performed, and the patient was discharged on the 5th day after the treatment. To the best of our knowledge, there have not been any previously reported cases of ileus caused by retroperitoneal abscess as a complication of horseshoe abscess. The case presented in this paper represents a rare complication, thereby contributing to the literature which remains to be explored.

Scorpion bite has different manifestations in vital organs and may cause blindness secondary to involvement in the circulation of these vital organs. We report a case of abrupt vision loss and periorbital edema and redness due to scorpion bite in the eyebrow in an endemic region of southern Iran. A 45-year-old woman referred to the emergency room of our ophthalmology center due to abrupt vision loss and periorbital edema in her right eye. Involvement of ocular vasculature by localizing stroke due to the coagulative disorder caused by scorpion venom leads to retinal vein occlusion in this case. Management of BRVO was done with intravitreal injection of bevacizumab in the early phase. The outcome was complete vision recovery. To the best of our knowledge, this is the first case of macular branch retinal vein occlusion after scorpion bite.

Tarsal coalition is an often unrecognised cause of foot and ankle pain and represents a congenital osseous, cartilaginous or fibrous connection between two or more tarsal bones. Fractures in combination with tarsal coalitions are rarely described in the literature. We report the case of a 43-year-old male patient with a talocalcaneal coalition who sustained an open comminuted calcaneal fracture and a closed transverse cuboid fracture. Due to the asymptomatic tarsal coalition and the already firmly fixed subtalar joint, the patient was treated with open reduction and internal fixation (ORIF) with satisfactory outcomes instead of ORIF in combination with subtalar arthrodesis. Ten months after the trauma, the patient was satisfactory and could return to his regular work. There is currently no evidence for the gold standard treatment of calcaneal fractures with combined tarsal coalitions. Due to the satisfactory results of this case, authors conclude that in case with prior asymptomatic coalitions, singular ORIF without subtalar arthrodesis may be performed.

Pneumothorax as a complication of pleural catheter insertion could be very dangerous in patients under mechanical ventilation. In ICU patients, physical examination and supine chest x-ray (CXR) are poorly sensitive in diagnosis of pneumothorax. Moreover, CT scan has also disadvantages, such as radiation, high cost, time consuming and need for patient transfer to radiology suit. In comparison to CXR and CT scan, ultrasonography is an available tool for early and rapid detection of this complication. In this study, we reported a 21-year-old woman, a victim of trauma, undergone pleural catheter insertion for drainage of hemothorax. She developed pneumothorax after the procedure. We discuss the usefulness of ultrasonography after pleural catheter insertion and concluded its adequacy and effectiveness in early diagnosis and also follow-up of pneumothorax.

Dear Editor,
With great interest we have read the outstanding publication in the recent Bulletin of Emergency and Trauma issue by Ghafarypour-Jahrom et al. entitled “Validity and Reliability of the Emergency Severity Index and Australasian Triage System in Pediatric Emergency Care of Mofid Children’s Hospital in Iran” [1]. We bring your attention to the concerning the reliability of Emergency Severity Index (ESI) in the mentioned study that may provide a new understanding to lead clinical practice in emergency department (ED). The study used Cohen kappa values to report inter-rater reliability of Level 1 to 5 are 0.833, 0.777, 0.520, 0.850 and 0.883. Thereliability coefficient for level 4, 5 and 1 is almost perfect (> 0.80) which is reported in other literature too [2]. The reliability coefficient for level 2 and 3 is substantial and moderate respectively, implying that the agreement between raters suffers from discrepancy. This issue is even more remarkable while bearing in mind that a large number of patients in the ED belong to these categories. Besides, these patients have strong potential to get into critically ill condition. Therefore, it is vital to address this flaw in the literature. One of the criteria in ESI level 2 is “high-risk patients”. Nurses must perceive high-risk condition in patients based on their knowledge and expertise. “high-risk patients” in ESI level II is a broad and general concept and to some extent ambiguous which is not enough clear to identify high-risk patients sufficiently and prevent misclassification. Tanabe et al. defined level II patients as individuals who are more stable than level I and they indicated critically ill patients’ triage criteria needs further revisions [3]. This ambiguity congests a considerable amount of patients in level II if nurses are going to keep undertriage rate low. In addition, it may turn to a great source of conflict between nurses and physicians due to the fact that they may interpret high-risk condition differently. The reliability coefficient of 0.777 clearly supports this hypothesis. The reliability coefficient of 0.520 may indicate there is low agreement between the raters regarding resources which is necessary to fulfill emergency care for patients. Patient influx in ESI level II causes other parts of the ED remain unused. This issue could not be tolerated in the ED because triage nurses wants to consume all ED resources as much as possible conscientiously and reduces overcrowding. This issue deterioratedlonger practice of ESI in ED. This discrepancy deserves to be considered in further study. Conflicts of Interest: None declared.