Analgesic effects of inhalation of nitric oxide [Entonox] and parenteral morphine sulfate in patients with renal colic; a randomized clinical trial

Objective: To compare the analgesiceffects of Nitrous oxide and morphine sulfate in patients with acute renal colic due to urolithiasis

Methods: This was randomized clinical trial being performed in Imam Hossein hospital affiliated with Shahid Beheshti University of Medical Sciences during a 1-year period from May2013 to May2014. A total of number of 100 patients, with an age range of 20-50 years, who presented with renal colic secondary to urolithiasis confirmed by ultrasonography were randomly assigned to receive morphine sulfate injection [0.1 mg/kg] with 100 mg diclofenac suppository [n=50] or Entonox exhalation [50% nitric oxide and 50% oxygen]for 30-minutes with 100 mg diclofenac suppository [n=50]. Quantitative measurement was of pain was performed according to a visual analogue scale [VAS], before, 3, 5, 10 and 30-minute after the intervention. The pain severity and side effects were measured between two study groups

Results: The baseline characteristics of the patients in two study groups were comparable. The frequencies of pain persistence [at least 50%] at 3-, 5-, 10- and 30-minute intervals in morphine sulfategroup were 96%, 80%, 50% and 8%, respectively; these frequencies in Entonex were 82%, 42%, 12% and 2%, respectively [p<0.001]. Cox regression modeling showed that use of Entonox was the only effective agent in the success of treatment, compared to the use of morphine, i.e. use of Entonox increased the success of treatment up to 2.1 folds compared to the use of morphine [HR=2.1; 95% CI: 1.2-3.6; p=0.006]

Conclusion: The results of the present study demonstrate that inhalation of Entonox is an effective and safe analgesic regimen for acute renal colic. It acts more rapidly and is more potent in relieving renal colic when compared to morphine sulfate.Entonox can be regarded as an appropriate alternative to analgesics like opioids in this ground

Axillary nerve block in comparison with intravenous midazolam/fentanyl for painless reduction of upper extremity fractures

The painful nature of fractures has made it inevitable to use various anesthetic techniques to reduce or immobilize fractured parts. In the present study, axillary nerve block was compared with intravenous midazolam/fentanyl to induce anesthesia for Painless Reduction of Upper Extremity Fractures. The subjects in the present clinical trial consisted of 60 patients with upper extremity fractures. They were randomly divided into two equal groups of intravenous sedation [IVS] with midazolam/fentanyl and axillary nerve block [ANB]. Rate of anesthesia induction, recovery time, and pain intensities at baseline, during the procedure and at the end of the procedure were recorded in both groups. Data was analyzed and compared between the two groups with SPSS 18 statistical software using appropriate tests. Demographic data, vital signs and means of pain intensities at the beginning of the procedure were equal in the two groups. In the IVS group, the overall duration of the procedure was shorter with more rapid onset of anesthesia [P<0.05]. In contrast, the recovery time was much shorter in the ANB group [P<0.001]. No life or organ threatening complications were observed in the two groups. Axillary nerve block can be considered an appropriate substitute for intravenous sedation in painful procedures of the upper extremity

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

Sonographic optic nerve sheath diameter as a screening tool for detection of elevated intracranial pressure

Timely diagnosis and treatment of post-traumatic elevated intracranial pressure [EICP] could be reduced morbidity and mortality, and improved patients' outcome. This study is trying to evaluate the diagnostic accuracy of sonographic optic nerve sheath diameter [ONSD] in detection of EICP. Sonographic ONSD of patients with head trauma or cerebrovascular accident suspicious for EICP were evaluated by a trained chief resident of emergency medicine, who was blind to the clinical and brain computed tomography scan [BCT] find-ings of patients. Immediately after ultrasonography, BCT was performed and reported by an expert radiologist without awareness from other results of the patients. Finally, ultrasonographic and BCT findings regarding EICP were compared. To evaluate the ability of sonographic ONSD in predicting the BCT findings and obtain best cut-off level, receiver operating characteristic [ROC] curve were used. Sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV], positive likelihood ratio [PLR], and negative likelihood ratio [NLR] of so-nographic ONSD in determining of EICP was calculated. P < 0.05 was considered as statistically significant. There were 222 patients [65.3% male], with mean age of 42.2 +/- 19.5 years [range: 16-90 years]. BCT showed signs of EICP, in 28 cases [12.6%]. The means of the ONSD in the patients with EICP and normal ICP were 5.5 +/- 0.56 and 3.93 +/- 0.53 mm, respectively [P<0.0001]. ROC curve demonstrated that the best cut off was 4.85 mm. Sensitivity, specificity, PPV, NPV, PLR, and NLR of ONSD for prediction of EICP were 96.4%, 95.3%, 72.2%, 98.9%, 20.6, and 0.04, respectively. Sonographic diameter of optic nerve sheath could be considered as an available, accurate, and noninvasive screening tool in determining the elevated intracranial pressure in cases with head trauma or cerebrovascular accident

Substance abuse among drivers of motor vehicle collisions

Motor vehicle collisions [MVC] comprise a majority cause of referral to the emergency department [ED]. A large proportion of MVC appear to be preventable, if more effective measures against driving after substance abuse can be implemented. This study was aimed to investigate the prevalence of substance abuse among drivers of MVC, following road traffic accidents [RTA]. This case-control research was conducted from July to October 2007. One hundred MVC drivers admitted in the ED were included as the case group and 110 hospitalized patients, due to nontraumatic causes were used as controls. History of substances abused was obtained and urine samples were tested for opium in both groups. Finally the history and laboratory results of the groups were compared using SPSS 18. Of the 100 patients in the case group, 39 [39%] were positive for substance abuse [100% male] On the other hand, 49 [44.5%] patients in the control group had positive history or laboratory findings of substance abuse [73.9% male]. Opioids were the most common agent abused in both groups. There was no significant difference between two groups regarding the prevalence of substance abuse [P = 0.92]. The prevalence of substance abuse is high among victims of road traffic injury but in equal proportion to the control group. Health education and counseling is needed to reduce substance abuse in the general population although it was not significantly related to the cause of RTA