Comparison of the diagnostic accuracy of CT scan with oral and intravenous contrast versus CT scan with intravenous contrast alone in the diagnosis of blunt abdominal trauma.

PURPOSE: Abdominal CT scan using oral and intravenous (IV) contrast is helpful in the diagnosis of intra-abdominal injuries. However, the use of oral and IV contrast delays the process of diagnosis and increases the risk of aspiration. It has also been shown that CT scan with IV contrast alone is as helpful as CT scan with oral and IV contrast and rectal CT scan in detecting abdominal injuries. Therefore, the present study aims to prospectively compare the diagnostic value of CT scan with oral and IV contrast versus CT scan with IV contrast alone in the diagnosis of blunt abdominal trauma (BAT). METHODS: Altogether 123 BAT patients, 60 (48.8%) women and 63 (51.2%) men with the mean age of (40.4 ± 18.7) years who referred to the emergency department of Imam Khomeini Educational and Medical Center in Sari, Iran (a tertiary trauma center in north of Iran) from November 2014 to March 2017 and underwent abdominal CT scans + laparotomy were investigated. Those with penetrating trauma or hemodynamically unstable patients were excluded. The participants were randomly allocated to two groups: abdominal CT scan with oral and IV contrast (n = 63) and CT scan with IV contrast alone (n = 60). No statistically significant difference was found between two groups regarding the hemodynamic parameters, age, gender, injury mechanisms (all p > 0.05). The results of CT scan were compared with that of laparotomy results. The collected data were recorded in SPSS version 22.0 for Windows. Quantitative data were presented as mean and SD. RESULTS: The sensitivity and specificity of CT scan using oral and IV contrast in the diagnosis of BAT were estimated at 96.48 (95% CI: 90.73 - 99.92) and 92.67 (95% CI: 89.65 - 94.88), respectively; while CT scan with IV contrast alone achieved a comparable sensitivity and specificity of 96.6 (95% CI: 87.45 - 99,42 and 92.84 (95% CI: 89.88 - 95.00), respectively. CONCLUSION: CT scan with IV contrast alone can be used to assess visceral injuries in BAT patients with normal hemodynamics to avoid diagnostic delay.

Clinical Predictors of Testicular Torsion in Patients with Acute Scrotum; a Cross-Sectional Study.

INTRODUCTION: Testicular torsion is an important and critical issue in patients with acute scrotum referring to emergency department (ED). Early detection is very important to save the testicles. This study aimed to determine the diagnostic accuracy of clinical variables in predicting the presence of testicular torsion. METHODS: This prospective cross-sectional study was done using the information of patients hospitalized from September 2015 to September 2020, with complaint of acute scrotum (ICD 10 code: N50.8), referring to ED for evaluation of the clinical predictors of testicular torsions, which were confirmed by surgery. RESULTS: 81 patients with the mean age of 20.07 ± 9.64 (3- 45) years were studied. After surgical exploration, 70 patients (86.4%) had testicular torsion. Patients with torsion had lower age (p < 0.0001), lower time from symptom to ED visit (p < 0.0001), sudden onset pain (p = 0.003), left side pain (p < 0.0001), and lower white blood cell (WBC) count (p = 0.001). The frequency of dysuria (p = 0.032), diarrhea/vomiting (p = 0.005), and fever (p = 0.002) was significantly lower in patients with torsion. The cremasteric reflex was absent in 57 (81.4%) cases who suffered from testicular torsion (p = 0.001). Based on the results of binary logistic regression analysis, age (B = -0.175, SE = 0.45; p < 0.0001) was the sole independent predictor of testicular torsion. The highest area under the receiver operating characteristics (ROC) curve in predicting the presence of torsion belonged to lower age [91.0 (95%CI: 83.2 - 98.7)], pain in left testis [0.931 (95%CI: 0.828-0.987)], and lower WBC count [0.805 (95%CI: 0.684-0.926)], respectively. CONCLUSION: It seems that clinical variables are not accurate enough to be considered as the sole predictor of testicular torsion and they should be used with caution and in combination with other available screening tools like Doppler ultrasonography in this regard.

One-Month Follow-Up of Patients with Unspecified Abdominal Pain Referring to the Emergency Department; a Cohort Study.

INTRODUCTION: About one third of patients referring to emergency department (ED) with abdominal pain, are discharged without a definite diagnosis. This study aimed to investigate the one-month outcome of patients with unspecified abdominal pain. METHODS: This cohort study was conducted on subjects who were evaluated in ED with unspecified abdominal pain and were referred to the gastroenterology clinic and followed for one month. Finally, they were divided into two groups of cases with clear cause of abdominal pain and unclear cause of abdominal pain and patients' characteristics were compared between the groups. RESULTS: 150 cases with the mean age of 40.68 ± 18.34 years were studied (53.3% female). After one month, 67 (44.7%) patients still complained of abdominal pain. A definitive cause of abdominal pain was established in 88 (58.7%) cases. There was not any significant difference between groups regarding, sex distribution (p = 012), duration of pain (p = 0.11), history of previous similar pain (p = 0.136), pain radiation (p = 0.737), length of hospital stay (p = 0.51), and presence of anorexia (p = 0.09), nausea and vomiting (p= 0.50), fever (p = 1.0), diarrhea (p = 0.23), and constipation (p = 0.07). There was a significant difference between the groups regarding location of pain (p = 0.017), age (p = 0.001) and history of comorbid diseases (p = 0.046). The predictive factors of finding a clear cause for abdominal pain in one-month follow-up, were leukocytosis (OR: 5.92 (95% CI: 2.62 - 13.39); p < 0.001), age (OR: 2.78 (95% CI: 1.15 - 6.71); p = 0.023), and outpatient follow-up (OR: 1.04 (95% CI: 1.02 - 1.07); p < 0.001). CONCLUSION: Approximately, 40% of patients who were discharged with unspecified abdominal pain did not receive a clear diagnosis after one month of follow-up. Older age, leucocytosis in initial evaluations, and outpatient follow-up increased the probability of finding a clear cause for abdominal pain in the mentioned cases.

Applications of End-Tidal Carbon Dioxide (ETCO2) Monitoring in Emergency Department; a Narrative Review.

Capnograph is an indispensable tool for monitoring metabolic and respiratory function. In this study, the aim was to review the applications of end-tidal carbon dioxide (ETCO2) monitoring in emergency department, multiple databases were comprehensively searched with combination of following keywords: "ETCO2", "emergency department monitoring", and "critical monitoring" in PubMed, Google Scholar, Scopus, Index Copernicus, EBSCO and Cochrane Database.

Propofol-fentanyl versus propofol-ketamine for procedural sedation and analgesia in patients with trauma.

OBJECTIVE: Many procedures performed in emergency department are stressful and painful, and creating proper and timely analgesia and early and effective assessment are the challenges in this department. This study has been conducted in order to compare the efficacy of propofol and fentanyl combination with propofol and ketamine combination for procedural sedation and analgesia (PSA) in trauma patients in the emergency department. METHOD: This is a randomized prospective double-blind clinical trial conducted in the emergency department of Imam Khomeini Hospital, a tertiary academic trauma center in northern Iran. Patients with trauma presenting to the emergency department who needed PSA were included in study. Patients were divided into two groups of propofol fentanyl (PF) and propofol ketamine (PK). Pain score and sedation depth were set as primary outcome measures and were recorded. RESULTS: Out of about 379 patients with trauma, who needed PSA, 253 met the criteria to be included in the study, 117 of which were excluded. The remaining 136 patients were randomly allocated to either PF group (n = 70) or PK group (n = 66). Pain management after drug administration was significantly different between the groups and the analgesia caused by fentanyl was significantly higher than ketamine. The sedation score after 15 min of PSA in the group PF was significantly higher than the group PK. CONCLUSION: It seems that regarding PSA in the emergency department, PF caused better analgesia and deeper sedation and it is recommended to use PF for PSA in the emergency departments.

Carbon monoxide poisoning in Iran during 1999-2016: A systematic review and meta-analysis.

BACKGROUND: Carbon monoxide (CO) poisoning is a common cause of emergency department (ED) visits worldwide with high levels of morbidity and mortality. No inclusive nationally statistics of CO poisoning in Iran is available. The present review aimed to describe and review the pattern of CO poisoning in Iran. METHODS: The search of Medline, SCOPUS, Cochrane library, Google Scholar, Magiran, IranDoc and SID (Scientific Information Database) yielded only 10 studies discussing the epidemiology of CO poisoning in Iran. Outcomes of interest were determining the demographic characteristics, prevalence and mortality rates, annual trends, main sources and mechanisms, location of incidents of CO poisoning as well as providing the safety awareness and precautions. RESULTS: Totally, 10 studies including 6372 victims of CO poisoning were reviewed. The estimated incidence rate of CO poisoning was 38.91 per 100,000, the proportionate mortality rate was 11.6 per 1000 death and the pooled case fatality rate of was 9.5% (95% CI 6.3%-14.30%). Of the total 5105 individuals with CO poisoning, 2048 (40.12%) were male and 3057 (59.88%) were female. In addition, of 5105 poisoned, 4620 (90.50%) were alive and 485 (9.50%) were dead. The number of fatal CO poisoning cases among men and women were 259 (5.07%) and 226 (4.43%) victims, respectively; while the number of non-fatal CO poisoning cases among men and women were 1790 (35.06%) and 2830 (55.44%) individuals, respectively. The mean age of victims was about 30 years. Most of the victims (36.37%) had the educational level of secondary school, marital status of single (52.74%), and occupational status of housekeeper (27.48%). CONCLUSION: The incidence, proportionate mortality and case fatality rates of CO poisoning is high in Iran, particularly in young individuals. It seems that preventive strategies should be taught by health care providers more thoroughly and implemented by policy makers more strictly as a mandatory law.

Comparison of APACHE II and SAPS II Scoring Systems in Prediction of Critically Ill Patients' Outcome.

INTRODUCTION: Using physiologic scoring systems for identifying high-risk patients for mortality has been considered recently. This study was designed to evaluate the values of Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiologic Score (SAPS II) models in prediction of 1-month mortality of critically ill patients. METHODS: The present prospective cross sectional study was performed on critically ill patients presented to emergency department during 6 months. Data required for calculation of the scores were gathered and performance of the models in prediction of 1-month mortality were assessed using STATA software 11.0. RESULTS: 82 critically ill patients with the mean age of 53.45 ± 20.37 years were included (65.9% male). Their mortality rate was 48%. Mean SAPS II (p < 0.0001) and APACHE II (p = 0.0007) scores were significantly higher in dead patients. Area under the ROC curve of SAPS II and APACHE II for prediction of mortality were 0.75 (95% CI: 0.64 - 0.86) and 0.72 (95% CI: 0.60 - 0.83), respectively (p = 0.24). The slope and intercept of SAPS II were 1.02 and 0.04, respectively. In addition, these values were 0.92 and 0.09 for APACHE II, respectively. CONCLUSION: The findings of the present study showed that APACHE II and SAPS II had similar value in predicting 1-month mortality of patients. Discriminatory powers of the mentioned models were acceptable but their calibration had some amount of lack of fit, which reveals that APACHE II and SAPS II are partially perfect.

Isolated Oculomotor Nerve Palsy Following Minor Head Trauma; a Case report.

Isolated third nerve palsy develops in numerous intracranial pathologies such as closed head trauma, tumor, and aneurysm. This report describes a 61 years old female with an abrasion on the left forehead and ptosis of the left eye. Initial computed tomography did not reveal any causative cerebral and vascular lesions or orbital and cranial fractures. High-resolution and multi-axial enhanced Magnetic resonance imaging (MRI) can be helpful in diagnosis and monitoring of patients with this rare phenomenon.

Determinants of Prolonged Length of Stay in the Emergency Department; a Cross-sectional Study.

INTRODUCTION: Timeliness has been considered as a key domain in quality of emergency department (ED) care and delay in care providing is influential determinants of patient's outcomes. The present study, aimed to evaluate the determinants of prolonged ED length of stay (LOS). METHODS: In this cross-sectional study, using adopted version of the latest form for external evaluation and accreditation of EDs introduced by Iranian Ministry of Health, determinants of prolonged LOS were evaluated in the ED of an educational Hospital. Using SPSS 11, multivariate binary logistic regression was applied to estimate adjusted odds ratios (OR) for determining factors associated with prolonged LOS. RESULTS: 162 (10.2%) cases with prolonged LOS were detected. Based on univariate analysis, female gender (OR: 1.42, 95% CI: 1.14-1.75, p = 0.001), older age (OR: 1.05, 95% CI: 1.02-1.08, p < 0.0001), admission on evening shifts (OR: 4.0; 95% CI: 1.84-8.68, p < 0.001), triage level I (OR: 1.76, 95% CI: 1.21-2.57, p = 0.003), lack of insurance support (OR: 1.56, 95% CI: 1.12-2.19, p = 0.010), higher number of ordered para-clinical tests (OR: 1.23, 95% CI: 1.11-1.37, p = 0.016), and disposition time > 6 hours (OR, 0.13, p < 0.0001), were significant risk factors of prolonged LOS. CONCLUSION: Older age, lack of insurance support, disposition time > 6 hours due to complexity of patients' complaint, and the necessity of repeated para-clinical measures were the most important reasons for failed provision of timely services. From the view point of ED personnel, a small part of prolonged LOS in ED was concerned with defective ED workflow, while, the most important cause of such delays was the delayed response of the consultancy services.

Serum Uric Acid Level in Relation to Severity of the Disease and Mortality of Critically Ill Patients.

AIM: This study was conducted to evaluate the validity of serum uric acid (UA) in prediction of mortality among patients in the emergency department. MATERIALS AND METHODS: This is a prospective cohort study which was conducted during 2014. In this study, 120 critically ill patients who required Intensive Care Unit care services were included. For evaluation of severity of the disease, mortality in emergency department score (MEDS) in the first 24 h of admission, the requirement of using mechanical ventilation, taking vasopressor during the hospitalization time and severity of the disease based on MEDS score were measured. The patients were divided into two groups: Patients with serum UA level lower than 7.3 mg/dl and patients with serum UA level of equal or more than 7.3 mg/dl. For comparison of the mortality rate in groups, Chi-square and fisher exact tests were applied. RESULTS: In patients, who needed mechanical ventilation, average of serum UA was 7.82 ± 2.82; however, in the patients who did not need mechanical ventilation this amount was 6.16 ± 2.7, a difference was statically significant. We found a statically meaningful difference between serum UA level with requiring mechanical ventilation and the predictive level of UA 6.95 ± 0.73 (F = 8.52; P ≤ 0.004). In the evaluation of MEDS, most patients with serum UA levels lower than 7.3 mg/dl had lower MEDS points (on average 4.6 ± 3.21) in compared to patients with serum UA level higher than 7.3 mg/dl (on average 12 ± 2.99). This difference was found to be statistically significant which indicates the patients whose serum UA was 7.3 mg/dl or higher, were at higher risk of mortality. CONCLUSION: The serum UA level in the 1st day of hospitalization of a critically ill patient is not an independent indicative factor in relation to mortality. High level of UA reveals critical status of the patient and requires mechanical ventilation.

Bilateral Abducent Nerve Palsy After Neck Trauma: A Case Report.

INTRODUCTION: The abducent nucleus is located in the upper part of the rhomboid fossa beneath the fourth ventricle in the caudal portion of the pons. The abducent nerve courses from its nucleus, to innervate the lateral rectus muscle. This nerve has the longest subarachnoid course of all the cranial nerves, it is the cranial nerve most vulnerable to trauma. It has been reported that 1% to 2.7% of all head injuries are followed by unilateral abducent palsy, but bilateral abducent nerve palsy is extremely rare. CASE PRESENTATION: A 65-year-old woman presented to the emergency department following a motor vehicle accident. A neurological assessment showed the patient's Glascow coma scale (GCS) to be 15. She complained of double vision, and we found lateral gaze palsy in both eyes. A hangman fracture type IIA (C2 fracture with posterior ligamentous C1 - C2 distraction) was found on the cervical CT scan. A three-month follow-up of the patient showed complete recovery of the abducent nerve. CONCLUSIONS: Conservative treatment is usually recommended for traumatic bilateral abducent nerve palsy. Our patient recovered from this condition after three months without any remaining neurological deficit, a very rare outcome in a rare case.

Myocardial infarction following a bee sting: A case report of Kounis syndrome.

In this case report study a 41-year-old man envenomed by a bee sting and diagnosed as Kounis syndrome secondary to hymenoptera envenomation. The patient developed a typical course of myocardial infarction, but the electrocardiogram changes were reversed to almost normal limits. He had a nonsignificant mild lesion in the proximal port of right coronary artery in coronary angiography. The case recovered and discharged after 6 days hospitalization. The clinical implications and pathophysiology of this dangerous association are discussed.

Patients' Attitude toward Breaking Bad News; a Brief Report.

INTRODUCTION: Delivering bad news is a stressful moment for both physicians and patients. The purpose of this investigation was to explore the patients' preferences and attitudes toward being informed about the bad news. METHODS: This cross-sectional study was done on patients admitted to Imam Khomeini Hospital, Sari, Iran, from September 2014 to February 2015. Patient attitude regarding breaking bad news was evaluated using a reliable and valid questionnaire. RESULTS: 130 patients were evaluated (61.5% male, mean age = 46.21 ± 12.1 years). 118 (90.76%) participants believed that the patient himself/herself should be informed about the disease's condition. 120 (92.30%) preferred to hear the news from a skillful physician and 105 (80.76%) believed that emergency department is not a proper place for breaking bad news. CONCLUSION: Based on the results of the present study, most participants believed that the most experienced and skillful physician should inform them completely regarding their medical condition. At the same time they declared that, it is best to hear bad news in a calm and suitable place and time rather than emergency department or hospital corridors during teaching rounds.

Infantile Apparent Life-Threatening Events, an Educational Review.

Many physicians have received a frantic call from anxious parents stating that their child had stopped breathing, become limp, or turned blue but then had recovered quickly. An apparent life-threatening event (ALTE) is defined as "an episode that is frightening to the observer, and is characterized by some combination of apnea, color change, marked change in muscle tone, choking, gagging, or coughing". The incidence of ALTE is reported to be 0.05% to 6%. The knowledge about the most common causes and factors associated with higher risk of ALTE could be resulted in a more purposeful approach, improving the decision making process, and benefiting both children and parents. The aim of this review article was to report the epidemiology, etiology, evaluation, management, and disposition of ALTE. Infants with an ALTE might present no signs of acute illness and are commonly managed in the emergency settings that often require significant medical attention; hence, the emergency medicine personnel should be aware of the its clinical importance. There is no specific treatment for ALTE; therefore, the clinical evaluations should be focused on the detection of the underlying causes, which will define the outcomes and prognosis. ALTE is a confusing entity, representing a constellation of descriptive symptoms and signs; in other words, it is not a diagnosis. There are multiple possible etiologies and difficulties in evaluating and managing infants with these events, which are challenges to primary care physicians, emergency medicine specialists, and subspecialty pediatricians. The evaluation of these events in infants includes a detailed history, appropriate physical examination, diagnostic tests guided by obtained clues from the history and physical examination, and observation in the emergency department.

Recurrent seizures after lidocaine ingestion.

Lidocaine has a concentration-dependent effect on seizures. Concentrations above 15 µg/mL frequently result in seizures in laboratory animals and human. We report a case of central nervous system (CNS) lidocaine toxicity and recurrent seizure after erroneous ingestion of lidocaine solution. A 4-year-old boy presented to the Emergency Department of Imam Hospital of Sari in December 2013 due to tonic-clonic generalized seizures approximately 30 min ago. 3 h before seizure, his mother gave him 2 spoons (amount 20-25 cc) lidocaine hydrochloride 2% solution instead of pediatric gripe by mistake. Seizure with generalized tonic-clonic occurred 3 times in home. Neurological examination was essentially unremarkable except for the depressed level of consciousness. Personal and medical history was unremarkable. There was no evidence of intracranial ischemic or hemorrhagic lesions in computed tomography scan. There were no further seizures, the condition of the patient remained stable, and he was discharged 2 days after admission. The use of viscous lidocaine may result in cardiovascular and CNS toxicity, particularly in children. Conservative management is the best option for treatment of lidocaine induced seizure.

Diagnostic Accuracy of Ascites Fluid Gross Appearance in Detection of Spontaneous Bacterial Peritonitis.

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) as a monomicrobial infection of ascites fluid is one of the most important causes of morbidity and mortality in cirrhotic patients. This study was aimed to determine the diagnostic accuracy of ascites fluid color in detection of SBP in cirrhotic cases referred to the emergency department. METHODS: Cirrhotic patients referred to the ED for the paracentesis of ascites fluid were enrolled. For all studied patients, the results of laboratory analysis and gross appearance of ascites fluid registered and reviewed by two emergency medicine specialists. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ration of the ascites fluid gross appearance in detection of SBP were measured with 95% confidence interval. RESULTS: The present project was performed in 80 cirrhotic patients with ascites (52.5 female). The mean of the subjects' age was 56.25±12.21 years (35-81). Laboratory findings revealed SBP in 23 (29%) cases. Fifty nine (73%) cases had transparent ascites fluid appearance of whom 17 (29%) ones suffered from SBP. From 21 (26%) cases with opaque ascites appearance, 15 (71%) had SBP. The sensitivity and specificity of the ascites fluid appearance in detection of SBP were 46.88% (Cl: 30.87-63.55) and 87.50% (95% Cl: 75.3-94.14), respectively. CONCLUSION: It seems that the gross appearance of ascites fluid had poor diagnostic accuracy in detection of SBP and considering its low sensitivity, it could not be used as a good screening tool for this propose.

Conservative care in successful treatment of abamectin poisoning.

Human intoxication with abamectin is an uncommon but potentially fatal cause of pesticide poisoning. In this study a 42-year-old man was intoxicated with 3600 mg abamectin orally. On admission patient was fully alert with the smell of the poison from the mouth. Vital signs were normal and conjunctiva was hyperemic. Conservative cares such as gastric lavage was performed and charcoal was administered. After 2.5 hours, the patient gradually developed altered mental status as drowsiness, hypotension, tachycardia and dermal erythema. He was treated with H1 and H2 blockers and vasoactive agents and after 2 days was discharged in good condition. In comparison with organophosphates, abamectin intoxication has less risk in humans. However, consumption of large amounts in human can be fatal. Altered mental status could be considered as the first sign of abamectin intoxication. Normal level of consciousness is the best indicator of improvement of the condition. Conservative treatment is recommended.