Low-dose intravenous ketamine versus intravenous ketorolac in pain control in patients with acute renal colic in an emergency setting: a double-blind randomized clinical trial / 대한통증학회지

BACKGROUND: This study was conducted to compare the effectiveness of low-dose ketamine versus ketorolac in pain control in patients with acute renal colic presenting to the emergency department (ED). METHODS: This is a double-blind randomized clinical trial. The initial pain severity was assessed using the numerical rating scale (NRS). Then, ketamine or ketorolac was administered intravenously at a dose of 0.6 mg/kg and 30 mg respectively. The pain severity and adverse drug reactions were recorded 5, 15, 30, 60, and 120 min thereafter. RESULTS: The data of 62 subjects in the ketamine group and 64 patients in the ketorolac group were analyzed. The mean age of the patients was 34.2 ± 9.9 and 37.9 ± 10.6 years in the ketamine and ketorolac group, respectively. There was no significant difference in the mean NRS scores at each time point, except for the 5 min, between the two groups. Despite a marked decrease in pain severity in the ketamine group from drug administration at the 5 min, a slight increase in pain was observed from the 5 min to the 15 min. The rate of adverse drug reactions, including dizziness (P = 0.001), agitation (P = 0.002), increased systolic blood pressure (> 140 mmHg), and diastolic blood pressure (> 90 mmHg) was higher in the ketamine group. CONCLUSIONS: Low dose ketamine is as effective as ketorolac in pain management in patients with renal colic presenting to the ED. However, it is associated with a higher rate of adverse drug reactions.

Intravenous caffeine citrate vs. magnesium sulfate for reducing pain in patients with acute migraine headache; a prospective quasi-experimental study

BACKGROUND: Current evidence suggests that intravenous magnesium sulfate might be effective for reducing migraine pain. In a recent pilot study, we showed that intravenous caffeine citrate could reduce the severity of migraine headache. The objective of this study is to investigate the efficacy of intravenous caffeine citrate vs. magnesium sulfate for management of acute migraine headache. METHODS: We conducted a prospective quasi-experimental study from January until May 2016 in two educational medical centers of Shahid Beheshti University of Medical Sciences (Shoahadaye Tajrish Hospital and Imam Hossein Hospital), Tehran, Iran. The study included patients who were referred to the emergency department and met the migraine diagnosis criteria of the International Headache Society. Patients were allocated into 2 groups receiving either 60 mg intravenous caffeine or 2 g intravenous magnesium sulfate. The pain scores, based on the visual analog scale, were recorded on admission, as well as one and two hours after receiving the drug. A Chi-Square test and student t-test were used for analysis of baseline characteristics. A Mann-Whitney U test and Wilcoxon singed rank test were used to analyze differences in the visual analogue scale (VAS) score between and within the groups respectively. RESULTS: In total, 70 patients (35 patients in each group) with the mean age of 33.1 ± 11.3 years were included (64.3% female). For the Caffeine citrate group, the median pain score decreased from 9.0 (2.0) to 5.0 (4.0) after one hour and to 3.0 (4.0) after two hours. For the magnesium sulfate group, the pain score decreased from 8.0 (2.0) to 2.0 (2.0) after one hour and to 0.0 (1.0) after two hours. Both intravenous caffeine citrate and intravenous magnesium sulfate reduced pain scores significantly but the magnesium sulfate group showed more improvement than the Caffeine citrate group after one hour (P < 0.001) and after two hours (P < 0.001). CONCLUSIONS: It is likely that both intravenous caffeine and intravenous magnesium sulfate can reduce the severity of migraine headache. Moreover, intravenous magnesium sulfate at a dose of 2 g might be superior to intravenous caffeine citrate 60 mg for the short term management of migraine headache in emergency departments.

Evidence based emergency medicine part 3: positive and negative likelihood ratios of diagnostic tests

In the previous two parts of educational manuscript series in Emergency, we explained some screening characteristics of diagnostic tests including accuracy, sensitivity, specificity, and positive and negative predicative values [1, 2]. In the 3rd part we aimed to explain positive and negative likelihood ratio [LR] as one of the most reliable performance measures of a diagnostic test [3]. To better understand this characteristic of a test, it is first necessary to fully understand the concept of sensitivity and specificity. So we strongly advise you to review the 1st part of this series again [1, 2]. In short, the likelihood ratios are about the percentage of people with and without a disease but having the same test result [4]. The prevalence of a disease can directly influence screening characteristics of a diagnostic test, especially its sensitivity and specificity. Trying to eliminate this effect, LR was developed. Pre-test probability of a disease multiplied by positive or negative LR can estimate post-test probability. Therefore, LR is the most important characteristic of a test to rule out or rule in a diagnosis. A positive likelihood ratio > 1 means higher probability of the disease to be present in a patient with a positive test. The further from 1, either higher or lower, the stronger the evidence to rule in or rule out the disease, respectively [5]. It is obvious that tests with LR close to one are less practical. On the other hand, LR further from one will have more value for application in medicine. Usually tests with LR < 0.1 or > 10 are considered suitable for implication in routine practice

Medical Journalism and Emergency Medicine

Nowadays, many researches in the field of medicine are conducting all around the world and medical journalism is a way to share the results. In fact, dissemination of the related manuscripts can pre-vent the repetitive research or may even lead to conducting a better survey. Therefore high quality medical journals are considered as up-to-date resources for further investigations [1, 2]. Medical journals are propagating their papers in various media including television pro-grams, newspapers, internet websites and different social media. So they can influence the government policy makers, health-care professionals and even public [3-5]. Moreover, most researchers hear about medical discoveries for the first time through medical journals and their related social media. So as well a high quality journal can help to improve medical science, a journal of poor quality can be damaging and distorting. Indeed, popular journals have the power of inventing a "communication storm" to draw attention to a certain topic. Thus they have to respect the accepted international principles to prevent spreading inaccurate and misleading data [6, 7]. This paper aims to review the previous and current situation of medical journalism by focus on field of emergency medicine

Evidence based emergency medicine part 2: positive and negative predictive values of diagnostic tests

In volume 3, number 2, pages 48-49, we explained some screening characteristics of a diagnostic test in an educational manuscript entitled "Simple definition and calculation of accuracy, sensitivity and specificity" [1]. The present article was aimed to review other screening performance characteristics including positive and negative predictive values [PPV and NPV]. PPV and NPV are true positive and true negative results of a diagnostic test, respectively [2]. In other words, if a subject receives a certain diagnosis by a test, predictive values describe how likely it is for the diagnosis to be correct

Correlation of blood gas parameters with central venous pressure in patients with septic shock; a pilot study

Objective: To determine the correlation between blood gas parameters and central venous pressure [CVP] in patients suffering from septic shock

Methods: Forty adult patients with diagnosis of septic shock who were admitted to the emergency department [ED] of Shohadaye Tajrish Hospital affiliated with Shahid Beheshti University of Medical Sciences, and met inclusion and exclusion criteria were enrolled. For all patients, sampling was done for venous blood gas analysis, serum sodium and chlorine levels. At the time of sampling; blood pressure, pulse rate and CVP were recorded. Correlation between blood gas parameters and hemodynamic indices were

Results: A significant direct correlation between CVP with anion gap [AG] and inversely with base deficit [BD] and bicarbonate. CVP also showed a relative correlation with pH, whereas it was not correlated with BD/ AG ratio and serum chlorine level. There was no significant association between CVP and clinical parameters including shock index [SI] and mean arterial pressure [MAP]

Conclusion: It seems that some of non invasive blood gas parameters could be served as alternative to invasive measures such as CVP in treatment planning of patients referred to an ED with septic shock

Utilization of failure mode and effects analysis [FMEA] method in increasing the revenue of emergency department; a prospective cohort study

The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments [ED] are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis [FMEA] method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided into one main system and six subsystems, based on FMEA. The study was divided into two phases. In the first phase, the problems leading to the loss of revenue in each subsystem were identified and weighted into four groups using risk priority number [RPN], and the solutions for fixing them were planned. Then, in the second phase, discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after intervention using the repeated measure ANOVA test. 100 financial records of ED patients were evaluat-ed during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1 +/- 3.65 thousand US dollars/month. 12 types of errors were detected in the predefined subsystems. ED reve-nue rose from 73.1 to 153.1, 207.06, 240, and 320 thousand US dollars/month after solving first, second, third, and fourth priority problems, respectively [337.75% increase in two years] [p<0.001]. 111.0% increase in the ED revenue after solving of first priority problems revealed that they were extremely indispensable in decreasing the revenue [p<0.0001]. The findings of the present study revealed that FMEA could be considered as an efficient model for increasing the revenue of emergency department. According to this model, not recording the services by the nursing unit, and lack of specific identifying code for the patients moving from ED to any other department, were the two first priority problems in decreasing our ED revenue

Emergency department performance indexes before and after establishment of emergency medicine

Emergency department performance index [EPI] greatly influences the function of other hospital's units and patient satisfaction. Recently, the Iranian Ministry of Health has defined specific national EPI containing five indexes. In the present study the performance indexes of emergency department [ED] in one educational hospital has been assessed before and after establishment of emergency medicine. In the present cross-sectional study the ED of Shohadaye Tajrish Hospital, Tehran, Iran was assessed during one-year period from March 2012 to February 2013. The study was divided into two six-month periods of before and after establishment of emergency medicine. Five performance indexes including: the percentage of patients were disposed during 6-hour, left the ED in a 12-hour, had unsuccessful cardiopulmonary resuscitations [CPR], discharged against medical advice, and the mean time of triage were calculated using data of department of medical records on daily patients' files. Then, Mann-Whitney U test was used to make comparisons at P<0.05. The average triage time decreased from 6.04 minutes in the first six months to 1.5 minutes in the second six months [P=0.06]. The percentage of patients leaving the ED in a 12-hour decreased from 97.3% to 90.4% [P=0.004]. However, the percentage of disposed patients during 6-hour [P=0.2], unsuccessful CPR [P=0.34] and discharged against medical advice [P=0.42] did not differ between the two periods. It seems that establishment of emergency medicine could be able to improve ED performances indexes such as time to triage and leave in a 12-hour period

33-year-old woman with severe postpartum headache

Patient was a 33-year-old woman underwent her first time cesarean section combined with spinal epidural anesthesia 5 days before and discharged the day after with good condition. She got severe headache with pain score about 8-9, 2 days after discharge from hospital. Her headache was severe, bilateral, pulsatile and almost likely sudden onset accompanied with nausea that mildly progressed after starting. She went to the hospital, which her delivery was taken; with impression of Post Dural Puncture Headache [PDPH] 10mg IV morphine sulfate was administered totally and subsequently discharged home with relative decreased headache. The day after first headache attack, when she admitted in our Hospital, claimed that could not hold her baby for breast-feeding. In minimental status examination, time disorientation was obvious but orientation to place and person was intact. In motor examination, we found right side hemiparesis and decreased right upper and lower limbs tone. Brain computed tomography [CT] scan and magnetic resonance imaging [MRI] revealed a massive cortico-subcortical hemorrhagic infarction on left parieto-occipital lobes. With attention to significant nonhomogeneous occupying lesion, brain MRI with gadolinium and magnetic resonance venography [MRV] were performed

[Preventive measures for blood borne diseases by emergency medicine residents]

Objective: To determine the application of preventive measures by emergency medicine residents for blood born diseases and detection of possible constraints at Imam Hussein Hospital in 2009-2010

Methods: In this observational descriptive cross-sectional study, all 40 emergency medicine residents from the first to third year of practice, were observed and evaluated during work at emergency department of Imam Hussein Hospital in 2009-2010. Data were collected by utilizing an observational checklist and a personal characteristics information form. Content validity and inter rater reliability[r=0.89] of the instruments was confirmed

Results: The mean age of the residents was 32.7+/-4.3 years. Twelve subjects [30%] were female. Fifteen residents [37.5%] were in first educational year, six subjects [14%] were in the second year, and 19 residents [47.5%] were in their third year of practice. Three most respected items were covering the hands by latex gloves before medical procedures [95+/-20 points], cleaning the bloody skin after phlebotomy or IV line preparation [88+/-32 points], and developing no blood spreading after phlebotomy, suction, or lines removal [77+/-43 points]. Higher residency educational degree and IV line preparation were the effective factors for better application of preventive measures by emergency medicine residents for blood born diseases, compared to intubation procedure [P<0.05]. The most common constraints for application of preventive measures by emergency residents for blood born diseases were high rate of patients' attending the emergency room [85%], high work load [80%], and need for fast performance at work [68%]

Conclusions: Generally, according to the obtained results, it may be concluded that the preventive measures for blood borne diseases are not optimally practiced by emergency medicine residents, and therefore, it is necessary to promote their information and practical knowledge especially with explanatory classes and continuous quality improvement