Frontiers in Emergency Medicine

Impact of cigarette smoking on the outcomes of ST-elevation myocardial infarction after primary percutaneous coronary intervention in metropolitan Tehran

Babak Geraiely — 2024-08-24

Objective: Although the adverse effects of smoking are well-established, evidence shows a longer survival rate following an acute myocardial infarction (MI) among smokers or the so-called “smoker's paradox”. This study aimed to determine the impact of smoking on the one-year clinical outcomes of ST-elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI) in a large registry of the Iranian population.

Methods: A total of 3087 patients diagnosed with acute STEMI who underwent PPCI between 2013 and 2018 were enrolled in the study. Patients' smoking status was determined based on self-reported history and categorized into two groups: current smokers and non-smokers. Clinical and angiographic data were collected from the Tehran Heart Center (THC) registry. The primary outcome was one-year of major adverse cardiac and cerebrovascular events (MACCE). The effect of smoking on MACCE was evaluated using a Cox model.

Results: From the study population, 1967 (63.7%) were non-smokers, and 1120 (36.3%) were current smokers. Non-smokers had higher rates of prior CABG (5.3%) as well as a higher history of co-morbidities, including a history of diabetes mellitus (46.0%), hypertension (52.7%) and hyperlipidemia (55.4%) than smokers (2.3%, 30.4%, 35.7%, and 49.8% respectively). Smokers had a higher reference vessel diameter than non-smokers (P=0.005). The unadjusted hazard ratios (HRs) for MACCE within one year were significantly lower in smokers than non-smokers (0.73, 95% CI: [0.58,0.92]; P=0.009); however, after adjustment for confounders, the HRs for MACCE in smokers were similar to non-smokers (HR: 1.00, 95% CI: [0.73,1.38]).

Conclusion: The study found that smoking had no significant impact on the one-year clinical outcomes of STEMI patients after PPCI in the Iranian population. This study is the first of its kind to assess the effect of smoking on STEMI patients in Iran and highlights the need for further research in this area.

Utilizing injury severity score, Glasgow coma scale, and revised trauma score for trauma-related in-hospital mortality and ICU admission prediction; originated from 7-year results of a nationwide multicenter registry

Armin Khavandegar — 2024-08-24

Objective: During the past few decades, many scoring systems have been developed to evaluate the severity of injury and predict the outcome in trauma patients. This study aimed to assess the capacity of three common trauma scoring systems: injury severity score (ISS), Glasgow coma scale (GCS), and revised trauma score (RTS) in predicting in-hospital mortality and ICU admission in patients with traumatic injury.

Methods: This is a multicenter study of the hospital-based national trauma registry of Iran (NTRI), an ongoing registry-based trauma database. This study included trauma cases from 12 major trauma centers throughout the country admitted between July 2016 and November 2023. The inclusion criteria were all patients admitted to the emergency department due to trauma, hospitalized for at least 24 hours, deceased within the first 24 hours of admission, and patients transferred from the intensive care unit (ICU)s of other hospitals.

Results: A total of 50,458 traumatic patients, with 38,740 (76.9%) being male, were included in this study. After adjustment for confounders, head, face, and neck injuries were associated with the highest odds of death (OR: 7.51, P-value<0.001), whereas abdominal injuries were associated with the highest odds of ICU admission (OR: 4.58, P-value<0.001). Each Unit increase in RTS score was accompanied by a 61% decrease in odds of death (OR: 0.39, P-value<0.001). The area under the ROC curve for predicting in-hospital mortality was 0.81 (0.79 to 0.82) in ISS, 0.78 (0.77 to 0.80) in GCS, and 0.75 (0.73 to 0.76) in RTS. There was a significant difference between RTS and GCS, as well as RTS and ISS for in-hospital mortality prediction (P-values< 0.001). The area under the ROC curve for the prediction of ICU admission was 0.75 (0.74 to 0.75) in ISS, 0.63 (0.62 to 0.63) in GCS, and 0.62 (0.61 to 0.63) in RTS. There was a statistically significant difference between ISS and GCS, as well as ISS and RTS, for ICU admission prediction (P-value<0.001).

Conclusion: ISS is the best predictor of in-hospital mortality and ICU admission, compared to GCS and RTS.

The challenges of children's safety in pre-hospital emergencies: a qualitative study

Hamidreza Aghababaeian — 2024-08-24

Objective: Exploring the challenges experienced by the pre-hospital emergency personnel to prevent the secondary injuries and provide more effective services to children can be helpful. This study aims to explain the safety challenges of children in the pre-hospital emergencies.

Method: This qualitative study, which was conducted with the content analysis approach, was a semi-structured, and in-depth data collection process with the field notes for pre-hospital emergency personnel in Dezful city in 2022. Sampling was done in a targeted and available manner. The sampling process continued until the data saturation was reached. The trustworthiness of data was improved by reviewing and revising the data, experience and expertise of the interviewer, review of research participants and researchers. The research data, including interview texts and field notes, were divided into the semantic units, and then summarized by compression, and then abstracted in the order of subclasses, main classes, and finally themes.

Results:

Qualitative data analysis of interviews and notes led to the extraction of eight themes, which expressed the nature of children's safety challenges in the pre-hospital emergency: the lack of pre-hospital equipment for children, physical and mental characteristics of children, the lack of safety of vehicles for children, the lack of clinical skills of personnel for children, anxiety and non-cooperation of parents, operational and legal problems, the lack of attention to professional responsibility and high work pressure in children's missions .

Conclusion:

This study’s results showed that identifying children's safety challenges for pre-hospital emergency personnel can help better understand the care needs of this age group and help managers plan in order to reduce children's safety challenges in the pre-hospital missions.

Comparative analysis of four upper gastrointestinal bleeding scoring systems for predicting multiple outcomes: an observational study in the emergency department

Najmeh Tohidi — 2024-08-24

Objective: Numerous scoring systems have been developed to assess the risk associated with upper gastrointestinal bleeding (UGIB), and several studies have investigated their comparative accuracy in predicting patient outcomes. This study was undertaken to compare four well-known scoring systems, namely the pre-endoscopy Rockall score, full Rockall score, Glasgow-Blatchford Bleeding score (GBS), and AIMS65, with the aim of predicting five distinct outcomes in cases of non-variceal UGIB.

Methods: This prospective observational study was conducted focusing on adult patients with UGIB presenting to the emergency department (ED). The primary endpoints of this study included in-hospital mortality, the need for re-endoscopy, the requirements for packed red blood cell (PRBC) transfusion, massive transfusion, and one-month rebleeding.

Results: A total number of 320 patients were enrolled, with 44 (13·75%) in-hospital deaths. Based on the area under the curves (AUC), while certain scores outperformed others in specific outcome prediction, the AIMS65 scoring system demonstrated superior predictive capability for both in-hospital mortality (0.91) and massive transfusion (0.71). Regarding PRBC transfusion requirements, both AIMS65 and GBS exhibited similar predictive capacities (AUC=0.67 and 0.68, respectively). In terms of re-endoscopy and one-month rebleeding, the GBS scoring system displayed slightly better performance compared to the other systems (AUC=0.61 and 0.63, respectively). In the composite outcome, all scores had significant associations, and among them, the AIMS-65 score had the highest AUC (0.76).

Conclusion: The AIMS65 scoring system was the most reliable tool for predicting in-hospital mortality and, to a lesser extent, massive transfusion requirements, while GBS and AIMS65 could be moderately and cautiously relied on for preparations regarding the need for PRBC transfusion.

Comparison of neutrophil-to-lymphocyte ratio,platelet-to-lymphocyte ratio ,and red blood cell distribution width during the attack phase of familial Mediterranean fever with the silent phase of the disease in patients referred to the emergency department

Babak Sandoghchian Shotorbani — 2024-08-24

Objective: As patients with acute-phase familial Mediterranean fever (FMF) require prompt diagnosis for optimal management, we are conducting a study to compare inflammatory markers during the attack and silent phases in individuals referred to the emergency department.

Methods: This case-control study involved 184 FMF patients under 16 years old, with data collected at Bo Ali Hospital's emergency department in Ardabil city throughout 2022. Patients in the attack phase were assessed by emergency medicine specialists, while those in the silent phase were recruited from the rheumatology clinic. Hematological parameters were obtained from venous blood samples, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and red blood cell distribution width (RDW) were calculated. Statistical analyses included 1-Sample Kolmogorov-Smirnov, ANOVA, Tukey's-b post hoc, Independent Samples T-test, Kruskal-Wallis, and Pearson Chi-squared tests.

Results: In the attack group, the NLR correlated with increased leukocytes (r=0.652, P<0.001) and RDW (r=0.310, P=0.003). The non-attack group showed a correlation between the NLR and higher leukocytes (r=0.384, P<0.001) and ESR (r=0.214, P=0.04). Additionally, the attack group exhibited a correlation between the PLR and higher leukocytes (r=0.711, P=0.009), and ESR (r=0.285, P=0.014) while no correlation was found in the non-attack group.

Conclusion: Our study revealed that RDW levels were significantly higher in FMF patients, indicating clinical inflammation. During FMF attacks, NLR and PLR ratios were notably elevated, making them key markers for systemic inflammation in these patients.

Simulation training improves resident physicians’ confidence in managing first trimester bleeding in the emergency department

Maria Leis — 2024-08-24

First trimester bleeding is commonly encountered in pregnancy and can be potentially life-threatening. Simulation training provides an ideal opportunity for resident medical learners to improve clinical knowledge and gain confidence in managing life-threatening causes of first trimester bleeding in a realistic but safe clinical environment. The objective of this study was to assess the effectiveness of simulation in improving family medicine residents’ confidence and knowledge in identifying and managing first trimester bleeding in the emergency department (ED). The intervention was a two-hour educational simulation focusing on management of unstable first trimester bleeding. Twenty-one family medicine residents (67% female) at the University of Toronto participated in the simulation and completed pre- and post-simulation questionnaires assessing their confidence and knowledge in management of first trimester bleeding. This study demonstrates that simulation training improves resident physicians’ confidence in managing first trimester bleeding in the ED. Additionally, it improves their objective history taking skills. Post-graduate medical programs should consider developing structured simulation, particularly for high-yield clinical cases residents may not otherwise have acute exposure to and are required to be competent in managing.

Difficult intubation in critical patient: how can we manage it? a case report

Gaetano Ottoveggio — 2024-08-24

Difficult airway management represents a challenge. Guidelines recommend choosing the airway technique based on physicians’ skills, equipment, available devices and context.

A man with acute respiratory failure needed an emergent intubation. He was obese with Mallampati score 4, Cormack-Lehane grading 4, macroglossia, reduced mouth opening, stocky and wide neck, and deviated laryngo-tracheal axis due to expanding neck hematoma. After endotracheal intubation failure, the anesthetist placed a second-generation laryngeal mask airway and started ventilation. In the next step, definite airway was provided by an endotracheal tube placed through the mask under flexible fiberscope vision.

Supraglottic airway devices are recommended in cases of unanticipated difficult intubation after endotracheal intubation failure. They are used to ensure satisfactory oxygenation and occasionally to guide the endotracheal tube. Fiberscope is useful to ensure vision of larynx and trachea in these scenarios. This is a unique case of emergency and difficult airway management using this combined approach.

A rare case of emphysematous cystitis

Sepideh Aarabi — 2024-08-24

Emphysematous cystitis is a rare complication that can occur as a result of a lower urinary tract infection. Diabetic patients are at a heigh risk of developing emphysematous cystitis due to their susceptibility to urinary infections caused by gas-producing bacteria. The recommended diagnostic test for this condition is a computed tomography (CT) scan, which is effective in identifying gas buildup in the bladder wall and lumen. The prognosis of this condition depends on how quickly it is treated. In this report, we describe a woman with diabetes mellitus type-2 presented with emphysematous cystitis. Fortunately, she was treated with a combination of antibiotics, insulin therapy, and bladder drainage.

Intravascular volume status in patients with moderate to severe COVID-19: a case series

Hamideh Akbari — 2024-08-24

The Article Abstract is not available.