A comparative study of intranasal desmopressin and intranasal ketamine for pain management in renal colic patients: a randomized double-blind clinical trial.

OBJECTIVE: Urolithiasis is one of the most common urological diseases worldwide, usually presenting as renal colic that leads to severe pain that requires analgesic treatment. This study aimed to compare the efficacy of ketamine and desmopressin in the pain management of renal colic patients. METHODS: This double-blind, randomized clinical trial was conducted on renal colic patients referred to the emergency department from June 2021 to July 2022. Patients were randomly assigned to three groups. In the desmopressin group, patients were treated with intranasal desmopressin and intravenous ketorolac. The ketamine group was treated with intranasal ketamine and ketorolac. The control group received ketorolac and an intranasal placebo. Vital signs were evaluated at baseline and 60 minutes; and pain scores were assessed at baseline, 10, 30, and 60 minutes after treatment. RESULTS: Enrollment included 135 patients, the mean (standard deviation) age was 44.1±11.4 years, and 82 (60.7%) were men. The mean visual analog scale scores were significantly lower at 10, 30, and 60 minutes in the ketamine group (5.6±1.2, 3.0±1.1, and 0.9±0.9, respectively) compared to the control (8.2±1.1, 5.1±2.0, and 2.3±2.6, respectively) and desmopressin (6.7±1.8, 4.2±2.2, and 1.3±1.4, respectively) groups (P<0.05). Although patients in the desmopressin group had lower mean pain scores than the control group at 10, 30, and 60 minutes, this difference was only significant at 10 minutes after the intervention (P<0.05). No significant differences in vital signs were found at 60 minutes after treatment. CONCLUSION: Ketamine showed more favorable analgesic effects in renal colic patients than desmopressin, although desmopressin showed efficacy in the first minutes posttreatment.

Dexmedetomidine versus propofol: An effective combination with ketamine for adult procedural sedation: A randomized clinical trial.

BACKGROUND: Recently, drug combination protocols have been preferred over single drugs in procedural sedation and analgesia (PSA). This study aimed to compare the effectiveness and hemodynamic profile of ketamine-dexmedetomidine (ketodex) and ketofol as drug combinations with ketamine as a single medication for PSA in the emergency department (ED). METHODS: This prospective, randomized, double-blind clinical trial was performed among adult patients (≥18 years) requiring PSA for a painful procedure in the ED. 135 patients were enrolled and assigned into three equal groups to receive either ketodex, ketofol, or ketamine. Additional ketamine was used as a rescue agent for inadequate sedation in three groups. Oxygen saturation, heart rate, and blood pressure were recorded from baseline until 120 min after induction of PSA. Adverse events, hemodynamic variables, induction, and recovery time were recorded and compared between groups. RESULTS: The mean age of the patients was 38.16 ± 19.09 years and no differences were observed between the three groups in terms of demographic variables, pain scores, and procedures between the three groups. Respiratory events had similar incidences between the three groups. The O2 reduction was less in the Ketodex group in comparison with Ketofol and Ketamine groups (1.9%, 6.5%, and 3.8%, P = 0.015). No patient needed endotracheal intubation. Changes in mean arterial pressure from the baseline in Ketamine and Ketofol groups compared to Ketodex was higher (difference was 12.9 mmHg [95% CI, 9.5 to 20.3] and 8.6 mmHg [95% CI, 3.4 to 13.7]. Tachycardia in the Ketamine group had a significantly higher incidence. The recovery time was statistically shorter in the Ketofol group in comparison with other groups. The differences between Ketofol with Ketamine and Ketodex groups were 9.8 min (95% CI, [2.5 to 17.1]) and 8.3 min (95% CI, [1.5 to 15.1]). CONCLUSION: Ketodex, as well as ketofol, were effective and safe combinations with good recovery profiles and hemodynamic stability for adult PSA in ED.

Quality of Professional Life and Its Association with Emotional Well-Being among COVID-19 Physicians and Nurses.

Background: The present study was to compare the professional quality of life (ProQOL) and its association with the emotional well-being among the physicians and nurses in contact with COVID-19 patients in Iran and France. Materials and Methods: The study was performed on 903 nurses and physicians in contact with COVID-19 patients in Iran and France.he subjects completed their demographics online and then answered questions addressing their job stress and emotion associated with their contact with COVID-19 patients and ProQOL. Finally, the collected data were analyzed using the SPSS software (ver. 25). Results: According to the results of the present study, the degree of contact with COVID-19 patients had a significant role in compassion satisfaction, burnout, and compassion fatigue, with the coefficient effects of 0.459, 0.688, and 0.433, respectively (P < 0.05). The emotional well-being had a significant role in increasing compassion satisfaction (B = 0.505, P < 0.05). Conclusion: According to the results of the present study, factors such as contact with a COVID-19 patient, emotional well-being, gender, and marital status had a significant effect on dimensions of ProQOL in both Iran and France. Considering that the entire focus of the physicians and nurses is on the health of COVID-19 patients and they have no concentration on improving their emotional state, it seems that supporting them in terms of psychological self-care and considering its indirect impact on the quality of professional performance are of particular significance.

The Effectiveness of Cognitive-Behavioral Therapy Courses in Improving the Emergency Medicine Residents and Interns' Ability to Regulate their Emotions in Threatening or Stressful Events.

Background: Given that the duties of an emergency medicine (EM) specialist are much more complicated than the other health care professionals, inexperience, weakness or inability to make appropriate decisions, and lack of control over their emotions and stress can lead to medical errors. This study aimed at determining the effect of cognitive-behavioral therapy (CBT) of emotion regulation on the EM assistants' and interns' level of satisfaction and cognitive control of anger and stress. Materials and Methods: In this study, 25 EM residents and interns were trained in the virtual CBT course while 19 ones were not given any training in the control group and Cognitive Emotion Regulation Questionnaire (CERQ) were filled before and after the training intervention. Results: After the training intervention, the dimensions of catastrophizing and other blame in the experimental group with the means of 3.84 ± 1.40 and 3.16 ± 0.94 respectively were significantly lower than these dimensions in the control group with the means of 5.68 ± 1.76 and 4.73 ± 1.15, respectively (P value < 0.05). Moreover, the refocus on planning in the experimental group with the means of 8.40 ± 1.53 was significantly higher than in the control group with the means of 7.00 ± 2.05 (P value < 0.05). Conclusion: CBT method used in this study may be effective in controlling the emotions of EM interns and residents. CBT may help them to regulate anger and stress and have the ability to control their emotions during or after the experience of threatening or stressful events.

Diagnostic accuracy of ultrasonography for diagnosis of elbow fractures in children.

BACKGROUND: Elbow injuries and fractures are a common pathology in the pediatric emergency unit. X-ray and CT scan of the elbow are the standard diagnostic procedures, which increase exposure to radiation in children. Previous studies have shown that fractures can also be visualized by ultrasound (US); thus, this study aimed to evaluate the diagnostic accuracy of elbow US compared with radiography for the diagnosis of elbow fracture in children. MATERIALS AND METHODS: This was a prospective observational study of patients aged 2-14 years that presented to emergency departments with a suspected elbow fracture requiring radiographic evaluation. Elbow US for diagnosing elevated posterior fat pad or lipohemarthrosis was performed. All patients underwent elbow radiography and received clinical follow-up. Initial or follow-up X-ray or CT scan was used as the reference standard for fracture diagnosis. RESULTS: Seventy-five patients with a mean age of 6.51 ± 3.68 years were enrolled in the study. Twenty-eight (37.3%) patients had positive results for fracture. The sensitivity, specificity, and accuracy of US in the diagnosis of elbow fractures were 92.9% (95% CI 76.5-99.1%), 89.4% (95% CI 76.9-96.5%) and 90.7% (95% CI 81.7-96.2%). In patients with fracture, US demonstrated a lipohaemarthrosis in 20 patients (71.4%), elevated posterior fat pad in 19 patients (67.9%), cortical disruption in 10 patients (35.7%), and effusion in three patients (10.7%). CONCLUSION: Our results showed high diagnostic accuracy for the ultrasonography diagnosis of an elbow fracture, which allows us to confirm ultrasonography imaging of the elbow as a safe alternative in the primary evaluation of pediatric elbow injuries.

Physiologic Scoring Systems versus Glasgow Coma Scale in Predicting In-Hospital Mortality of Trauma Patients; a Diagnostic Accuracy Study.

INTRODUCTION: In recent years, several scoring systems have been developed to assess the severity of trauma and predict the outcome of trauma patients. This study aimed to compare Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) in predicting the in-hospital mortality of trauma patients. METHODS: This diagnostic accuracy study was done on adult patients admitted to the emergency department (ED) between June 21, 2019, and September 21, 2020, following multiple trauma. Patients were followed as long as they were hospitalized. The REMS, MEWS, GCS, and ISS were calculated after data gathering and comprehensive assessment of injuries. Receiver operating characteristics (ROC) analysis was performed to examine the prognostic performance of the four different tools. RESULTS: Of the 754 patients, 32 patients (4.2%) died and 722 (95.8%) survived after 24 hours of admission. The mean age of the patients was 38.54 ± 18.58 years (78.9% male). The area under the ROC curves (AUC) of REMS, MEWS, ISS, and GCS score for predicting in-hospital mortality were 0.942 (95% CI [0.923-0.958]), 0.886 (95% CI [0.861-0.908]), 0.866 (95% CI [0.839-0.889]), and 0.851 (95% CI [0.823-0.876]), respectively. The AUC of REMS was significantly higher than GCS (p=0.035). The sensitivities of GCS ≤ 11, ISS ≥ 13, REMS ≥ 4, and MEWS ≥ 3 scores for in-hospital mortality were 0.56, 0.97, 0.81, and 0.94, respectively. Also, the specificities of GCS, ISS, REMS, and MEWS scores for in-hospital mortality were 0.93, 0.82, 0.81, and 0.85, respectively. CONCLUSION: It seems that REMS is more accurate than GCS, ISS, and MEWS in predicting in-hospital mortality ≥ 24 hours of multiple trauma patients.

Comparison of the effects of dexmedetomidine and propofol in reducing recovery agitation in pediatric patients after ketamine procedural sedation in emergency department.

BACKGROUND: Ketamine has been a safe and effective sedative agent commonly used for painful pediatric procedures in the emergency department (ED). This study aimed to compare the effect of dexmedetomidine (Dex) and propofol when used as co-administration with ketamine on recovery agitation in children who underwent procedural sedation. MATERIALS AND METHODS: In this prospective, randomized, and double-blind clinical trial, 93 children aged between 3 and 17 years with American Society of Anesthesiologists Class I and II undergoing short procedures in the ED were enrolled and assigned into three equal groups to receive either ketadex (Dex 0.7 µg/kg and ketamine 1 mg/kg), ketofol (propofol 0.5 mg/kg and ketamine 0.5 mg/kg), or ketamine alone (ketamine1 mg/kg) intravenously. Incidence and severity of recovery agitation were evaluated using the Richmond Agitation-Sedation Scale and compared between the groups. RESULTS: There was no statistically significant difference between the three groups with respect to age, gender, and weight (P > 0.05). The incidence of recovery agitation was 3.2% in the ketadex group, 22.6% in the ketofol group, and 22.6% in the ketamine group (P = 0.002, children undergoing short procedures were recruited). There was a less unpleasant recovery reaction (hallucination, crying, and nightmares) in the ketadex group compared with the ketofol and ketamine groups (P < 0.05). There was no difference in the incidence of oxygen desaturation between the groups (P = 0.30). CONCLUSION: The co-administering of Dex to ketamine could significantly reduce the incidence and severity of recovery agitation in children sedated in the ED.

Topical Lidocaine plus Diclofenac as a Local Anesthetic Agent in Central Venous Catheterization; a Randomized Controlled Clinical Trial.

INTRODUCTION: Various methods of analgesia can be used to reduce or prevent procedural pain in emergency department (ED). This study aimed to evaluate the effectiveness of topical lidocaine-diclofenac combination compared to lidocaine-prilocaine combination (Xyla-P) in reduction of the pain during central venous catheter (CVC) insertion. METHODS: In this randomized clinical trial, 100 adult patients requiring CVC insertion in the ED were enrolled. These patients were randomly divided into two groups. The site of CVC insertion was covered with 2 g of topical Xyla-P cream in the first group, and 2 g of topical lidocaine-diclofenac cream in the second group. The primary outcome was the pain during CVC implantation. The secondary outcomes were physician satisfaction and the incidence of side effects. RESULTS:  On the visual analog scale (VAS), the pain score during CVC insertion was significantly lower in the second group (p = 0.027). However, there was no difference in pain scores during lidocaine injection between the two groups (p = 0.386). Also, there was no significant difference in the rate of side effects between the two groups (p = 1.0). The physician's satisfaction with the first group was significantly lower than the second group (p = 0.042). CONCLUSION: Although the CVC insertion pain was significantly lower in patients who received the topical combination of Lidocaine plus Diclofenac, there was no clinically important difference between the two groups and both topical anesthetics were effective and safe in reducing pain intensity. Also, lidocaine-diclofenac combination cream was more cost-effective than Xyla-P cream.

The Role of Cardiac Arrest Sonographic Exam (CASE) in Predicting the Outcome of Cardiopulmonary Resuscitation; a Cross-sectional Study.

INTRODUCTION: Ultrasonography (US) has been suggested as an integral part of resuscitation to identify potentially reversible causes of cardiac arrest (CA). This study aimed to evaluate the association between cardiac activity on ultrasonography during resuscitation and outcome of patients with non-shockable rhythms. METHODS: We conducted a prospective, observational study on adult patients presenting with CA or experiencing CA in the emergency department (ED), and initial non-shockable rhythm. US examination of the sub-xiphoid region was performed during the 10-second interval of rhythm and pulse check and the association of US findings and patients' outcomes was evaluated. RESULTS: 151 patients with the mean age of 65.32 ± 11.68 years were evaluated (76.2% male). 43 patients (28.5%) demonstrated cardiac activity on the initial US. The rate of asystole in initial rhythm was 58.9% (n=89). Return of spontaneous circulation (ROSC) was achieved in 36 (23.8%) patients, twenty (13.2%) survived to hospital admission and seven (4.6%) survived to hospital discharge. When the cardiac standstill duration increased to six minutes, no patient survived hospital discharge. Potentially reversible causes were detected in 15 cases (9.9%), and four of them survived to hospital discharge. Cardiac activity on first scan was associated with ROSC (OR: 6.86, 95%CI: 2.92-16.09; p < 0.001), survival to hospital admission (OR: 17.80, 95%CI: 3.95-80.17; p < 0.001), and survival to hospital discharge (OR: 17.35, 95%CI: 2.02-148.92; p = 0.001). CONCLUSION:  In non-traumatic cardiac arrest patients with non-shockable rhythms, bedside US is of great importance in predicting ROSC. The presence of pulseless electrical activity (PEA) rhythm and cardiac activity on initial US were associated with ROSC, survival to hospital admission, and hospital discharge. When the cardiac standstill duration increased to six minutes, no patient survived hospital discharge.

A comparative study of dexmedetomidine and propofol to prevent recovery agitation in adults undergoing procedural sedation with ketamine: A randomized double-blind clinical trial.

BACKGROUND: The present study was designed to evaluate the effect of dexmedetomidine and propofol on ketamine-induced recovery agitation in adults when used as co-administration with ketamine. METHODS: In this prospective, randomized, and double-blind clinical trial, 93 patients aged 18 years or older who were candidates for painful procedures in the emergency department (ED) were enrolled and assigned into three equal groups to receive either ketadex (dexmedetomidine 0.7 µg/kg and ketamine 1 mg/kg), ketofol (propofol 0.5 mg/kg and ketamine 0.5 mg/kg) or ketamine alone (1 mg/kg) intravenously. Incidence and severity of recovery agitation were evaluated using the Richmond Agitation-Sedation Scale and compared between groups. RESULTS: There were no significant differences in demographic characteristics, procedures, pain scores, pre-sedation agitation, and duration of procedure between the three groups. The incidence of recovery agitation was 26% in the Ketadex group, 29% in the Ketofol group, and 58% in the Ketamine group. The difference in incidence of recovery agitation between Ketadex group and Ketamine group was 32% (95% confidence interval (CI), 9 to 56]) and between Ketofol group and Ketamine group was 29% (95% CI, 6 to 53). The severe agitation was significantly higher in Ketamine group, with a difference between Ketamine and Ketadex group of 19% (95% CI, 6 to 33), and a difference between Ketamine and Ketofol group of 16% (95% CI, 1 to 31). CONCLUSIONS: In this study, a combination of ketamine-dexmedetomidine and ketamine-propofol reduced the incidence and severity of ketamine-induced recovery agitation in adults undergoing procedural sedation in the ED.

Comparing the Effect of Lidocaine-Prilocaine Cream and Infiltrative Lidocaine on Overall Pain Perception During Thoracentesis and Abdominocentesis: A Randomized Clinical Trial.

BACKGROUND: Acute pain management is a core ethical commitment to medical practice. However, there is evidence to suggest that sometimes infiltrative lidocaine (IL) is not used prior to thoracentesis and abdominocentesis due to the belief that two needles cause greater pain than one. However, topical anesthetics like lidocaine-prilocaine cream (LPC) are painless, easy to use, and have less systemic side effects. Therefore, LPC can be a suitable substitute for medical procedures. OBJECTIVES: This study was designed to compare the analgesic effects of LPC with IL in thoracentesis and abdominocentesis. METHODS: Patients were divided into two study groups, including individuals seeing a physician for a thoracentesis (N = 36) and those seeing a physician for an abdominocentesis (N = 33). Patients were randomly assigned to the IL (N = 35) or LPC (N = 34) groups for diagnostic and/or therapeutic purposes. The IL group received 100 mg of 2% lidocaine 5 minutes prior to their procedure, whereas the LPC group received 2.5 g of lidocaine-prilocaine cream. The cream was spread over a 20 - 25 cm2 area and occluded with dressing plaster for 30 minutes prior to the procedure. In both study groups, the thoracentesis and abdominocentesis were ultrasound-guided. RESULTS: The findings suggest a non-significant difference between overall pain perception in LPC and IL groups generally, as well as specifically in abdominocentesis and thoracentesis groups. Furthermore, the result remained the same after controlling for confounding variables. The number of attempts to perform successful abdominocentesis was significantly higher in the LPC than IL (P-value = 0.003) group but was not significant in the thoracentesis group (P-value = 0.131). The level of patient satisfaction in the LPC and IL groups were not significantly different (P-value > 0.05). CONCLUSIONS: Overall, LPC appears to be an appropriate alternative to IL in reducing pain during thoracentesis and abdominocentesis, but it seemed to increase unsuccessful medical procedure attempts.

Decreased Emergency Department Overcrowding by Discharge Lounge: A Computer Simulation Study.

BACKGROUND: In the past decade, factors such as population growth, increased environmental incidents, and substance abuse have caused patient-overcrowding in emergency departments (EDs). Our main objective was to assess the effects of a discharge lounge on decreasing the patient waiting time and ED overcrowding by computer simulation. METHODS: In this cross-sectional retrospective study, the statistical population consisted of 39264 persons referred to the ED of Al-Zahra Hospital. The sample size was calculated as 1275 through systematic random sampling at 99% confidence. To increase research accuracy, the number of patients was increased to 2515. Data were collected by standardized checklists and hospital information systems. RESULTS: Mean waiting time for level 2 patients who left the ED against medical advice after completing the treatment was declined from 56 min to 44 min and before completing the treatment process from 80 min to 50 min. Average waiting time for level 3 patients for personal satisfaction after completing the treatment process decreased from 15 min to 13 min and before the completion of the treatment process from 67 min to 41 min; the number of discharged patients awaiting discharge was decreased at level 2 from 3 to 2 and at level 3 from 2 to 1. The number of patients waiting for admission at triage stations reduced from 44 to 39%, and the average number of patients discharged from emergency room was increased from 7 to 12. CONCLUSIONS: ED overcrowding is the hallmark of a mismatch between the availability of health care resources and patient demand for emergency care. Among major factors contributing to these situations are hindrances in patient flow and occupation of ED beds by nonurgent patients. The establishment of a discharge unit in the ED could be a practical solution to ED overcrowding.

Comparing Sedative Effect of Dexmedetomidine versus Midazolam for Sedation of Children While Undergoing Computerized Tomography Imaging.

BACKGROUND: Pediatric anxiety and restlessness may create issues and difficulties in performing accurate diagnostic studies even noninvasive ones, such as radiological imaging. There are some agents that will help to get this goal. This study aimed to compare the intranasal effect of dexmedetomidine (DEX) and midazolam (MID) for sedation parameters of children undergoing computerized tomography (CT) imaging. MATERIALS AND METHODS: A double-blind clinical trial was conducted on 162 eligible children who underwent CT imaging. These patients were divided into two groups including MID (n = 81) with dose of 0.3 mg.kg and DEX (n = 81) with dose of 3 µg.kg, which was consumed intranasally. The mean blood pressure (MBP), respiratory rate (RR), heart rate (HR), and oxygen saturation (O2Sat) in children were recorded. Then, time of initiation, level of sedation, and duration effect of medication were measured at 0, 10, 20, and 30 min. Parents and clinician satisfaction score was asked. All data were analyzed using the Statistical Package for the Social Sciences (SPSS) software by t test and chi-square test. RESULTS: Decreasing in MBP and HR was higher in DEX group than MID group (P < 0.001), whereas decrease of O2Sat in MID group was higher than DEX group (0.009). Starting time of sedation (22.72 ± 11.64 vs. 33.38 ± 10.17, P = 0.001) was lower in DEX group. Parents (P < 0.001) and physician (P < 0.001) satisfaction score was higher in DEX group than the MID group. CONCLUSION: Using 3 µg/kg intranasal DEX for sedation of 1-6-year-old children was a suitable method to undergo noninvasive studies such as CT imaging. Intranasal DEX is superior to MID due to higher sedation satisfactory, faster starting effect of sedation, and lower side effects and complications. Nevertheless, in children with hemodynamic instability DEX is not an appropriate choice.

Comparison of Wound Tape and Suture Wounds on Traumatic Wounds' Scar.

BACKGROUND: Several methods have been used in wound closure for traumatic wounds, but it is not clear that which of these methods has more safety and efficacy. This study aimed to compare scar width due to standard and current treatments in wound repair by suturing and method of wound restoration using wound tape in patients with traumatic ulcers. MATERIALS AND METHODS: This randomized clinical trial was done in ninety patients with wounds in the facial area. They were divided randomly into two groups of 45. The wounds in the first group were sutured, and wound tapes were used to wound closure in the second group. After 2 months, length and width of scar and results of life-size photography were recorded in a list, especially prepared for this purpose. RESULTS: The mean age of the patients was 22.7 ± 12.9 years with 46 males (56.1%) and 36 females (43.9%). After 2 months, scars width in suture wound group was 2.9 mm and in wound tape group was 2.5 mm, with no statistically significant difference (P = 0.07). In patients with wound length of >20 mm, scars width was similar between groups and no significant differences was noted (P = 0.27), but in patients with wound length of <20 mm, scars width in wound tape group was significantly less than suture wound group (1.7 vs. 2.5 mm, respectively, P = 0.01). Wound complications were not significantly different between the two groups. CONCLUSION: Findings revealed that scar formation in wounds lower than 20 mm treated using wound tape was lower than suture, but for wounds between 20 and 50 mm were similar between wound tape and suture.

Ketamine versus Ketamine / magnesium Sulfate for Procedural Sedation and Analgesia in the Emergency Department: A Randomized Clinical Trial.

BACKGROUND: The present study was designed to evaluate the effectiveness of magnesium sulfate (MgSO4) in procedural sedation and analgesia (PSA) when combined with ketamine in patients with fractures in emergency departments and required short and painful emergency procedures. MATERIALS AND METHODS: In this study, 100 patients with fractures and dislocations who were presented to the emergency departments and required PSA for short and painful emergency procedures were randomly allocated to groups of ketamine plus MgSO4 or ketamine alone. Train of four (TOF) stimulation pattern was assessed using nerve stimulator machine and compared between groups. RESULTS: The mean age of studied patients was 46.9 ± 9.3 years old. 48% were male and 52% were female. No significant differences were noted between groups in demographic variables. The status of TOF, 2 min after the injection of ketamine (1.5 mg/kg), in both groups was similar. After the injection of the second dose of ketamine (1 mg/kg) the status of TOF in four patients in ketamine plus MgSO4 (0.45 mg/kg) group changed, it was three quarters but in ketamine group, the status of TOF in all patients was four quarters. The difference between groups was not statistically significant (P = 0.12). CONCLUSION: The findings revealed that for muscle relaxation during medical procedures in the emergency department, ketamine in combination with MgSO4 with this dose was not effective for muscle relaxation during procedures.

Saline Flush versus Chest x ray in Confirmation of Central Venous Catheter Placement; a Diagnostic Accuracy Study.

INTRODUCTION: Central venous catheterization (CVC) is a commonly performed procedure in critically ill patients of emergency department. This study was designed to compare the diagnostic accuracy of saline flush with CXR in confirmation of above-the-diaphragm CVC placement. METHODS: This prospective cross sectional study was conducted on adult patients in need of CVC placement in emergency department. Placement Confirmation was performed with saline flush method and CXR, then chest computed tomography (CT) was performed as the gold standard. The screening performance characteristics of the two methods were calculated and compared using SPSS 21 and STATA 11. RESULTS: 103 cases with the mean age of 57.18±9.3 (35 -80) years were studied (52.4% male). The mean duration of procedure was 2.5±1.24 in saline flush and 32.11±5.52 minutes in CXR method (P<0.001(. The area under the ROC curves for saline flush and CXR in confirmation of CVC placement were 0.90 (95%CI: 0.70 - 0.100) and 0.80 (95%CI: 0.55 - 0.100), respectively (p = 0.317). The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of saline flush were 80%, 100%, 100, 98.9%, Infinity, and 0.01, respectively. These measures were 60%, 100%, 100%, 98%, Infinity, and 0.02 for CXR, respectively. CONCLUSION: It seems that saline flush method could be considered as a safe, rapid, and accurate bedside method for CVC placement confirmation in emergency department.

Predictive Value of Tracheal Rapid Ultrasound Exam Performed in the Emergency Department for Verification of Tracheal Intubation.

BACKGROUND: Verification of the correct placement of the endotracheal tube (ETT) has been one of the most challenging issues of airway management in the field of emergency medicine. Early detection of oesophagal intubation through a reliable method is important for emergency physicians. AIM: The aim of this study was to assess the diagnostic accuracy of tracheal rapid ultrasound exam (TRUE) to assess endotracheal tube misplacement during emergency intubation. METHODS: This was an observational prospective study performed in the emergency department of the major tertiary referral hospital in the city. We included a consecutive selection of 100 patients. TRUE was performed for all these patients, and subsequently, quantitative waveform capnography was done. The later test is considered as the gold standard. RESULTS: From our total 100 eligible patients, 93 (93%) participants had positive TRUE results (tracheal intubation) and 7 (7%) patients have negative TRUE results (esophageal intubation). Quantitative waveform capnography report of all 93 (100%) patients who had positive TRUE was positive (appropriate tracheal placement). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TRUE for detecting appropriate tracheal placement of ETT were 98.9% (95% CI, 93.3% to 99.8%), 100% (95% CI, 51.6% to 100%), 100% (95% CI, 95.1% to 100%) and 85.7% (95% CI, 42% to 99.2%) respectively. CONCLUSIONS: Performing TRUE is convenient and feasible in many emergency departments and pre-hospital settings. We would recommend emergency units explore the possibility of using TRUE as a method in the assessment of proper ETT placement.

The Relationship between Risk Factors of Head Trauma with CT Scan Findings in Children with Minor Head Trauma Admitted to Hospital.

BACKGROUND: In emergency medicine for determining the intracranial injury (ICI) in children with head trauma, usually brain CT scan is performed. Since brain CT scan, especially in children, has some disadvantages, it is better to find a procedure which could help to choose only the children with real head trauma injury for brain CT scan. AIMS: The aim of this study is to find such procedure. This study was descriptive, analytic and non-interventional. METHODS: We reviewed the archived files of children with head trauma injuries referred to the emergency department of Imam Hossein Hospital within two years. Patient's CT scan findings and head trauma risk factors were evaluated in this study. RESULTS: Out of 368 patients, 326 patients had normal brain CT scan. 28 of them showed symptoms of ICI consisting intraventricular haemorrhage (IVH), contusion, subarachnoid haemorrhage (SAH), subdural haemorrhage (SDH), epidural hematoma (EDH), and pneumocephalus. Twenty-seven patients showed skull FX, which 14 of them had an Isolated fracture, and 13 of them also showed symptoms of ICI. Since patients with isolated FX usually discharge quickly from Emergency Department; their data did not include in results of the study. The patients have been divided into two groups: 1- ICI, 2- without ICI. RR (relative risk), CI (Confidence interval) and sensitivity, positive predictive value (PPV), negative predictive value (NPV) and association of these risk factors with ICI were assessed with the Chi-2 test. In the end to determine the indications of CT scan, the presence of one of these five risk factors is important including abnormal mental status, clinical symptoms of skull FX, history of vomiting, craniofacial soft tissue injury (including subgaleal hematomas or laceration) and headache. CONCLUSIONS: For all other patients without these risk factors, observation and Follow Up can be used which has more advantages and less cost.

Investigation of changes in brain natriuretic peptide serum levels and its diagnostic value in patients with mild and moderate head trauma, in patients referred to emergency department of Alzahra Hospital, Isfahan, 2013-2014.

BACKGROUND: Head trauma is one of the most common reasons for emergency department (ED) care. Over the past decade, initial management strategies in mild and moderate head trauma have become focused on selective computed tomography (CT) use based upon presence or absence of specific aspects of patient history and/or clinical examination which has received more attention following reports of increased cancer risk from CT scans. Recently changes in serum brain natriuretic peptide (BNP) levels following head trauma have been studied. We investigated the changes in serum levels of BNP in patients with mild and moderate head trauma, in whom the first brain CT scanning was normal. MATERIALS AND METHODS: This study is a cross-sectional, descriptive research. It was performed in patients with mild and moderate head trauma. Forty-one patients with isolated mild and moderate traumatic brain injury (Glasgow Coma Scale = 9-15) were included. First brain CT scans were obtained during 2 h after ED arrival and the second one after 24 h. Plasma BNP levels were determined using a specific immunoassay system. RESULTS: Twenty-three patients were in Group A (with normal first and second brain CT) and 18 patients in Group B (with normal first and abnormal second brain CT). With P = 0.001, serum BNP level = 9.04 was determined for differentiating two groups. CONCLUSION: We concluded that serum BNP level is higher in patients with mild and moderate head trauma with delayed pathologic changes in second brain CT relative to patients with mild and moderate head trauma and with normal delayed brain CT.

Comparing the Antiemetic Effects of Ondansetron and Metoclopramide in Patients with Minor Head Trauma.

INTRODUCTION: Nausea and vomiting are the most common complications after minor head trauma that increases the risk of intracranial pressure rising. Therefore, the present study was aimed to compare the antiemetic effects of metoclopramide and ondansetron in the treatment of post-traumatic nausea and vomiting. METHODS: The study was a controlled, randomized, double blind clinical trial, which was conducted in the first 6 months of 2014 in emergency department Al-Zahra and Kashani Hospitals in Isfahan, Iran. The patients with minor head trauma associated with nausea and vomiting were randomly divided into 2 groups: treatment with metoclopramide (10mg/2ml, slow injection) and treatment with ondansetron (4mg/2ml, slow injection). The comparison between the 2 groups was done regarding antiemetic efficacy and side effects using SPSS 21 statistical software. RESULTS: 120 patients with minor head trauma were distributed and studied into two groups of 60 patients (mean age 35.6±14.1 years; 50.0% male). Administration of both ondansetron and metoclopramide significantly reduced the severity of nausea (P<0.001). Changes in the severity of nausea in both groups before and after the treatment revealed that nausea had been decreased significantly in both groups (P < 0.001). The incidence of fatigue (p=0.44), headache (p=0.58) and dystonia (p=0.06) had no significant difference in the two groups but the incidence of drowsiness and anxiety in the metoclopramide group was significantly higher (P < 0.001). CONCLUSION: The present study indicated that the treatment effectiveness of ondansetron and metoclopramide are similar. However, incidence of drowsiness and anxiety in the metoclopramide was considerably higher. Since these complications can have adverse effects on the treatment of patients with brain injury, it is suggested that it may be better to use ondansetron in these patients.