Journal of Emergency Practice and Trauma

Abstract Cellulitis is treated with antibiotics as routine management and based on the literature the cellulitis hospitalization can be avoided by 11% if appropriate antibiotics are used.1 Randomized clinical trials and Cochrane reviews have suggested that oral antibiotics are non-inferior to intravenous administration (1). We would like to highlight here the unrequired use of intravenous antibiotics in cellulitis. Intravenous antibiotics are recommended in patients with sepsis. This is supported by a study done on 1800 patients with cellulitis diagnosis, where one third of patients were hospitalized

Abstract Colonic injuries after blunt trauma abdomen are a rare entity which may sometimes have a delayed presentation
. In the intensive care unit (ICU), various interventions like sedation, analgesia and paralysis may confound
clinical examination findings pertaining to abdominal pathology. Computed tomography (CT) provides an
excellent diagnostic modality in blunt trauma abdomen but requirement of high ventilatory support and/or
vasopressors may preclude safe transfer of patients from ICU to radiology suites. Point of care ultrasound (POCUS)
provides an excellent adjunct in diagnosis of hollow viscus perforation and is considered as a reliable alternative to
plain radiograph for the diagnosis of pneumoperitoneum

Abstract Objective: In order to heal burn wounds, many researches have been done, including the use of biological scaffolds due to their ability to achieve the desired properties. Owing to the appropriate biological properties of chitosan such as biocompatibility and antimicrobial properties as well as the promotion of wound healing in biomedical applications, we aimed to perform a systematic review to investigate the effect of this technology on the treatment of burn hazards victims.
Methods: The present research was conducted in 2020 as a systematic review of studies related to the effect of chitosan on burns. In this study, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Critical Appraisal Skills Programme (CASP) guidelines were used to assess the articles. The key words “Chitosan,” “Chitin,” “victim,” “Injury,” “Burn,” “Heal,” “wound” “treat,” “hazard,” and “care” were used in combination with the Boolean operators OR and AND. The ISI web of science, PubMed, Scopus, Science Direct, Ovid, Pro Quest, Wiley and Google Scholar were searched.
Results: Recently, chitosan and its derivatives have been proposed as suitable candidates for scaffolding and can be used as temporary scaffolds to modify and stimulate the growth of new tissues. Studies to demonstrate the use of chitosan in the treatment of burns have been limited to research on animal models and have been superior to conventional therapies in terms of time, pain, and efficacy.
Conclusion: The effect of chitosan on burns has been positive in animal models and has accelerated wound healing. Since the main ingredient of chit powder is chitosan and due to the limited studies done on humans, it cannot be said with certainty that the use of chitosan and its derivatives to treat burns is better than other ways to treat burns.

Abstract Objective: The adherence of the physicians to guidelines in resuscitation of the patients
is of great importance since it can predict the outcome. To evaluate the adherence of the
physicians of our center in hydration of traumatic patients with crystalloids regarding the
Advanced Trauma Life Support (ATLS) guidelines.
Methods: We designed an algorithm obtained from ATLS guidelines using vital signs
and status of bleeding of the traumatic patients to classify them. After categorizing the
patients according to the algorithm, we evaluated the adherence of the physicians to the
guideline in hydration of traumatic patients with crystalloids.
Results: This is a cross-sectional study in which 998 traumatic patients who were admitted
to the emergency ward of Rajaee trauma hospital were enrolled. Most of the patients were
men (89.6%) and the most common causes of traumatic injuries were traffic accidents.
Proper hydration was seen in only 14.7% of the patients. Most of the patients were overhydrated (85%) regarding both our algorithm and the patients’ base excess.
Conclusion: The present study showed that the adherence of physicians in our center
in resuscitation with crystalloid was low. Also, most of the traumatic patients were
overhydrated with crystalloids. It is suggested that physicians retrain concerning the
side effects of over hydration. In addition, we need a user friendly and more applicable
guideline for hydration with crystalloids

Abstract Objective: Hand lacerations are among the most frequent causes of visiting emergency
departments (EDs). Wound infection is one of its complications. There is still an ongoing
disagreement on the administration of oral versus intravenous (IV) antibiotics (ABs). The
objective of this study is to compare the effectiveness of oral versus IV ABs in preventing
wound infection of hand lacerations.
Methods: In this double-blind, randomized clinical trial, we enrolled all patients with hand
lacerations (based on the inclusion criteria) during 6 months in the EDs of 2 tertiary referral
centers. Convenient sampling was done. Finally, in the first group, 382 patients received
oral AB (two 500 mg cephalexin capsules) and the other 382 patients in the second group
received IV AB (1 gr IV cefazolin) before wound management. Both groups were followed
and received oral cephalexin during 48 hours after suturing. Rates of wound infection and
different complications were compared between the two groups. T-test, Mann-Whitney U
test, Chi square and Fisher analysis were used.
Results: Both groups had the same age and gender distribution rate (79.8% of males with
the mean age of 30.8 years in the first group, and 83.5% of males with the mean age of 32.6
years in the second group (P = 0.19 and 0.39, respectively). In our study, wound infection
developed in 2.6% and 1.8% of patients in the first and second groups, respectively (P =
0.46).
Conclusion: Based on the results of this study, oral and IV ABs were not significantly
different in terms of preventing wound infection

Abstract Objective: The goal of our study was to determine the prognostic value of CURB-65,
Sequential Organ Failure Assessment (SOFA), pneumonia severity index (PSI), MuLBSTA,
and Acute Physiology and Chronic Health Evaluation (APACHE) II upon admission in
patients with coronavirus disease 2019 (COVID-19, as well as the prediction cut-off value
for death regarding these parameters.
Methods: This observational retrospective study was performed in COVID-19 triage
in Peymaniyeh hospital in Jahrom in 2021. In order to calculate SOFA, APACHE II, PSI,
MuLBSTA, and CURB-65, data were collected from patients who were selected by available
sampling method from PCR-confirmed COVID-19 patients. Thirty-day mortality was
assessed as the primary outcome. ROC analysis was conducted using the STATA software to
evaluate the prognostic value of the scoring systems. DeLong test was utilized to compare
AUC of scores using a web based tool.
Results:Ninety-two patients were included in this study with the mean age of 51.02±17.81
years (male to female ratio was 1:1). SOFA had an AUC of 0.656 (P=0.130), but other indices
had statistically significant values of AUC. Based on the comparison of the AUCs, SOFA
was the worst scoring system in COVID-19 as it had significantly lower AUC than PSI and
APACHE II (P<0.05); while its comparison with MULBSTA and CURB65 was not statistically
significant (P>0.05).
Conclusion: It seems that APACHE II and PSI are the best prognostic factors in our study
with no statistical difference compared together (P>0.05). The sensitivity of APACHE II and
PSI was 0.857 with the specificity of 0.927 and 0.976, respectively. The optimal cut-off point
was 13 and 50 for APACHE II and PSI, respectively

Abstract Objective: In general, spinal fusion surgery causes heavy bleeding. The purpose of this
study was to evaluate the use of two different doses of magnesium sulfate to control the
bleeding in lumbar fusion surgery.
Methods: This study was carried out as a randomized double-blinded clinical trial in 2020
in Al-Zahra hospital in Isfahan. The participants were 60 patients selected using inclusion
and exclusion criteria and were randomly allocated into three groups. In the first group,
50 mg/kg and in the second group, 40 mg/kg magnesium sulfate was infused. The third
group received normal saline. From the beginning of anesthesia, heart rate, diastolic and
systolic blood pressure, respiratory rate and blood oxygen saturation percentage were
monitored and logged every 30 minutes during the operation and recovery. The volume
of bleeding during the operation was calculated by counting the number of gauzes used
and the amount of suctioned blood during the operation. Other required information
such as the duration of operation, duration of anesthesia, time of intubation and the time
period of hospitalization and recovery were determined and recorded in all patients. We
used independent t-test and repeated measure ANOVA tests to compare data between
different time lines and also different groups. P value<0.05 was considered as significance
threshold. The collected data were analyzed by using SPSS software version 23.
Results: The group receiving 50 mg/kg magnesium sulfate had a significantly lower systolic
blood pressure compared to other groups within 15, 30 and 45 minutes after the injections
(P=0.04 for all). The pulse rate was significantly lower in the 50 mg/kg magnesium sulfate
group compared to other groups within 15, 30 and 45 minutes after the injections (P<0.05
for all). Patients that received 50 mg/kg magnesium sulfate had a lower duration of surgery
(P=0.007), lower duration of anesthesia (P=0.007), lower bleeding volume (P<0.001),
lower fluid intake (P=0.01) and also lower transfused blood (P=0.01). The surgeons also
had a significantly higher satisfaction with these patients (P=0.001).
Conclusion: Injection of 50 mg/kg magnesium sulfate had a correlation with reduced
blood pressure as well as bleeding volume compared to 40 mg/kg magnesium sulfate.

Abstract Objective: Cardiopulmonary arrest is a devastating outcome of some clinical situations
and requires strict implementation of cardiopulmonary resuscitation (CPR) protocols.
Since ultrasound is one of the recommended tools to determine the presence of cardiac
movements and may be a predictor of the outcome, this study examined the relationship
between echocardiographic findings during CPR with patients’ outcomes.
Methods: This cross-sectional prospective observational study was conducted on patients
with cardio-respiratory arrest in the emergency department of Shariaty hospital during
2019. sampling method was random. Echocardiography was done at the patient’s bedside
during the CPR process in accordance with the last advanced cardiac life support (ACLS)
guidelines, on two points, after the end of the second and 10th minutes from the start of
CPR. The echocardiography findings (cardiac movement vs standstill) were recorded, and
patient outcomes were followed. Thirty-two patients enrolled in this study with a mean
age of 56.9±15.3 years. Chi-square and Mann-Whitney U tests were used to calculate the
association between heart contractions during resuscitation and the outcomes via SPSS
V.22. Fisher’s exact test and Kruskal-Wallis test were used to evaluate the relationship
between heart rhythm in the second and tenth minutes with the outcomes of CPR.
Results: The presence of cardiac movement in the 10th minute of CPR, in contrast to the
findings of the second minute, had a significant correlation with the success rate of CPR
and outcomes (P<0.05). Moreover, patients with ventricular tachycardia (VT)/ventricular
fibrillation (VF) cardiac rhythm had a better resuscitation rate, 24-hour survival rate, and
better outcome than patients with other cardiac rhythms and asystole (P<0.05).
Conclusion: Echocardiographic findings in the 10th minute of the CPR process can be
used as a prognostic factor for cardiac arrest

Abstract Objectives: Pandemics would certainly have a negative impact on mental health. Positive
modifications as well as negative alterations have been documented in earlier viral
pandemic according to previous investigations. Teenagers face a variety of challenges
during adolescence. Adolescents may become more concerned if this time coincides with
other worries. This study aims to investigate the positive changes that occur in a young
adolescent’s life after COVID-19 pandemic, and to see how they relate to perceived social
support.
Methods: This cross-sectional study was performed on adolescents who were randomly
selected from high schools in Kerman, Iran 2020 during the COVID-19. the sample size
was 108 and for sampling wes used multi-stage random sampling at the end the data was
analyzed by Pearson correlation test. Demographic information, the Multidimensional
Scale of Perceived Social Support (MSPSS) and Posttraumatic Growth Inventory short form
(PTGI-SF) were used to collect data. The data were subjected to descriptive and analytical
statistical tests (Pearson correlation) using SPSS software version 24.
Results: Statistically a positive correlation was found between the PTG total score and
young homeschooled adolescents, parents working remotely, income loss and COVID-19
experience. Moreover, during the COVID-19 pandemic, a positive association was found
between perceived social support and PTG total scores in young adolescents. There were
also substantial positive connections between the MSPSS subscales and the PTGI overall
score.
Conclusion: Based on the findings, an overall growth in all areas of PTG was observed
during the COVID-19 among young adolescents. Perceived social support scores have a
positive and significant relationship with COVID-19 effects. In the crises we face throughout
life, intimate family members and friends play a significant supporting role in adapting to
these situations

Abstract Objective: One of the most important indicators used in the evaluation of emergency centers is the chronometric analysis of patients’ workflow. The aim of this study was to provide a chronometric analysis of patients’ workflow (patients’ waiting time in the emergency department) and related factors.
Methods: This hospital-based prospective cohort study was carried out in Khatam al-Anbia hospital in Shoushtar in 2020. Random sampling was used and patients referred to the emergency ward in three shifts based on the ESI 5-level triage system. The research tools were the emergency workflow chronometry form and a questionnaire of determining the factors related to the speed of emergency services and using a stopwatch. In order to analyse the data, Stata software version 16 and Weibull model of survival analysis were used.
Results: Of 468 participants, the most common cause of referral was trauma with 21.7%. The median ± interquartile range duration of giving the final result was 6.06 ± 4.48 hours, which was more than 0.54 times shorter in clients with level 3. There was a statistically significant difference in the duration of making the final decision based on the request for testing, manner of referring and the type of initial diagnosis (P < 0.05).
Conclusion: The duration of service provision in the studied hospital is appropriate for an Iranian hospital, but it should be closer to international standards. At level 2 triage, patients stayed longer. This can be reduced by lessening the time of consultations which can help the emergency ward.

Abstract Objective: Fractures of orbital rims are common and restoration of these fractures back to
its normal anatomic form is essential to maintain the function and aesthetics of the eyes.
Low profile miniplates are the rigid fixation device of choice for such fractures. But in case
of sagittal and grossly displaced fractures of orbital rims it is difficult to achieve stability by
using miniplate osteosynthesis. The low profile miniplates may not be able to withstand
the forces to reduce this kind if grossly displaced fractures, another stable option needs to
be considered in these situations.
Case presentation: This case report presents a simple and effective technique of reduction
and fixation of an oblique fracture of infraorbital rim fracture using lag screw principle.
A standard titanium screw of 2 mm diameter and 10 mm length is being used in the
described technique for stable fixation of fractured segments.
Conclusion: The technique is simple, hardware’s are easily available and can be practised
in emergency circumstances where newer advanced technologies are not available

Abstract Objective: Orbital emphysema, defined as the presence of air in orbital and periorbital tissues, is a relatively uncommon clinical condition which occurs mostly following facial trauma. It can not only resolve spontaneously without any treatment, but it can also cause life threatening complications such as pneumomediastinum (PM). PM is an uncommon complication of facial fractures and is defined as the presence of air in the mediastinal space. Developing PM following blunt trauma is commonly considered as a red flag for underlying injuries, such as trachea and esophagus rupture. Therefore, other complementary diagnostic procedures, including bronchoscopy and esophagostomy, are often necessary for patients developing this condition.
Case Presentation: A 31-year-old man with a history of facial and neck trauma was presented to the emergency room of our tertiary referral hospital with a complaint of right orbital swelling. On physical examination, vital signs were stable. There was a mild swelling of right upper eyelid, but no proptosis. An hour after admission, following sneezing and blowing his nose, the patient had further swelling of his right face with extension of swelling through the right side of his neck to the nipple. He also complained of dyspnea and acute severe progressive epigastric pain.
Conclusion: Orbital emphysema following orbital wall fracture is typically benign and self- limited, but physicians should be aware of serious complications such as PM. Therefore, monitoring the patient is crucial and should be considered in such ct

Abstract Objective: Purtscher’s retinopathy is the retinal damage following trauma or non-traumatic systemic disease, which may contain cotton-wool spots (CWSs), and may cause Purtscher flecken, atrophy of the optic nerve, and hemorrhage of the posterior pole of the eye.
Case Presentation: A 28-year-old male patient fell down from a height of 10 m and was admitted with swelling and ecchymosis of the peri-orbit of the right eye. The patient’s vision was at the level of light perception. A mild subconjunctival hemorrhage and hyphema were seen in the right eye. In the fundus, the hemorrhage, edema, and CWS were seen in the posterior pole and around the optic disk. Macular thickness (MT) in Purtscher’s retinopathic eye was 353 μm. Also, the patient had a nose and mandibular fracture and was hospitalized for several days.
Conclusion: The findings indicate a decrease in the vision due to Purtscher’s retinopathy caused by trauma. There was no improvement spontaneously

Abstract Objective: Gastrointestinal bleeding is one of the surgical emergencies that is routinely
visited in emergency departments. Although most of these patients are managed with
endoscopic modalities, some of them are managed with surgical interventions. Most of
emergency surgical interventions are done via laparotomy. With evolution in minimal
invasive surgery, the role of laparoscopic surgeries in emergency settings is on a rise.
Case Presentation: In this report we describe a case of lower gastrointestinal bleeding
that was presented with melena and during workups no bleeding lesion was detected
in colon, stomach or duodenum. Further investigations revealed bleeding of proximal
jejunum mass that was resected with the laparoscopic approach which is rarely used in
the emergency management of patients with gastrointestinal bleedings. Also, resection
and anastomosis of proximal jejunal loop was challenging in this case.
Conclusion: This report is intended to describe the feasibility of laparoscopy in proximal
small bowel lesion resection in emergency settings as well as the role of CT angiography in
detecting the source of obscure gastrointestinal bleeding

Abstract Objective: To demonstrate the significance of fused cervical vertebrae in emergency
medicine practice.
Case report: A 35-year-old male was brought to the emergency department (ED) who
attempted suicide by hanging and was later found to have congenital fusion of cervical
vertebra C2 and C3, a condition referred to as - vertebra critica. This is the only case report
of a patient with vertebra critica admitted for near hanging. The patient was intubated
with a Portex® North Polar endotracheal tube (ETT) through the nasal route. This proved to
be a critical decision as it helped early airway control avoiding any complication.
Conclusion: As the victims of near-hanging should have cervical spine restriction,
judicious use of flexible portex® ETT may help in early intubation and resuscitation
without aggravating the neurological injuries. It must be noted that nasal intubation is
contraindicated in base of skull fractures and it should be avoided in patients with obvious
traumatic injury to the neck including laryngeal trauma, tracheal disruption and vessel
injuries.

Abstract Objective: Since the identification and spread of the novel coronavirus disease 2019
(COVID-19) in December 2019, respiratory presentations have been introduced as the
main symptoms of this new type of viral disease; however, the extra-pulmonary features
are raising awareness for researchers due to the vast diversity of vital organs affected
by the virus. Among the wide range of clinical manifestations, limited data are available
regarding rhabdomyolysis (RML) in COVID-19.
Case Presentation: In this report, we present a 58-year-old woman with COVID-19
presenting with RML, with extremely elevated creatinine phosphokinase (CPK) and lactate
dehydrogenase (LDH) levels (3283 and 1280 U/L, respectively) as the second sign of
disease. Since the onset of the COVID-19 pandemic, several COVID-19 induced RML cases
have been reported, and timely diagnosis and proper management are of paramount
importance.
Conclusion: Due to the findings that rhabdomyolysis can be a critical and missed cause of
myalgia in COVID-19 patients, the importance of checking the serum level of CPK in patients
with myalgia and fatigue in the era of COVID-19 upon their arrival will be highlighted.

Abstract Objective: Rhabdomyolysis is an important etiology for developing acute kidney injury
(AKI). Among the many varying reasons for rhabdomyolysis, electrical injury seems to be
a lesser-known factor. The clinical presentation of rhabdomyolysis is usually in the form
of severe and widespread pain, tenderness, weakness in the muscles and dark urine. It
is characterized by the disruption of cell integrity in myocytes as a result of widespread
damage to skeletal muscles and the passage of intracellular components into the
circulation.
Case Presentation: Here we presented a case report of a young man who had
rhabdomyolysis induced by electrical injury which is relatively less common among the
other etiological factors with preserved renal functions. He had electrical injury related
wounds on extremities. Urgent intravenous fluid therapy was initiated as soon as his
admission to the emergency department (ED), without delay.
Conclusion: AKI is very common due to the nephrotoxic effect of myoglobinuria and the
prerenal status. It is rare that AKI does not develop in patients with a severe increase in
creatinine kinase. It is a very important point to start effective fluid therapy in a short time.

Abstract Objective: Ultrasound assessment of inferior vena cava (IVC) collapsibility is performed to
determine the volume status of critically ill patients. We propose a new acoustic window
for visualizing a vein in a prone patient.
Case Presentation: A healthy volunteer took part in the study. The study protocol includes
two stages: 1) performing a magnetic resonance imaging (MRI) examination to determine
the projection of a certain IVC area on the posterior chest surface (holotopy), 2) performing
an ultrasound scanning in the area of IVC projection in order to identify it and determine
its dimensions.
Conclusion: The 11th intercostal space parallel to the paraspinal line allows to visualize
the IVC in the prone position. This gives a potential opportunity to use it to assess the IVC
collapsibility. Its potential advantage is the ability to assess the compressibility of IVC in
the antero-posterior direction