Prediction of difficult laryngoscopy / difficult intubation cases using upper airway ultrasound measurements in emergency department: a prospective observational study.

INTRODUCTION: Difficult laryngoscopy and intubation are serious problems among critically ill patients in emergency department (ED) so utility of a rapid, accurate and noninvasive method for predicting of these patients are necessary. Ultrasonography has been recently used in this regard and this study was conducted to investigate the correlation of some introduced upper airway ultrasound parameters with difficult laryngoscopy / difficult intubation in patients referred to the ED. METHOD: In this prospective observational study all patients ≥ 18-year-old who had an indication for rapid sequence intubation (RSI) were included. Ultrasound parameters including Hyoid Bone Visibility (HBV), Distance from Skin to Hyoid Bone (DSHB), Distance from Skin to Vocal Cords (DSVC), Distance from Skin to Thyroid Isthmus (DSTI), and Distance between Arytenoids Cartilages (DBAC) were measured in all cases. The patients underwent RSI and thereafter the patients' baseline characteristics, Cormack-Lehane grade, number of attempted laryngoscopy were recorded in a pre-prepared check list and compared with measured ultrasound parameters. The "difficult laryngoscopy" was defined as Cormack-Lehane classification grades III/IV; and need for more than 3 intubation attempts was considered as "difficult intubation". RESULTS: One hundred and twenty-three patients (52% male) were included of whom 10 patients (8.1%) were categorized as difficult laryngoscopy cases; and just 4 (3.3%) cases underwent more than 3 laryngoscopy attempts who considered as difficult intubation cases. The mean age of the patients in non-difficult and difficult intubation groups were 69.2 ± 15.16 and 68.77 ± 17.37 years, respectively (p > 0.05). There was no significant relationship between difficult laryngoscopy and HBV (p = 0.381) but has significant correlation with difficult intubation (p = 0.004). The DSHB had a significant correlation with difficult laryngoscopy (p = 0.002) but its correlation with difficult intubation was not significant (p = 0.629). The DSVC and DSTI had a significant relationship with both difficult laryngoscopy (p = 0.003 and p = 0.001), and difficult intubation (p = 0.025 and p = 0.001). The DBAC had not significant correlation neither with the difficult laryngoscopy (p = 0.142), nor with difficult intubation (p = 0.526). CONCLUSION: The findings showed that ultrasound parameters including soft tissue DSHB, DSVC and DSTI could be proper predictors of difficult laryngoscopy. Also, HBV, DSVC and DSTI may be proper predictors for difficult intubation. But DBAC was not useful in this regard.

The Outcome Predictors of the Patients with Traumatic Brain Injury; A Cross-Sectional Study.

Objective: To probe the factors associated with the outcomes of traumatic brain injury (TBI) patients admitted to emergency department (ED). Methods: This is a cross-sectional study that data gathering was performed via census methods, retrospectively. During one year, all head injury's patients who admitted to the ED of a tertiary center in Tehran, Iran were included. Age, gender, mechanism of injury, Glasgow coma scale (GCS) and injury severity score (ISS) on admission, presence of extra-cranial injuries, findings of brain computed tomography (CT), duration of hospitalization, and in hospital outcomes were recorded. Outcome's assessment for survivors was performed within a 6 months-period after discharge based on Glasgow outcome scale (GOS). The variables and outcomes' association were assessed. Results: Totally, 506 patients were evaluated with the mean age of 36.77±21.1 years that 411 (81.2%) were men. Follow up at 6-months post injury was feasible in 487 (96.2%) patients; 59 (11.7%) out of 506 eligible patients died. Logistic regression analysis showed the association between assessed variables and patients' outcome as follows: age>65 years (OR: 12.21; p<0.001), GCS on admission <8 (OR: 62.99; p<0.001), presence of traumatic Intracerebral hemorrhage (ICH) in brain CT scan (OR: 20.11; p=0.010), duration of hospitalization ≥ 5 days (OR: 0.28; p=0.001). Conclusion: The findings of the current study distinguished some variables that were associated with the poor outcome of the patients with TBI. Therefore, TBI patients with any of these risk factors may need close continues monitoring, early ICU admission, and some other special extra care in ED.

Intravenous morphine plus ibuprofen or ketorolac versus intravenous morphine alone in reducing renal colic pain intensity in emergency department: A randomized, double-blind clinical trial.

OBJECTIVES: This study aimed to compare the efficacy of intravenous (IV) morphine plus ibuprofen or ketorolac versus IV morphine alone in controlling renal colic pain in the emergency department. METHODS: This double-blind, randomized clinical trial was conducted during November 2018 and March 2019 in Iran. Patients aged 18-65 years with acute renal colic and numerical rating scale (NRS) score of higher than 6 of 10 were enrolled to the study. They were randomly assigned to I, K, and control groups receiving 5 mg morphine with 800 mg ibuprofen (n = 65), 5 mg morphine with 30 mg ketorolac (n = 65), or only 5 mg morphine (n = 65) intravenously, respectively. NRS was evaluated 0, 15, 30, 60, and 120 min after injection. RESULTS: A total of 195 participants took part in the study. The presence of stone in pelvis area was higher in I group (P = 0.027). The mean rescue analgesic dose was higher in the control group and lower in K group (P = 0.031). From the 15th min, the NRS reduction in I and K group was higher than the control group (P < 0.001), but the difference between I and K group was not statistically significant in total (P = 1.0) or in the all follow-up time intervals (15th P = 0.864, 30th P = 0.493, 60th P = 0.493, and 120th min P = 1.0). The largest difference in pain reduction was observed in 120th min and mean of NRS was 2.9 (95% confidence interval [CI]: 2.6-3.3), 2.9 (95% CI: 2.6-3.3) and 7.0 (95% CI: 6.7-7.4) in I, K and control group, respectively. The adverse effects showed in 18.5%, 20.0%, and 13.8% of I, K, and control group, respectively. CONCLUSION: IV ibuprofen plus morphine and IV ketorolac plus morphine had similar effects in reducing renal colic pain but were more effective than IV morphine alone.

Sub dissociative dose of ketamine with haloperidol versus fentanyl on pain reduction in patients with acute pain in the emergency department; a randomized clinical trial.

BACKGROUND: Ketamine is known to be an effective factor in reducing pain without significant side effects. OBJECTIVE: One of the limited side effects of Ketamine is agitation. Due to the reduction of this symptom with Haloperidol, we decided to design a randomized clinical trial to compare the analgesic effect of Ketamine with Haloperidol and Fentanyl in reducing acute pain and its complications. METHODS: In this study, 200 adult patients who presented to the emergency department with acute pain are examined. They are randomly divided into two groups. One group received intravenous Ketamine with Haloperidol and the other group received intravenous Fentanyl. Patients are then compared for their pain score before and after administration of the drugs, as well as the side effects they experienced. RESULTS: There was no significant difference between the mean scores of initial pain in the two groups, but at all intervals of 5, 10, 15 and 30 min after injection, the mean of pain scores of patients in the group receiving Ketamine and Haloperidol were lower. The need for injection of rescue analgesic was 9% in the Ketamine and Haloperidol group and 34% in the Fentanyl group. The mean agitation score did not differ between the two groups except in the tenth minute. At tenth minute, the mean agitation score of the Ketamine group was higher. CONCLUSION: Ketamine works better than fentanyl in controlling acute pain, and limited side effect of agitation can be controlled if injected with haloperidol. Due to its better function and fewer side effects, it seems that in controlling acute pain, Ketamine along with Haloperidol can be a good alternative to opioids.

Ultrasonography indicators for predicting difficult intubation: a systematic review and meta-analysis.

BACKGROUND: Ultrasonography (US) is recently used frequently as a tool for airway assessment prior to intubation (endotracheal tube (ETT) placement), and several indicators have been proposed in studies with different reported performances in this regard. This systematic review and meta-analysis reviewed the performance of US in difficult airway assessment. METHODS: This systematic review and meta-analysis was conducted according to the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane book. All the studies that had carried out difficult airway assessments using US, had compared the indicators in difficult and easy groups, and had published the results in English by the time we conducted our search in April 28, 2020, were included. RESULTS: In the initial search, 17,156 articles were retrieved. After deleting the duplicate articles retrieved from multiple databases, 7578 articles remained for screening based on the abstracts and titles. Finally, the full text of 371 articles were assessed and the data from 26 articles were extracted, which had examined a total of 45 US indicators for predicting difficult intubation. The most common US index was the "thickness of anterior neck soft tissue at the vocal cords level". Also, "skin to epiglottis" and "anterior neck soft tissue at the hyoid bone level" were among the most common indicators examined in this area. CONCLUSION: This systematic review showed that US can be used for predicting difficult airway. Of note, "skin thickness at the epiglottis and hyoid levels", "the hyomental distance", and "the hyomental distance ratio" were correlated with difficult laryngoscopy in the meta-analysis. Many other indicators, including some ratios, have also been proposed for accurately predicting difficult intubation, although there have been no external validation studies on them.

Ketamine Sub-Dissociative Dose Vs. Morphine Sulfate for Acute Pain Control in Patients with Isolated Limb Injuries in the Emergency Department: A Randomized, Double-blind, Clinical Trial.

OBJECTIVE: To compare the ketamine efficacy at a sub-dissociative morphine dose to reduce pain in isolated limb traumatic injuries. METHODS: A double-blind randomized clinical trial study was carried out on patients referred to emergency departments (EDs) due to isolated limb traumatic injuries. Eligible patients were divided into two groups which one group received 0.1 mg/kg ketamine and the other group received 0.05 mg/kg morphine, intravenously. An observed side effect includes pain scores and vital signs were recorded at baseline of every 5 minutes for 30 minutes. RESULTS: Totally, 73 patients with the mean age of 32.9±10.4 were enrolled of whom 59 (80.8%) individuals were men. The baseline characteristics difference of the two study groups was not statistically significant. The results showed that the change of mean pain score was -6.2 (95% CI: -5.72 to -6.69) points in the group receiving ketamine compared to -5.8 (95%CI: -5.15 to - 6.48) in the group who were administered morphine. At all assessed checkpoints, the pain mean score was lower in the ketamine group than in the morphine group (p<0.05); the mean of total pain reduction was greater in the ketamine group during the observation period compared with patients who received morphine (p=0.002). CONCLUSION: The study findings suggest that the sub-dissociative ketamine efficacy in controlling of the acute pain is not lower than morphine sulfate in patients with isolated limb trauma in ED's. Thus, it can be considered as a safe and effective alternative approach.

How much change in pain score does really matter to patients?

OBJECTIVE: The goal of this study was to determine the minimal change in pain score recognized by patients as meaningful known as minimal clinically important difference (MCID). METHODS: Pain was recordedupon admission, 30 and 60 min later and patients were asked todescribe the extent of pain change on a 5-point Likert scale ranging from "much better" to "much worse". Patients reported their pain by two common pain scales comprising numeric rating scale (NRS) and visual analog scale (VAS). We used receiver operating characteristiccurve to assess the accuracy of pain scales. We then calculated the mean change in pain scores among patients who reported their pain change as "a little better" or "a little worse" and also analyzed regression to evaluate the MCID. RESULTS: A total of 150 patients and 253 pain changes were recruited. The MCID ±â€¯SD (95% CI) was 1.65 ±â€¯1.58 (1.32-1.97) for NRS and 16.55 ±â€¯17.53 (12.96-20.15) for VAS. The area under the curve by NRS and VAS were 0.86 and 0.89. For linear regression, the line slope and the y-intercept were 17.56 and 1.88, for VAS; these values were 1.73 and 0.31 for NRS, respectively. CONCLUSIONS: Recognizing the extent of change in pain score that really matters to patients is crucial for the evaluation of treatment effect. Patients perceived a change of 1.65 points on NRS and 16.55 on VAS in their pain severity as meaningful. This value was not different whether the pain was perceived alleviated or aggravated.

A clinical prediction rule for uncomplicated ureteral stone: The STONE score; a prospective observational validation cohort study.

INTRODUCTION: Renal colic is one of the most common complaints in patients admitted to Emergency Department (ED). Computed Tomography (CT) is the reference standard for the diagnosis of any stones in the kidneys or ureters. However, CT has classical disadvantages, such as radiation exposure, cost and availability. Recently, STONE clinical prediction criteria were suggested to identify uncomplicated ureteral stone cases among patiens admitted to the ED with abdominal pain. Primary objective of this study was the external validation of the STONE criteria. METHODS: This was a diagnostic accuracy study conducted on a prospective, observational cohort. All consecutive patients who underwent a non-enhanced abdominopelvic CT scan in the ED with an initial diagnosis of ureteral stone disease were enrolled. Using a pre-prepared checklist, all data and the final diagnosis according to the CT scan were recorded. STONE score was calculated for all patients. The area under the curve (AUC) of the STONE Score and the CT, the reference standard, were compared using the ROC curve analysis. RESULTS: Totally, 237 patients (59.9% male) with an average age of 41.54 years (SD: 13.37) were evaluated, and 156 cases (65.8%) were proved to have renal stone. The mean (SD) STONE scores in the groups of patients with renal stone and in the group of patients without renal stone group were 9.1 (2.6) and 6.0 ( 2.8), respectively (p < 0.001). The area under the curve (AUC) for the STONE score was 0.789 (95% confidence interval (CI) 0.725 to 0.852). The optimum threshold value of the STONE score for the diagnosis of a renal stone was 8 or more, which had a sensitivity of 75.0% and a specificity of 70.4%. CONCLUSION: Despite the acceptable diagnostic accuracy, further modifications and enhancements of the STONE score are needed to differentiate patients with low risk prior to imaging.

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

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

Oral Piracetam vs Betahistine in Outpatient Management of Peripheral Vertigo; a Randomized Clinical Trial.

INTRODUCTION: Although vertigo is a common complaint in patients presenting to the emergency department (ED), its ideal treatment is still under debate. This study was conducted to compare oral betahistine and oral piracetam in management of outpatients with peripheral vertigo. METHODS: This was a randomized clinical trial performed on patients who were presented to the EDs of 4 teaching hospitals, with complaint of true vertigo. Patients were randomly allocated to either betahistine or piracetam group and their 7-day outcomes were compared. RESULTS: 100 cases with the mean age of 54.72 ± 14.09 years were randomly allocated to either group (62.0% female). The two groups were similar regarding age, sex, and intensity of symptom at the time of presenting to the ED. Twelve (24%) patients in piracetam group and 6 (12%) patients in betahistine group experienced adverse events (odds ratio: 2.32, CI 95%: 0.79-6.76; p = 0.125). There were 3 (6%) patients in each group that experienced a recurrence of their symptoms and 2 (4%) patients in each group saw another physician for vertigo. CONCLUSION: Oral piracetam is a potentially proper treatment for management of peripheral vertigo and there are few adverse effects associated with it.

Intranasal Ketamine Administration for Narcotic Dose Decrement in Patients Suffering from Acute Limb Trauma in Emergency Department: a Double-Blind Randomized Placebo-Controlled Trial.

INTRODUCTION: pain management is an important and challenging issue in emergency medicine. Despite the conduct of several studies on this topic, pain is still handled improperly in many cases. OBJECTIVE: This study investigated the effectiveness of low-dose IN ketamine administration in reducing the need for opiates in patients in acute pain resulting from limb injury. METHOD: This randomized, double-blind, placebo-controlled trial was conducted to assess the possible effect of low-dose intranasal (IN) ketamine administration in decreasing patients' narcotic need. Patients in emergency department suffering from acute isolated limb trauma were included. One group of patients received 0.5 mg/kg intravenous morphine sulfate and 0.02 ml/kg IN ketamine. The other group received the same dose of morphine sulfate and 0.02 ml/kg IN distilled water. Pain severity was measured using the 11 points numerical rating scale at 0, 10, 30, 60, 120, and 180 minutes. RESULTS: Ninety-one patients with mean age of 31.59 ± 11.33 years were enrolled (38.8% female). The number of requests for supplemental medication was significantly lower in patients who received ketamine (12 patients (30%)) than those who received placebo (27 patients (67.5%)) (p = 0.001). CONCLUSION: It is likely that low-dose IN ketamine is effective in reducing the narcotic need of patients suffering from acute limb trauma.

Implementation a Medical Simulation Curriculum in Emergency Medicine Residency Program.

Applying simulation in medical education is becoming more and more popular. The use of simulation in medical training has led to effective learning and safer care for patients. Nowadays educators have confronted with the challenge of respecting patient safety or bedside teaching. There is widespread evidence, supported by robust research, systematic reviews and meta-analysis, on how much effective simulation is. Simulation supports the acquisition of procedural, technical and non-technical skills through repetitive practice with feedbacks. Our plan was to induct simulation in emergency medicine residency program in order to ameliorate our defects in clinical bedside training. Our residents believed that simulation could be effective in their real medical practice. They mentioned that facilitators' expertise and good medical knowledge, was the strongest point of the program and lack of proper facilities was the weakest.

The Accuracy of Emergency Physicians in Ultrasonographic Screening of Acute Appendicitis; a Cross Sectional Study.

INTRODUCTION: Diagnostic values reported for ultrasonographic screening of acute appendicitis vary widely and are dependent on the operator's skill, patient's gender, weight, etc. The present study aimed to evaluate the effect of operator skill on the diagnostic accuracy of ultrasonography in detection of appendicitis by comparing the results of ultrasonography done by radiologists and emergency physicians. METHODS: This prospective diagnostic accuracy was carried out on patients suspected to acute appendicitis presenting to EDs of 2 hospitals. After the initial clinical examinations, all the patients underwent ultrasonography for appendicitis by emergency physician and radiologist, respectively. The final diagnosis of appendicitis was based on either pathology report or 48-hour follow-up. Screening performance characteristics of appendix ultrasonography by emergency physician and radiologist were compared using STATA 11.0 software. RESULTS: 108 patients with the mean age of 23.91 ± 7.46 years were studied (61.1% male). Appendicitis was confirmed for 37 (34.26%) cases. Cohen's kappa coefficient between ultrasonography by the radiologist and emergency physician in diagnosis of acute appendicitis was 0.51 (95% CI: 0.35 - 0.76). Area under the ROC curve of ultrasonography in appendicitis diagnosis was 0.78 (95% CI: 0.69 - 0.86) for emergency physician and 0.88 (95% CI: 0.81 - 0.94) for radiologist (p = 0.052). Sensitivity and specificity of ultrasonography by radiologist and emergency physician in appendicitis diagnosis were 83.87% (95% CI: 67.32 - 93.23), 91.5% (95% CI: 81.89 - 96.52), 72.97% (95% CI: 55.61 - 85.63), and 83.10% (95% CI: 71.94 - 90.59), respectively. CONCLUSION: Findings of the present study showed that the diagnostic accuracy of ultrasonography carried out by radiologist (89%) is a little better compared to that of emergency physician (80%) in diagnosis of appendicitis, but none are excellent.

Outcome of Trauma Patients Admitted to Emergency Department Based on Full Outline of Unresponsiveness Score.

INTRODUCTION: Full Outline of Unresponsiveness (FOUR) score is one of the existing scoring scales, which has been used for evaluating the level of consciousness in recent years. OBJECTIVE: The present study has been done with the aim of evaluating the ability to predict the outcome of patients with head trauma based on FOUR score on admission to emergency department (ED). METHODS: In the present prospective cross-sectional study, head trauma patients with any changes in alertness level presenting to ED were evaluated. FOUR score measurement was done on admission and 6 hours after that. The studied outcomes in the current study included discharge without sequel, discharge with neurologic sequel, brain death or death during 1 month after admission of the patients. To evaluate the correlation between FOUR score and the studied outcomes, area under the receiver operating characteristic (ROC) curve was used. RESULTS: In the end, 52 patients with the mean age of 32.67 ± 15.20 years were evaluated (84.6% male). Traffic accident with the frequency of 39 (75.0%) patients was the most common mechanism of trauma among the studied patients and finally, after 1 month follow up it was determined that 13 (25%) patients were discharged without sequel and 31 (59.6%) died. Area under the ROC curve for prediction of the final outcome of death using FOUR score on admission and after 6 hours were 0.889 (95% confidence interval: 0.800 - 0.977) and 0.974 (95% confidence interval: 0.938 - 1.000), respectively. Best cutoff points for FOUR score were the scores 8 and 9 on admission of the patients, and the score 5, six hours after admission. CONCLUSION: Based on the findings of this study, it seems that FOUR score is applicable for prediction of probable death outcome in patients with head trauma presenting to ED.

Efficacy of Intravenous Paracetamol Versus Intravenous Morphine in Acute Limb Trauma.

BACKGROUND: Efficient pain management is one of the most important components of care in the field of emergency medicine. OBJECTIVES: This study was conducted to compare intravenous paracetamol and intravenous morphine sulfate for acute pain reduction in patients with limb trauma. PATIENTS AND METHODS: In a randomized double-blinded clinical trial, all patients (aged 18 years and older) with acute limb trauma and a pain score of greater than 3/10 in the emergency department were recruited; they received either 1 g intravenous paracetamol or 0.1 mg/kg intravenous morphine sulfate over 15 minutes. The primary outcome was the pain score measured on a numerical rating scale at 0, 15 and 30 minutes after commencing drug administration. The requirement for rescue analgesia and the frequency of adverse reactions were also recorded. RESULTS: Sixty patients randomly received either IV paracetamol (n = 30) or IV morphine (n = 30). The mean reduction in numerical rating scale pain intensity scores at 30 minutes was 3.86 (± 1.61) for paracetamol, and 2.16 (± 1.39) for morphine. However, pain relief was significantly higher in the paracetamol group compared to the morphine group (P < 0.001). Four patients in the paracetamol group and 15 patients in the morphine group needed rescue analgesia and the difference was significant (P = 0.05). CONCLUSIONS: Intravenous paracetamol appears to provide better analgesia than intravenous morphine in acute limb trauma. Further larger studies are required.