Intravenous Paracetamol vs Intranasal Desmopressin for Renal Colic in the Emergency Department: A Randomized Clinical Trial.

OBJECTIVE: To evaluate the analgesic efficacy of intranasal desmopressin alone vs intravenous paracetamol in patients referred to the emergency department with renal colic. DESIGN: Randomized clinical trial. SETTING: This study was conducted in the emergency unit of a university hospital. SUBJECTS: Patients referred to the emergency room with renal colic. PRIMARY OUTCOME: Effect of intranasal desmopressin in pain relief in comparison with intravenous paracetamol. METHODS: In this trial, 240 patients diagnosed with renal colic were randomly divided into two groups to compare the analgesic effect of intravenous paracetamol (15 mg/kg) and intranasal desmopressin spray (40 µg). Pain scores were measured by a numeric rating scale at baseline and after 15, 30, and 60 minutes. Adverse effects and need for rescue analgesic (0.05 mg/kg max 3 mg morphine sulphate) were also recorded at the end of the study. RESULTS: Three hundred patients were eligible for the study; however, 240 were included in the final analysis. The patients in the two groups were similar in their baseline characteristics and baseline pain scores. The mean pain score after 15 minutes was more reduced and was clinically significant (>3) in the desmopressin group (P < 0.0001). There was no significant difference between mean pain scores in the two groups after 30 minutes (P = 0.350) or 60 minutes (P = 0.269), but the efficacy of the two drugs was significant in terms of pain reduction (>6). CONCLUSIONS: Our study showed that intranasal desmopressin is as effective as intravenous paracetamol for renal colic pain management; however, significant clinical reduction in pain score occurred faster with intranasal desmopressin.

Diagnostic accuracy of emergency-performed focused assessment with sonography for trauma (FAST) in blunt abdominal trauma.

INTRODUCTION: Intra-abdominal hemorrhage due to blunt abdominal trauma is a major cause of trauma-related mortality. Therefore, any action taken for facilitating the diagnosis of intra-abdominal hemorrhage could save the lives of patients more effectively. The aim of this study was to determine the accuracy of focused assessment with sonography for trauma (FAST) performed by emergency physicians. METHODS: In this cross-sectional study from February 2011 to January 2012 at 7th Tir Hospital in Tehran (Iran), 120 patients with abdominal blunt trauma were chosen and evaluated for abdominal fluid. FAST sonography was performed for all the subjects by emergency residents and radiologists while they were blind to the other tests. Abdominal CTs, which is the gold standard, were done for all of the cases. SPSS 20.0 was used to analyze the results. RESULTS: During the study, 120 patients with abdominal blunt trauma were evaluated; the mean age of the patients was 33.0 ± 16.6 and the gender ratio was 3/1 (M/F). The results of FAST sonography by emergency physicians showed free fluid in the abdomen or pelvic spaces in 33 patients (27.5%), but this was not observed by the results of CT scans of six patients; sensitivity and specificity were 93.1 and 93.4%, respectively. As for tests performed by radiology residents, sensitivity was a bit higher (96.5%) with lower specificity (92.3%). CONCLUSION: The results suggested that emergency physicians can use ultrasonography as a safe and reliable method in evaluating blunt abdominal trauma.

The association between serum 25-hydroxyvitamin D level and recurrent falls in the elderly population: a cohort study.

INTRODUCTION: Serum vitamin D concentration is a major contributing factor for increasing the risk of fall and fall-related injuries in older adults. However, when prescribed and supplemented for these populations, the outcomes are controversial, and in several cases no improvement has been reported in reducing the risk of recurrent falls. This study aimed to examine the association between serum vitamin D concentration and recurrent falls in Iranian older adults. METHODS: This cohort study was conducted in the emergency departments of two university hospitals. A cohort of 82 elderly participants aged over 60 and suffered from an unintentional episode of falling was evaluated six months after their first ED visit. A structured, self-administered checklist was developed to obtain the participants' demographic and clinical information. Participants also were asked about any recurrent fall experience during follow-up. RESULTS: The mean (SD) age of the study population was 75 (8). Over half of the participants were male (57.3%). The mean (median) serum 25-hydroxyvitamin D (25 (OH)D) concentration was 38 (34) ng/ml. Mean serum 25(OH)D levels varied slightly between gender groups (p=0.450). An inverse but insignificant association was found between the age of participants and their serum 25(OH)D levels (r=-0.03, p=0.7). A small but insignificant association also was found between the mean serum 25(OH)D level and the number of recurrent falls in elderly patients irrespective of their age, gender, or physical activity groups (OR=1.008, p=0.992). CONCLUSION: In contrast to previous studies, no significant association of serum 25(OH)D concentration was found with recurrent falls in Iranian older adults.

Randomized, controlled trial of povidone-iodine to reduce simple traumatic wound infections in the emergency department.

INTRODUCTION: Povidone Iodine (PVI) has been used to prevent wound infection for a long time, yet the merits and effectiveness of this agent in reducing the rates of infection in simple traumatic wounds have been debated. The aim of this study is determine the effect of PVI as skin disinfectant in preventing simple traumatic wound infection after repair in emergency departments. METHODS: This study is a single-blind, randomized, controlled trial, conducted at the emergency departments of two university hospitals. In this trial, those collecting and analyzing data were unaware of the assigned treatment. Participants included ED patients with simple traumatic wounds, randomly assigned to either experiment or control groups. Wounds were similarly irrigated with normal saline in both groups. But the skin around the wounds of patients in the experiment group was cleansed by PVI solution. The patients were followed till their next ED visit for stitch removal. The presence or absence of wound infection was considered as the primary outcome and assessed by an ED physician. RESULTS: In total, 444 patients were screened and included in the study. The patients were statistically similar according to their baseline characteristics. Men constituted 85% of the study participants. The highest numbers of reported wound sites belonged to head (30%), lower limbs (24%) and upper limbs (19%) accordingly. The rates of infections in the experiment and control groups were similar (p=0.231) but a significant association was observed between the rate of infections and wound location. Lower limbs (OR=9.23, p<0.0001) and upper limbs (OR=5.47, p=0.011) indicated the highest risks of wound infections among other locations. CONCLUSION: Our study showed that using PVI in the management of traumatic wounds did not reduced rate of infections.

Azithromycin versus Cephalexin for Simple Traumatic Wounds in the Emergency Department: A Randomised Trial.

OBJECTIVE: The aim of this study was to investigate efficacy of azithromycin versus cephalexin for infection prophylaxisis in patients with simple traumatic wounds managed at emergency department. METHOD: This randomized controlled trial compared short-course therapy of once-daily azithromycin (500 mg before the wound repair followed by 250 mg/day for 5 days) with cephalexin (1000 mg before wound repair followed by 250 mg every 6 hours for 5 days) in the treatment of patients with simple traumatic wounds. A total of 366 patients were randomly selected for the study and 303 were evaluated for the final analysis. RESULTS: On completion of therapy, the rate of observed infection was 9.6% in the cephalexin group (15 patients, odds ratio=0.77, 95% confidence interval, 0.56 to 1.06) and 5.4% in the azithromycin group (8 patients, odds ratio 1.42, 95% confidence interval, 0.80 to 2.52). Both treatment indicated similar prophylactic efficacy during the study (P=0.197). CONCLUSION: Our study showed that Azithromycin as infection prophylaxis in simple traumatic wounds had the same effect as cephalexin but azithromycin is easier to use and more cost-effective compared to cephalexin.

Social network analysis of Iranian researchers on emergency medicine: a sociogram analysis.

BACKGROUND: The purpose of this study was to report interaction patterns among Iranian authors of emergency medicine using social network analysis methodology, focusing on coauthorship network. METHODS: The bibliographic data of Iranian authors on the 'emergency medicine' field during the years 2001-2011 were retrieved from the Science Citation Index Expanded database. Co-occurrence matrices were made by BibExcel and were imported to Ucinet and NetDraw to delineate coauthorship network. To detect structural patterns among authors, we considered some measures of social network analysis, such as density, centralisation indices, component analysis and cut-points. Lastly, subject experts separately analysed the content of papers. RESULTS: Of 116 papers published, the network was composed of 10 components, with the largest component having 25 authors. Using social network analysis measures, we identified science bottlenecks in knowledge sharing, hub authors and accelerators of information flow. Topic analysis showed 'Wounds and Injuries' as the most recent theme in all components because of existence of national registry for trauma, high burden of road traffic injuries and research priority of injuries in Iran. CONCLUSIONS: because of Iranian low productivity in the emergency medicine field, social network analysis seems to be a proper option for bibliometrics to identify central authors and detect knowledge structure in this field.

Serum Sodium and Potassium Levels in Cerebro-vascular Accident Patients.

BACKGROUND: We aim to assess serum sodium and potassium levels in patients with different types of cerebro-vascular accidents (CVA) in comparison to control group. METHODS: A comparative cross-sectional study conducted on patients admitted to the emergency department from January to August 2012. Control group consisted of patients admitted to emergency department due to common cold, urinary tract infection, low back pain, cluster, and tension headache or migraine. Serum sodium and potassium levels were measured via standard laboratory methods. RESULTS: There were 77 patients in control group and 78 in CVA group. Forty nine patients from the CVA group had ischemic CVA, 11 had hemorrhagic CVA and 18 suffered a transient ischemic attack (TIA). Serum sodium level in control group was significantly lower than in patients with TIA, ischemic CVA, and hemorrhagic CVA (P < 0.001). Serum potassium level in control group was higher than patients with TIA, ischemic CVA, and hemorrhagic CVA (P < 0.001). Patients with hemorrhagic CVA showed significantly lower serum potassium level than patients with TIA and ischemic CVA (P < 0.001). Correspondingly, it was observed that serum sodium to potassium ratio was higher in patients with TIA, ischemic CVA, and hemorrhagic CVA (P < 0.001). In patients with hemorrhagic CVA serum sodium to potassium ratio was higher when compared to patients with TIA and ischemic CVA (P < 0.001). CONCLUSION: This study shows that higher serum sodium and lower serum potassium level may be associated with higher incidence of CVA. Further studies are paramount to elucidate the role of serum electrolyte levels in vascular events.

Ketamine and atropine for pediatric sedation: a prospective double-blind randomized controlled trial.

INTRODUCTION: Sedation in children can be a challenge for emergency physicians, which demands for selecting an effective medication with few complications and good analgesic effects. This study has been performed to evaluate the adverse effects of ketamine while using either atropine or placebo in emergency departments. METHODS: This is a prospective randomized controlled trial involving 200 patients with age ranging between 2 and 15 years, who need a painful procedure. Participants randomly were divided into 2 groups both treated by ketamine (1 mg/kg intravenously administered); group 1 received excessive intravenous atropine (0.01 mg/kg), whereas distilled water was given to group 2 as placebo. Adverse effects and duration of the treatments were recorded. RESULTS: From March to September 2010, 200 of 218 eligible patients were enrolled. The mean (SD) age of patients in the intervention group was 7.0 (3.6) years that showed no statistical difference with the control group (age range, 2-15 years; mean, 7.1 [3.8] years). The mean procedure and sedation time between the intervention and placebo groups were not significantly different (P = 0.919 and 0.783, respectively). Several differences between the intervention and placebo groups were noted including nausea and vomiting, but only the difference in hypersalivation was statistically significant (12% vs 28%). Low oxygen saturation was reported only in 2% of the participants, whereas none of the children experienced apnea or laryngospasm during the sedation process. CONCLUSIONS: Atropine added to ketamine significantly reduces hypersalivation without producing any adverse effects on the procedure duration or success rate.

Alterations in Circulating Adhesion Molecules in Acute Myocardial Infarction before and after Thrombolysis with Streptokinase.

INTRODUCTION: The role of adhesion molecules in the development and progression of coronary atherosclerosis is inevitable. It is not clear yet whether these molecules increase or decrease in level after thrombolytic therapy. This study was designed to compare concentrations of soluble forms of adhesion molecules in patients with acute myocardial infarction before and after reperfusion by thrombolysis with streptokinase (SK). METHODS: In this study, in 40 patients with acute myocardial infarction who were admitted in our Emergency Department undergoing thrombolysis with SK, plasma concentrations of six adhesion molecules [soluble L-selectin, P-selectin, E-selectin, intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and platelet endothelial cell adhesion molecule-1 (PECAM-1)] were measured by enzyme linked immunosorbent assay (ELISA), before and 3 hours after intervention. RESULTS: While soluble E-selectin and PECAM-1 concentrations did not differ within the 3 hours after interventions (P> 0.05), the level of P-selectin, L-selectin, ICAM-1, VCAM-1 were significantly reduced after thrombolysis with SK (P< 0.05). CONCLUSION: Adhesion molecules which mediate the interactions in leukocyte endothelium vary in levels after reperfusion with SK. It was shown that 4 out of 6 adhesion molecules significantly reduced after thrombolysis with SK.

How do Iranian emergency doctors decide? Clinical decision making processes in practice.

INTRODUCTION: Emergency doctors must make decisions for many patients in a limited time. Various emergency cases are not compatible with routine conditions as described in textbooks, so doctors use clinical decision making (CDM) processes to act in the best possible way. In the present work, these processes and some of the related factors were assessed. METHODS: Decisions made by doctors were studied via patient medical records, doctors' notes and interviews with decision-making doctors from the Emergency Department of Rasul-Akram Hospital, Tehran, Iran. All doctors were unaware of this research, and they had previously studied CDM processes as part of their training curriculum. A total of 10 day and 10 night shifts (240 h) between 1 March 2010 and 30 May 2010 were considered for the study. RESULTS: Rule-based, event-driven, knowledge-based and skill-based decisions, respectively, were the most frequent processes used by doctors in 726 first visits. It was also found that 7% of decisions were not made on a known CDM basis, that all of them were for non-urgent and 'standard' patients, and that most patients who were non-urgent were referred to first-year postgraduates. Skill-based decisions were not applied in very urgent cases; 107 out of 726 decisions on first visits had shifted to knowledge-based process by the time of final treatment decisions. For final treatment decisions, rule-based and knowledge-based processes were more frequently used than other CDM processes. CONCLUSIONS: The rule-based process is the most common CDM process used by emergency doctors, perhaps because of the minimisation of human error in this process. CDM choice may be influenced by triage level, treatment room and doctors' educational levels. Revealing and studying these factors may help shift decisions to the best possible decision making levels, defining a model in future research.

Burden of circulatory system diseases and ignored barriers of knowledge translation.

Circulatory system disease raise third highest disability-adjusted life years among Iranians and ischemic cardiac diseases are main causes for such burden. Despite available evidences on risk factors of the disease, no effective intervention was implemented to control and prevent the disease. This paper non-systematically reviews available literature on the problem, solutions, and barriers of implementation of knowledge translation in Iran. It seems that there are ignored factors such as cultural and motivational issues in knowledge translation interventions but there are hopes for implementation of started projects and preparation of students as next generation of knowledge transferors.

Prophylactic Antibiotic Therapy in Contaminated Traumatic Wounds: Two Days versus Five Days Treatment.

INTRODUCTION: Emergency department manages several kinds of wounds including simple, non-bite traumatic wounds and lacerations. Prophylactic antibiotic therapy is one of pre-scribed treatment in these conditions. We aimed to compare the clinical efficacy of the two day regimen of prophylactic antimicrobial agents with the five day regimen in simple traumatic but highly contaminated wounds. METHODS: Between January 2010 and May 2010, patients presenting with simple traumatic wounds or lacerations in different parts of the body, highly contaminated with soil, debris or feces in emergency department of a referral educational hospital in Tehran (Rasul-Akram hospital), Iran, went for primary closure. All of the patients were provided prophylactic antibiotic, however, prescribed for one group (A) of patients for 2 days and other group (B) received for 5 days, according to the physician concerned. As these treatments were routine, we selected 70 patients from each group using table of random numbers. The patients were warned about the signs of infection including long-lasting erythema, purulent discharge and inflammation and were supposed to inform the concerned physician in any of such alarming situations. Oral Cephalexin 500 mg qid was prescribed for all patients enrolled for prophylaxis treatment. RESULTS: On follow-up 11 (8.2%) patients were found to develop sutured site infection (6 out of 70 (8.57%) in group A, and five out of 70 (7.14%) in group B (P=0.31)). There was no statistical difference between infection rates between men (8.6%) in comparison to women (6.25%) (P>0.05; CI=95%). CONCLUSION: Our study showed that 2-day prophylactic antibiotic therapy using Cephalexin is at least as effective as a 5-day regimen in relation to development of surgical site infection in patients with simple traumatic contaminated wounds or lacerations.

Reduction of anterior shoulder dislocation in emergency department; is entonox(®) effective?

INTRODUCTION: An appropriate procedural sedation and analgesia (PSA) is crucial to reduce a dislocated shoulder successfully in emergency department. This study compares sedative effect of inhalational Entonox(®) (En) to intra-venous (IV) Midazolam plus Fentanyl (F+M). METHODS: 120 patients with recurrent anterior shoulder dislocation were randomly assigned into two groups. 60 patients (group F+M) received 0.1 mg/kg IV Midazolam plus 3µg/kg IV Fentanyl and 60 patients (group En) received Entonox(®) with self administration face mask on an on-demand basis. Traction/counter-traction method was used to reduce the dislocated shoulder joint in both groups. RESULTS: 48 out of 60 (80%) patients in group F+M and 6 out of 60 (10%) patients in group En had successful reduction (p < 0.0001). The mean pain score reduction was 6.3 ± 1.2 for group F+M and 3 ± 0.9 for group En (p < 0.0001). There was a statistically significant difference in mean patient satisfaction (assessed with Likert score) between two groups (4.45 ± 0.6 for group F+M and 2.3 ± 1 for group En; p < 0.0001). Duration of entire procedure (since the beginning of PSA up to the end of successful or unsuccessful reduction) was shorter in Group F+M, but successful reductions occurred earlier in group En. No major side effect such as airway compromise, retracted respiratory depression, or circulatory failure was occurred in any group. CONCLUSION: Entonox(®) may not be an appropriate agent to help reducing a dislocated shoulder.

Effects of hyperbaric oxygenation on survival time of aluminum phosphide intoxicated rats.

BACKGROUND: Aluminium phosphide (AlP) is used as a fumigant. It produces phosphine gas which is a mitochondrial poison. Although this poisoning has been repeatedly reported in literature with a high mortality rate, there is no known antidote for AlP intoxication. In the present study, we studied the effects of hyperbaric oxygenation (HBO) on the survival time of AlP intoxicated rats. METHODS: Intoxicated rats with AlP (11.5 mg/kg, oral gavage) were placed in hyperbaric oxygenation with different concentrations of compressed air and oxygen. RESULTS: All the animals exposed to AlP died within 5 days. The mean survival times of rats exposed to AlP without any intervention, treated with hyperbaric condition by compressed air, and treated with hyperbaric condition by pure O2 were 91 ± 1, 262 ± 8, and 276 ± 6 minutes, respectively. In analysis of survival times, there was a significant difference between Group 2 which received AlP and the groups which underwent intervention (Groups 2 and 3, p < 0.001; Groups 2 and 4, p < 0.001). CONCLUSIONS: Hyperbaric oxygenation may probably improve the survival time of the intoxicated rats with aluminium phosphide, but it may not decrease the mortality rate.