Designing a model of emergency medical services preparedness in response to mass casualty incidents: a mixed-method study.

BACKGROUND: Emergency medical services preparedness in mass casualty incidents is one of the most important concerns in emergency systems. A mass casualty incident is a sudden event with several injured individuals that overwhelms the local health care system. This study aimed to identify and validate the components of emergency medical services readiness in mass casualty incidents which ultimately led to designing a conceptual model. METHODS: This research was an explanatory mixed-method study conducted in five consecutive stages in Iran between November 2021 and September 2023. First, a systematic review was carried out to extract the components of emergency medical services preparedness in mass casualty incidents based on the PRISMA guideline. Second, a qualitative study was designed to explore the preparedness components through in-depth semi-structured interviews and analyzed using the content analysis approach. Third, the integration of the components extracted from the two stages of the systematic review and qualitative study was done by an expert panel. Fourth, the obtained components were validated using the Delphi technique. Two rounds were done in the Delphi phase. Finally, the conceptual model of emergency medical services preparedness in mass casualty incidents was designed by a panel of experts. RESULTS: 10 articles were included in the systematic review stage and sixteen main components were extracted and classified into four categories. In the second stage, thirteen components were extracted from the qualitative study and classified into five categories. Then, the components of the previous two phases were integrated into the panel of experts and 23 components were identified. After validation with the Delphi technique, 22 components were extracted. Lastly, the final components were examined by the panel of experts, and the conceptual schematic of the model was drawn. CONCLUSIONS: It is necessary to have an integrated framework and model of emergency medical service readiness in the planning and management of mass casualty incidents. The components and the final model of this research were obtained after the systematic scientific steps, which can be used as a scheme to improve emergency medical service preparedness in response to mass casualty incidents.

Emergency medical services preparedness in mass casualty incidents: A systematic review.

OBJECTIVE: The role of emergency medical services (EMS) preparedness in mass casualty incidents (MCIs) is crucial. MCIs are increasing worldwide, and EMS must enhance preparedness for them. For this purpose, the main components of EMS preparedness should be identified. This study aimed to describe the components of EMS preparedness in response to MCIs. DESIGN AND SETTING: This systematic review was conducted based on the Preferred Reporting Item for Systematic Reviews and Meta-analyses guideline. The articles published from January 1970 to February 2022 were searched to discover the main components of EMS preparedness in MCIs. The electronic databases including PubMed, Cochrane Library, Scopus, Science Direct, and ProQuest were searched using predetermined keywords. Ten articles were selected and included in this review. RESULTS: After reviewing the articles, we identified the components of EMS preparedness in MCIs. Accordingly, 16 main components were extracted and classified into four categories, ie, individual improvement, group improvement, resources, and operations. CONCLUSION: MCIs are so complicated that they require adequate prehospital preparedness. This study described the components of EMS preparedness in MCIs. The authorities in EMS will benefit from this framework in planning and responding to MCIs.

Emergency medical services preparedness in mass casualty incidents: A qualitative study.

Background and Aims: The effective response of emergency medical services in mass casualty incidents (MCIs) calls for sufficient preparation. The components of preparation must be determined first to achieve this goal. This study aimed to describe the elements of preparedness of emergency medical services for MCIs. Methods: A qualitative study was carried out on emergency medical service systems in Iran (from April 2022 to mid-March 2023), using in-depth semistructured interviews with participants who were managers and members of the incident command team, experts, technicians, paramedics, and telecommunicators of emergency medical services. Interviews were carried out face-to-face and via telephone. The data were collected using voice recorder and transcript and analyzed by content analysis method. This study was conducted using the consolidated criteria for reporting qualitative research. Results: Thirty-six participants were included in the study. A total of 834 codes were analyzed. Thirteen components were extracted from the study and classified as five categories including "Strengthening management and organization," "individual and group empowerment," "capacity expansion," "technology and infrastructure development," and "operational response measures." Conclusion: Emergency medical service preparedness in response to MCIs is a critical issue. For improving preparedness, the main components must be identified. The study results described the elements of emergency medical service preparedness, which could be used as a framework for developing the national model of emergency medical service preparedness in MCIs.

Alternative Water Resources Selection to Supply Drinking Water in Flood Disasters by Multicriteria Decision-Making Techniques (DANP and VIKOR).

Background: Emergency is generally caused by natural disaster and infectious disease outbreaks, or it is man-made. Floods are natural phenomena that generally appear in multiple parts of the world. Flooding is one of the most destructive naturally occurring environmental hazards and can cause public, infrastructural, and environmental damage. The purpose of this study is to select alternative water resources for supplying Bandar Abbas in flood disasters by multicriteria decision-making techniques. Methods: Information required includes possible water resources alternative for flood, quantitative and qualitative characteristics of the water resources, climatic circumstances, and demographic information used in organizations data and previous studies. After selecting and proposing water resources alternative for Bandar Abbas in flood, the subcriteria were weighed applying DANP (DEMATEL-ANP) techniques and water resources were prioritized with the VIKOR technique. According to the network structure and internal and external dependence of the criteria and subcriteria, the advantages of DANP in calculating weights have been used to adapt to more real-world problems. The VIKOR technique was developed for multicriteria optimization of complex systems. Results: After reviewing and extracting the criteria from various studies, 9 main criteria and 44 subcriteria were defined to select water resources in disasters and emergencies. According to field studies and related organizations' information, the proposed water resources for Bandar Abbas to use in flood disasters include humidity, sea (Persian Gulf), Sarkhoon plain, and wastewater treatment plant of Bandar Abbas. Conclusion: Results showed that the optimal water resources for Bandar Abbas in flood disasters are the sea and wastewater treatment plant effluent (after advanced treatment). The study proposed appropriate model to select optimal water resources for various natural disasters in different geographical areas. This model can help officials and decision-makers to plan for drinking water supply from disaster-prone areas before disasters occur.

Impact of Peer-Assisted Learning in Chest Tube Insertion Education on Surgical Residents.

Objective: To investigate the impact of peer-assisted learning (PAL) in chest tube insertion education on surgical residents. Methods: This study is a quasi-experimental study conducted on thirty general surgeon residents enrolled in the PAL program. They were divided into two learner groups (A and B) based on the period of residency start. Group A and B had six and one months of general surgery residency experience, respectively. All participants received adequate training for chest tube insertion by a recently graduated general surgeon. Chest tubes insertion skill was assessed using the tool for assessing chest tube insertion competency (TACTIC) test. Results: Post-TACTIC test score was significantly higher (p=0.001) than Pre-TACTIC test score in both groups. However, a comparison of mean Pre-TACTIC test scores and mean Post-TACTIC test scores between group A and group B showed that PAL effectiveness in group A was significantly higher (p=0.001) than group B. Conclusion: There was a positive relationship between the PAL program and the improvement of chest tube insertion technical skills in surgical residents. Based on our findings and similar studies, it can be concluded that the PAL program can increase the chest tube insertion skill of surgical residents.

Comparison of chest CT scan findings between COVID-19 and pulmonary contusion in trauma patients based on RSNA criteria: Established novel criteria for trauma victims.

PROPOSE: In this study, we re-assessed the criteria defined by the radiological society of North America (RSNA) to determine novel radiological findings helping the physicians differentiating COVID-19 from pulmonary contusion. METHODS: All trauma patients with blunt chest wall trauma and subsequent pulmonary contusion, COVID-19-related signs and symptoms before the trauma were enrolled in this retrospective study from February to May 2020. Included patients (Group P) were then classified into two groups based on polymerase chain reaction tests (Group Pa for positive patients and Pb for negative ones). Moreover, 44 patients from the pre-pandemic period (Group PP) were enrolled. They were matched to Group P regarding age, sex, and trauma-related scores. Two radiologists blindly reviewed the CT images of all enrolled patients according to criteria defined by the RSNA criteria. The radiological findings were compared between Group P and Group PP; statistically significant ones were re-evaluated between Group Pa and Group Pb thereafter. Finally, the sensitivity and specificity of each significant findings were calculated. The Chi-square test was used to compare the radiological findings between Group P and Group PP. RESULTS: In the Group PP, 73.7% of all ground-glass opacities (GGOs) and 80% of all multiple bilateral GGOs were detected (p < 0.001 and p = 0.25, respectively). Single bilateral GGOs were only seen among the Group PP. The Chi-square tests showed that the prevalence of diffused GGOs, multiple unilateral GGOs, multiple consolidations, and multiple bilateral consolidations were significantly higher in the Group P (p = 0.001, 0.01, 0.003, and 0.003, respectively). However, GGOs with irregular borders and single consolidations were more significant among the Group PP (p = 0.01 and 0.003, respectively). Of note, reticular distortions and subpleural spares were exclusively detected in the Group PP. CONCLUSION: We concluded that the criteria set by RSNA for the diagnosis of COVID-19 are not appropriate in trauma patients. The clinical signs and symptoms are not always useful either. The presence of multiple unilateral GGOs, diffused GGOs, and multiple bilateral consolidations favor COVID-19 with 88%, 97.62%, and 77.7% diagnostic accuracy.

Evaluation of Chest CT Scan as a Screening and Diagnostic Tool in Trauma Patients with Coronavirus Disease 2019 (COVID-19): A Cross-Sectional Study.

BACKGROUND: The lack of enough medical evidence about COVID-19 regarding optimal prevention, diagnosis, and treatment contributes negatively to the rapid increase in the number of cases globally. A chest computerized tomography (CT) scan has been introduced as the most sensitive diagnostic method. Therefore, this research aimed to examine and evaluate the chest CT scan as a screening measure of COVID-19 in trauma patients. METHODS: This cross-sectional study was conducted in Rajaee Hospital in Shiraz from February to May 2020. All patients underwent unenhanced CT with a 16-slice CT scanner. The CT scans were evaluated in a blinded manner, and the main CT scan features were described and classified into four groups according to RSNA recommendation. Subsequently, the first two Radiological Society of North America (RSNA) categories with the highest probability of COVID-19 pneumonia (i.e., typical and indeterminate) were merged into the "positive CT scan group" and those with radiologic features with the least probability of COVID-19 pneumonia into "negative CT scan group." RESULTS: Chest CT scan had a sensitivity of 68%, specificity of 56%, positive predictive value of 34.8%, negative predictive value of 83.7%, and accuracy of 59.3% in detecting COVID-19 among trauma patients. Moreover, for the diagnosis of COVID-19 by CT scan in asymptomatic individuals, a sensitivity of 100%, specificity of 66.7%, and negative predictive value of 100% were obtained (p value: 0.05). CONCLUSION: Findings of the study indicated that the CT scan's sensitivity and specificity is less effective in diagnosing trauma patients with COVID-19 compared with nontraumatic people.

The Neutrophil-to-Lymphocyte Ratio at the Time of Admission: A New Prognostic Indicator for Hospital Mortality of Trauma Patients.

The elevated neutrophil-to-lymphocyte ratio (NLR) is associated with poor clinical outcomes, especially in pro-inflammatory states such as surgical injuries and severe hemorrhages. Therefore, it was hypothesized whether NLR value at the time of admission could be a prognostic indicator of hospital mortality in trauma patients. This retrospective cohort study was conducted on 865 trauma patients referred to Rajaee Hospital between April 2016 and July 2019. The NLR value was calculated at the time of admission, and receiver operating characteristics (ROC) curve analysis was used to determine the cut-off point value of admission NLR related to hospital mortality of trauma patients. Furthermore, Kaplan-Meier survival analysis and Cox regression models have been applied to determine the effectiveness and prognostic potential of the admission NLR in the hospital mortality of trauma patients. The median age of the trauma patients was 32 years with an interquartile range (IQR) of 23 to 48 years, and most of them were male (83.9%). Also, trauma patients had a median injury severity score (ISS) of 9 (IQR=4-16) and a median Glasgow coma scale (GCS) of 14 (IQR=9-15). The cut-off value for admission NLR was 5.27 (area under the curve: 0.642, 95%CI: 0.559-0.726, p=0.001). In Kaplan-Meier survival analysis, the admission NLR>5.27 was an indicator of hospital mortality in trauma patients (p=0.001). Multivariate Cox regression models demonstrated that trauma patients with an admission NLR>5.27 had a 2.33-fold risk of hospital mortality (hazard ratio=2.33, 95%CI: 1.02-5.38, p=0.041). Furthermore, the admission NLR>5.27 was associated with a higher risk of hospital mortality in trauma patients with age≥65 years, systolic blood pressure≤90 mmHg, blood potassium>4.5 mmol/L, blood sodium>144 mEq/L, blood potential hydrogen (pH)≤7.28, GCS≤8, ISS>24 and blood base excess≤-6.1 mEq/L. The NLR value greater than 5.27 at the time of admission was associated with poorer outcomes, and it can be considered an independent prognostic indicator of hospital mortality in trauma patients.

Should we change our approach to resuscitating victims of femoral fracture? A clinical experience in a busy trauma hospital in Shiraz, Iran.

PURPOSE: Traumatic hemorrhagic shock is a life-threatening event worldwide. Severe brain trauma accompanying femoral fractures can trigger inflammatory responses in the body and increase pre-inflammatory cytokines such as TNF-α, IL-1. The primary treatment in these cases is hydration with crystalloids, which has both benefits and complications. The purpose of this study was to investigate the effects of fluid therapy on the hemodynamics, coagulation profiles, and blood gases in such patients. METHODS: In this cross-sectional study, patients were divided into two groups: femoral fracture group and non-femoral group. The hemodynamic status, coagulation profile, and blood gases of patients in both groups were evaluated upon arrival at the hospital and again 2 h later. Data were analyzed by t-test and ANOVA with repeated data and paired samples t-test. RESULTS: A total of 681 trauma patients (605 men and 76 women) participated in this study, including 69 (86.3%) men and 11 (13.8%) women in femoral fracture group and 536 men (89.2%) and 65 women (10.8%) in non-femoral group. The laboratory parameters were evaluated in response to the equal amount of crystalloid fluid given upon arrival and 2 h later. Blood gases decreased in the fracture group despite fluid therapy (p < 0.003), and the coagulation profile worsened although the change was not statistically significant. CONCLUSION: The treatment of multiple-trauma patients with femoral bone fractures should be more concerned with the need for the infusion of vasopressors such as norepinephrine. If there is evidence of clinical shock, excessive crystalloid infusion (limited to 1 L) should be avoided, and blood and blood products should be started as soon as possible.

Our Experience of Trauma Management During Novel Coronovirus 2019 (COVID-19) Pandemic in a Busy Trauma Center in Southern Iran.

During the past few months, the novel coronavirus 2019 (COVID-19) pandemic has significantly affected medical service provision. In Iran, it has caused around 197,000 inflictions and 9200 deaths up to June 18, 2020. While many departments turned to telehealth in this era, the trauma service should provide non-stop in presence service to the trauma victims. Our trauma center is the largest in the southwest of Iran, with the mean annual admission of 18,500 polytrauma patients. In this center, we designed a safety protocol to mitigate the spread of disease and also have a more robust case finding system, especially among asymptomatic carriers who attend hospitals based on their trauma. In brief, all unstable patients were considered SARS-COV-2 positive and were directed toward the Specialized COVID-19 related ICU. For all stable patients, history, physical examination, CXR, and lab test (Complete Blood Count, Erythrocyte Sedimentation Rate, C-Reactive Protein) were ordered before entering the wards. If there was any suspicion of COVID-19, the stable patient was admitted to the COVID-19 specialized ward. Among all 1805 patients admitted during a ten weeks interval (from January 30, 2020, to April 14, 2020), 84 had a red flag and toward to COVID-19 related wards. Of those, 67 had positive PCR or evidence in CT in favor of the COOVID-19. Moreover, during regular workups, we found that 19 completely asymptomatic trauma victims had typical Chest CT scan findings of COVID-19.

Determinants of reoperation after decompressive craniectomy in patients with traumatic brain injury: A comparative study.

OBJECTIVES: Reoperation after decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) remains a dilemma and the risk factors are to be identified. The aim of the current study was to determine the determinants and risk factors of reoperation after DC in patients with TBI. PATIENTS AND METHODS: This retrospective case-controlled study was conducted during a 4-year period from September 2013 to October 2017 in a level I trauma center affiliated with Shiraz University of Medical Sciences in southern Iran. We included all the adult (≥18 years) patients with TBI who underwent primary or secondary DC in our center during the study period. Those who underwent reoperation were compared to those who underwent DC only regarding the demographic findings, clinical features and neuroimaging findings. A univariate and multivariate logistic regression analysis was performed to determine the determining factors of reoperation. RESULTS: Overall we included 371 patients with mean age of 36.45 ± 14.18 years. Among the patients there were 325 (87.6%) men and 46 (12.4%) women. The reoperation in patients undergoing DC due to TBI was associated with primary DC (p = 0.039) and higher Marshall grade (p = 0.027). Those who underwent reoperation after DC for TBI had significantly higher ICU (p = 0.007) and hospital LOS (p = 0.001) and lower 6-month GOSE (p = 0.010). Age (p < 0.001), GCS (p < 0.001) and pupils (p = 0.027) were predictors of outcome in reoperation group. Reoperation in primary DC group was associated with pupil reactivity (p = 0.002) and number of episodes with INR above 1.5 (p = 0.037) Conclusion: Reoperation after DC for TBI is associated with primary DC, and Marshall grade. The reoperation after DC is associated with worse outcome and longer ICU and hospital stay. The age, GCS and pupil reactivity are the main predictors of outcome in those with reoperation after DC for TBI.

Jejunostomy with Enteroenterostomy for Enteral Nutrition in Critically Ill Trauma Patients. A Novel Technique.

Purpose The aim of the current study was to report the surgical outcome and complications of jejunostomy with enteroenterostomy for enteral nutrition (EN) in critically ill trauma patients with prolonged nasogastric (NG) nutrition. Methods This cross-sectional study was carried out in a level I trauma center in Shiraz, southern Iran during a one-year period from 2016 to 2017. We included a total number of 30 patients with severe trauma admitted to the intensive care unit (ICU) with more than three months NG nutrition and bowel atrophy. We performed a novel jejunostomy with an enteroenterostomy procedure for providing a route for enteral nutrition in all 30 patients. The rate of complications, such as dislodgement, clogging, obstruction, leakage, mucosal bleeding, and infection, were recorded and reported. We also recorded the hospital and ICU length of stay (LOS). Results We included a total number of 30 patients with a mean age of 35.64 ± 8.91 years, and there were 23 (76.6%) men and seven (23.4%) women among the patients. Overall, 14 (46.6%) patients experienced complications related to the jejunostomy with enteroenterostomy. The most common complication was nausea and vomiting (33.3%) and distention (33.3%), followed by surgical site infection (30.0%). The mean ICU LOS and hospital LOS was found to be 16.8 ± 3.7 and 24.3 ± 4.1 days, respectively. The overall mortality rate was 17 (56.6%), which was secondary to the primary injury and was not related to the procedure. Conclusion Jejunostomy with enteroenterostomy is a safe and feasible method for providing a route for EN in critically ill trauma patients with prolonged NG nutrition and bowel atrophy.

Antimicrobial Survey of Local Herbal Drugs against Acinetobacter baumannii Isolated from Patients Admitted to a Level-I Trauma Center.

Objective: To determine the antimicrobial activity and entity of several local herbal plants against Acintobacters isolated from trauma patients admitted to a Level-I trauma center. Methods: The antibacterial activities of the Satureja bachtiarica oil and someselected Iranian medicinal plants (Artemisia sieberi and Tanacetum dumosum belonging to the Asteraceae/Compositae; Salvia mirzayanii and Mentha mozaffarianii belonging to the Lamiaceae/Labiatae) were assayed on A. baumannii by microdilution and agar disc diffusion methods. Having obtained the acceptable antibacterial data, the shade-dried aerial parts of the plants were extracted by hydrodistillation method using Clevenger apparatus according to European pharmacopeia for 3 h. The analysis of S. bachtiarica essential oil accompanied by other herbal drug oils were performed by using GC/FID and GC/MS methods. Results: Outcomes revealed that the S. bachtiarica essential oil exhibited the potent antibacterial capability against Acinetobacter strains in comparison with Colistin, as a positive control. For S. bachtiarica,the growth inhibition zone and minimum inhibitory concentration (MIC) values were 21 mm and 0.5 mg/ml, while, for Colistin, the data were in order: 8 mm and 0.016 mg/ml. Consequently, GC/MS outcomes demonstrated that the major components of the essence were carvacrol (48.6%), followed by p-Cymene (16.6%), γ-terpinene (6.9%) and linalool (5.3%). Conclusion: Based on the considerable inhibitory activity against nosocomial infections by essential oil of S. bachtiarica, it could be considered as the suitable candidate in the food industry and pharmaceutical uses.

Injury patterns among various age and gender groups of trauma patients in southern Iran: A cross-sectional study.

Administrative data from trauma referral centers are useful sources while studying epidemiologic aspects of injuries. We aimed to provide a hospital-based view of injuries in Shiraz considering victims' age and gender, using administrative data from trauma research center.A cross-sectional registry-based study of adult trauma patients (age ≥15 years) sustaining injury through traffic accidents, violence, and unintentional incidents was conducted. Information was retrieved from 3 hospital administrative databases. Data on demographics, injury mechanisms, injured body regions, and injury descriptions; outcomes of hospitalization; and development of nosocomial infections were recorded. Injury Severity Score (ISS) was calculated by crosswalking from ICD-10 (International Classification of Diseases) injury diagnosis codes to AIS-98 (Abbreviated Injury Scale) severity codes. Patients were compared based on age groups and gender differences.A total of 47,295 trauma patients with a median age of 30 (interquartile range: 24-44 years) were studied, of whom 73.1% were male and the remaining 26.9% were female (M/F = 2.7:1.0). The most common injury mechanisms in the male group were car and motorcycle accidents whereas females were mostly victims of falls and pedestrian accidents (P < .01). As age increased, a shift from transportation-related to unintentionally caused injuries occurred. Overall, young men had their most severe injuries on head, whereas elderly women suffered more severe extremity injuries. Injury severity was similar between men and women; however, elderly had a significantly higher ISS. Although incidence of nosocomial infections was independent of victims' age and gender, elderly men had a significantly higher mortality rate.Based on administrative data from our trauma center, male gender and age >65 years are associated with increased risk of injury incidence, prolonged hospitalizations, and in-hospital death following trauma. Development of a regional trauma surveillance system may provide further opportunities for studying injuries and evaluating preventive actions.

Objective Structured Clinical Examination (OSCE)-based Assessment of the Advanced Trauma Life Support (ATLS) Course in Iran.

OBJECTIVE: To evaluate the effect of advance trauma life support (ATLS®) training on general surgery residents clinical reasoning skills using the national boards-style objective structured clinical examination (OSCE). METHODS: This cross-sectional single-center study was conducted in Shiraz University of Medical Sciences including 51 surgery residents that participated in a mandatory national board style OSCE between May 2014 and May 2015. OSCE scores of two groups of general surgery residents including 23 ATLS® trained and 28 non-ATLS® trained were compared using Mann-Whitney U test. The exam was graded out of 20 points and the passing score was ≥14 including 40% trauma cases. RESULTS: There were 8(15.7%) women and 43(84.3%) men among the participants with mean age of 31.12 ± 2.69 and 33.67 ± 4.39 years in women and men respectively. Overall 7 (87.5%) women and 34 (79.07%) men passed the OSCE. The trauma section OSCE score was significantly higher in the ATLS® trained participants when compared to non-ATLS®(7.79 ± 0.81vs.6.90 ± 1.00; p=0.001). In addition, the total score was also significantly higher in ATLS® trained residents (16.07 ± 1.41 vs. 14.60 ± 1.40; p=0.001). There was no association between gender and ATLS® score (p=0.245) or passing the OSCE (p=0.503). CONCLUSION: ATLS® training is associated with improved overall OSCE scores of general surgery residents completing the board examinations suggesting a positive transfer of ATLS learned skills to management of simulated surgical patients including trauma cases.

Management of Deep Vein Thrombosis (DVT) Prophylaxis in Trauma Patients.

Deep vein thrombosis (DVT) and pulmonary embolism (PTE) are known as venous thromboembolism (VTE). DVT occurs when a thrombus (a blood clot) forms in deep veins of the body, usually in the lower extremities. It can cause swelling or leg pain, but sometimes may occur with no symptoms. Awareness of DVT is the best way to prevent the VTE. Patients with trauma are at increased risk of DVT and subsequent PE because of coagulopathy in patients with multiple trauma, DVT prophylaxis is essential but the VTE prophylaxis strategy is controversial for the trauma patients. The risk factors for VTE includes pelvic and lower extremity fractures, and head injury.