Ultrasonography in Emergency Department; a Diagnostic Tool for Better Examination and Decision-Making.

CONTEXT: The aim of this study is to evaluate the applications of ultrasonography (US) as a diagnostic tool in emergency settings. EVIDENCE ACQUISITION: In the present review article, search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane were searched for the applications of US in emergencies. Finally, related articles which were published between 2000 and 2017, were selected and by reviewing them an attempt was made to evaluate various applications of US for examining and facilitating decision-making in emergency department (ED). RESULTS: As a diagnostic tool, US can be of diagnostic help in emergency settings for the specialists and the treatment team regarding trauma, measuring intracranial pressure (ICP), hemothorax pneumothorax, abscess and its drainage, deep vein thrombosis (DVT), dyspnea, acute abdomen, appendicitis and biliary problems, renal colic and renal stones, shock, foreign object, bone fracture, peripheral nerve block, establishing central and peripheral venous access, lumbar puncture (LP), and confirmation of nasogastric tube (NGT) and endotracheal tube (ETT) placement. CONCLUSION: The results of this review study showed that US can be of help to EMPs as a diagnostic tool in a wide range of diseases and clinical conditions, which in turn can result in a decrease in the time needed for diagnosis and treatment, and therefore improve both the quality and quantity of the service provided in ED.

Pain Management in the Emergency Department: a Review Article on Options and Methods.

CONTEXT: The aim of this review is to recognizing different methods of analgesia for emergency medicine physicians (EMPs) allows them to have various pain relief methods to reduce pain and to be able to use it according to the patient's condition and to improve the quality of their services. EVIDENCE ACQUISITION: In this review article, the search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane for emergency pain management methods were reviewed. Among the findings, high quality articles were eventually selected from 2000 to 2018, and after reviewing them, we have conducted a comprehensive comparison of the usual methods of pain control in the emergency department (ED). RESULTS: For better understanding, the results are reported in to separate subheadings including "Parenteral agents" and "Regional blocks". Non-opioids analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of acute pain. However, the relief of acute moderate to severe pain usually requires opioid agents. Considering the side effects of systemic drugs and the restrictions on the use of analgesics, especially opioids, regional blocks of pain as part of a multimodal analgesic strategy can be helpful. CONCLUSION: This study was designed to investigate and identify the disadvantages and advantages of using each drug to be able to make the right choices in different clinical situations for patients while paying attention to the limitations of the use of these analgesic drugs.

A new modality for the estimation of corrected flow time via electrocardiography as an alternative to Doppler ultrasonography.

BACKGROUND: Evaluation of corrected flow time (FTc) via ultrasonography is one of the suggested modalities for the assessment of intravascular volume status. This study aimed to compare the results of FTc of carotid artery measured via ultrasonography, as a measure of mechanical outcome of the cardiac cycle, with the results of FTc estimation from a new modified formula via electrocardiography (ECG), as a measure of electrical function of the cardiac cycle. METHODS: Healthy volunteers were evaluated before and after a passive leg raising (PLR) maneuver. FTc was measured concurrently before and after PLR via a modified method from ECG and via ultrasonography of the carotid artery. RESULTS: A total number of 98 healthy volunteers (51 women and 47 men) with a mean age of 30.69 ± 6.28 years were included. There was a significant correlation between FTc measured by ultrasonography and estimated by ECG both before PLR and after PLR (r = .878, p < .0001 and r = .797, p < .0001, respectively). Changes in FTc were slightly higher in measurements by ultrasonography compared to estimations by ECG (22.33 ± 17.15 ms0.5 vs. 15.86 ± 14.25 ms0.5 , p = .001). CONCLUSION: Estimation of FTc via ECG is potentially an effective and feasible method for the assessment of volume status at the clinical settings. Further investigations should determine the significance of differences that may be observed between ultrasonography and ECG in patients with either dehydration or volume overload and in the need of real-time volume status assessment.

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.

Assessment of corrected flow time in carotid artery via point-of-care ultrasonography: Reference values and the influential factors.

OBJECTIVE: Assessment of Corrected Flow Time (FTc) in carotid artery has been suggested recently as a measure of intravascular volume status. This study aimed to determine the reference values of FTc in carotid artery in a normal population. METHODS: A total number of 142 healthy volunteers (73 females and 69 males) with a mean age of 36.65±10.52years were included. RESULTS: The mean FTc in carotid artery was 325.18±22.15ms0.5. The mean value of FTc differed significantly between females and males both before and after passive leg raise (PLR) (330.18±21.61ms0.5 vs. 319.88±21.62, P=0.005 before PLR, and 336.89±22.95ms0.5 vs. 326.51±21.21, P=0.006 after PLR). CONCLUSION: This study would potentially pave the way to determine clinically significant cutoff points in order to assess the diagnostic accuracy of FTc in predicting intravascular volume status and fluid therapy responsiveness.

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.

Evaluation of the Significance of Vital Signs in the Up-Triage of Patients Visiting Emergency Department from Emergency Severity Index Level 3 to 2.

The Emergency Severity Index (ESI) is a five-level triage system that has shown promising reliability and validity. According to ESI algorithm, in the presence of danger zone respiratory rate (RR), heart rate (HR) or Oxygen (O2) saturation, patients should be up-triaged from ESI level 3 to 2 Hence, the current study aimed to investigate the value of the measurement of vital signs in predicting the up-triage of patients from ESI level 3 to 2. Patients who visited the emergency department at Imam Khomeini Hospital Complex, Tehran, Iran, and were categorized into ESI level 3 were investigated. RR, HR, and O2 saturation were recorded by the triage nurse, and the rates of abnormalities in these three variables were evaluated. Out of 551 cases who were up-triaged from ESI level 3 to 2,489 (88.7%) had an increased RR, and 539 (97.8%) had an increased RR or HR. Only 12 cases (2.2%) had normal RR and HR, who were up-triaged only due to abnormal O2 saturation. Out of these 12 cases, 10 had O2 saturations <92% at common health status, 1 had acutely altered mental status and should have been triaged into ESI level 2 in the first place and 1 could not be located for further investigations. In conclusion, compared to O2 saturation, the abnormal findings during the assessment of RR and HR seem to much more commonly result in the up-triage of patients from ESI level 3 to 2.

Carotid artery corrected flow time measurement via bedside ultrasonography in monitoring volume status.

PURPOSE: The purpose of this study is to investigate the possible correlation between corrected flow time (FTc) in carotid artery and changes in volume status. MATERIALS AND METHODS: Ninety-three patients with end-stage renal failure who underwent fluid removal via hemodialysis were enrolled prospectively. The volume of fluid removed as well as prehemodialysis and posthemodialysis measures of FTc in the carotid artery, heart rate, and mean arterial pressure was evaluated. All imaging measurements were performed with patients at supine position, 15 minutes before and after the hemodialysis session, by evaluating the right common carotid artery at the level of the lower border of thyroid cartilage. RESULTS: The mean FTc before fluid removal was 345.07±37.19 milliseconds. This measure decreased significantly after the volume removal with a posthemodialysis mean of 307.77±31.76 milliseconds (P<.0001). There was a statistically significant and negative association between the volume of fluid removed by hemodialysis and the changes in FTc (Pearson correlation, -0.39; P<.0001). CONCLUSION: The assessment of changes in FTc of carotid artery via Doppler waveform analysis may predict the changes in intravascular volume. The use of this diagnostic modality may be an accurate and noninvasive alternative to currently available methods.