Comparative Study of Radial and Median Nerve Blocks with Hematoma Block under Ultrasound Guide in Distal Radius Fracture Reduction: A Randomized Clinical Trial.

Background: Distal radius fractures are one of the most common upper extremity fractures, and their incidence continues to increase due to an aging population and an increase in osteoporosis. Various methods of analgesia for distal radius fractures have been described-including hematoma blocks and nerve blocks. Hematoma blocks are a simple and effective method of providing analgesia; nonetheless, their efficacy may be limited in some cases. On the other hand, nerve blocks provide more targeted analgesia and may be more effective in reducing pain during fracture reduction. This study aimed to compare the analgesic effectiveness of radial and median nerve blocks with hematoma blocks under ultrasound guidance in treating distal radius fractures. Also, this study aimed to compare the analgesia of radial and median nerve blocks with hematoma blocks under ultrasound guidance to reduce distal radius fractures. Methods: In this prospective trial, patients with distal radius fractures referring to 2 academic centers were placed into 2 randomized groups, including hematoma block, and radial median block, both of which were ultrasound-guided. The patient's pain levels were measured and recorded based on the visual analog scale before the block, 5, 10, and 15 minutes after the block, at the start of reduction, during reduction, and 5, 10, and 15 minutes after reduction. Patient satisfaction and physician satisfaction rates were assessed, and side effects were also observed for 1 week. Quantitative variables were reported as mean ± standard deviation, and number and frequency percentages were reported for qualitative variables. The Student t test and the chi-square test were used on a case-by-case basis. The significance level was set at P ˂ 0.05. Results: In this study, 120 patients were included. The groups had no significant differences in pain reduction during the procedure. Analgesic medication was needed during the procedure for 17 patients; nerve blocks were applied for 6 patients, and hematoma blocks for 11 patients, which was statistically significant (P = 0.041). Satisfaction rates for patients and physicians performing the procedure were significantly higher in the nerve block group than in the hematoma block group ( P = 0.001; P ˂ 0.001, respectively). Conclusion: The results of this study suggest that ultrasound-guided radial and median nerve blocks can be used as alternative methods of analgesia with other techniques in the reduction of distal radius fractures in emergency departments.

Intravenous Acetaminophen vs. Ketorolac in Terms of Pain Management in Prehospital Emergency Services: A Randomized Clinical Trial.

INTRODUCTION: Although pain management in EDs has been fully addressed in clinical trials, prehospital settings have rarely been investigated. OBJECTIVE: The present study was conducted to compare the effectiveness of intravenous acetaminophen with that of ketorolac in pre-hospital pain control. METHOD: This randomized clinical trial (RCT) was performed at a prehospital setting during EMS missions in Tehran, Iran. The eligible candidates comprised all patients over the age of 7 years with a complaint of moderate to severe pain. The patients were randomly assigned to two groups, one receiving 30 mg of intravenous (IV) ketorolac and the other 1 g of IV acetaminophen. The pain intensity was measured using a visual analog scale (VAS) before administering the analgesic and upon admission to the ED. RESULTS: The present study was conducted on 150 patients aged 8-81 years with a mean age of 40.4 ± 17.7, including 84 (56%) males. The mean reduction in the pain score was 14.9±8.6 in the acetaminophen group and 16.0±8.8 in the ketorolac group. Univariate analyses suggested no statistically significant differences between the two groups in terms of delta pain score (pain reduction) (P=0.429). CONCLUSION: Based on the obtained findings, both ketorolac and acetaminophen could be administered for pain management in prehospital settings in both traumatic and non-traumatic patients in case their contraindications are considered.

Screening performance of Ultrasonographic B-lines in Detection of Lung Contusion following Blunt Trauma; a Diagnostic Accuracy Study.

INTRODUCTION: Chest ultrasonography is routinely used in evaluation of chest trauma for diagnosis of pulmonary injury. This study aimed to evaluate the accuracy of B-Lines for diagnosing lung contusion in patients with blunt trauma of the chest. METHODS: Trauma patients who met the inclusion criteria were enrolled in the study and underwent ultrasonography by trained emergency medicine residents. Ultrasound results were recorded in terms of number of B-lines and the existence of peripheral parenchymal lesion (PPL). After ultrasound, the patient underwent chest x-ray and chest CT scan (as reference test) and screening performance of B-lines and PPL were evaluated. RESULTS: 147 patients underwent chest ultrasound. The mean age of the patients was 40.74 ± 18.6 (78.9% male). B-lines˃3 had 94.0% (95% CI: 83.45-98.75) sensitivity and 57.7% (95% CI: 47.3-67.7) specificity, B-lines˃6 had 90.0% (95% CI: 78.2-96.7) sensitivity and 93.81% (95% CI: 87.0-97.7) specificity, and PPL had 34.0% (95% CI: 21.2-48.8) sensitivity and 100% (95% CI: 96.3-100.0) specificity. Composite findings of B-lines˃6 + PPL had 92.0% (95% CI: 80.8-97. 8) sensitivity and 93.8% (95% CI: 87.0-97.7) specificity in the diagnosis of lung contusion. CONCLUSION: PPL and B-Lines˃6 had the highest accuracy in detecting lung contusion. B-Line˃6 had high sensitivity and specificity and was easy to perform; thus, it seems that B-Line˃6 could be considered as an alternative screening tool in detection of lung contusion.

Can low-dose of ketamine reduce the need for morphine in renal colic? A double-blind randomized clinical trial.

BACKGROUND: The combination of morphine with low doses of ketamine (MK) has been utilized in the Emergency Department (ED) compared with morphine and placebo (MP) for the treatment of acute pain in few studies. The purpose of this study was to compare the effect of MP with MK for the treatment of severe pain with renal colic of patients who had been referred to the ED. METHODS: This study is a double blind randomized clinical trial on patients with severe renal colic pain who were referred to the ED. Patients were enrolled with pain severity of at least 6 of the 10 visual analogue scales (VAS). Patients were divided into two groups: Morphine 0.1mg/kg and placebo (MP group) and morphine 0.1mg/kg and ketamine 0.15mg/kg (MK group). Pain of patients was studied in 10, 30, 60, 90, and 120min after injection. RESULTS: Totally, 106 patients were enrolled in study groups. Assessment of the average pain during 120min at 10 and 30min after the start in the drug, MK group was significantly lower than the MP group (p=0.019 and p=0.003 respectively). CONCLUSION: Given that combinations of morphine with low doses of ketamine in patients with renal colic pain causes more pain and morphine consumption reduction then this combination is suggested as an alternative treatment that could be utilized in patients with renal colic.

Propofol-Ketamine vs. Propofol-Fentanyl Combinations in Patients Undergoing Closed Reduction: A Randomized, Double-blind, Clinical Trial.

INTRODUCTION: Painful surgical procedures require adequate sedation and analgesia. A vast array of medications can be used for Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs). OBJECTIVE: The present study was conducted to compare Propofol-Ketamine (PK) and Propofol-Fentanyl (PF) compounds in patients undergoing closed reduction in EDs. METHODS: This randomized, double-blind, clinical trial was conducted on 110 consecutive patients who required sedation for closed reduction. The patients were randomly divided into two groups of equal sizes. The PK group received an intravenous bolus of 1 mg/kg of propofol plus 0.5 mg/kg of ketamine, and the PF group received an intravenous bolus of 1 mg/kg of propofol plus 1 µg/kg of fentanyl. The analgesic effect and success rate were the primary outcomes under study. RESULTS: The PK group achieved more effective analgesia at the end of the experiment. The success rate was almost the same in both groups Shivering (p=0.005) and a drop in oxygen saturation to below 92% (p=0.048) were two side effects that were more prevalent in the FK group. The mean recovery time was significantly shorter in the PK group (p<0.001). The patients in the PK group were more satisfied. CONCLUSION: In comparison with the PF compound, the use of KP leads to better pain relief and greater patient satisfaction and shorter sedation time in PSA.

Demographics of Scorpion Sting in Iran; a Cross Sectional Study.

INTRODUCTION: Scorpion sting is an important public health problem in some countries, including Iran. This study aimed to describe the demographics of a large number of these victims in some endemic areas of Iran. METHODS: This cross-sectional study evaluated baseline characteristics, clinical findings, management, and disposition of scorpion stung cases in 26 cities of 4 provinces in the southwest quarter of Iran, during one year. RESULTS: 3008 cases of scorpion sting with mean age of 27.07 ± 16.58 years were studied (51.3% female). The mean time from sting to hospital was 1.89 ± 1.04 hours. No first aid measures had been taken in 96.6% of cases. Lower (39.5%) and upper (35.7%) extremities were stung most frequently. Midnight to 6:00 am was the period of time most of stings occurred (34.2%). Local pain (77.2%) and erythema (63.5) were among the most common signs and symptoms. 2026 (67.3%) victims had been discharged; 326 (10.8%) were admitted or referred to other hospitals and 5 (0.2%) cases died. CONCLUSION: It seems that demographic characteristics of scorpion sting in Iran are not so different from those reported from other sites of the world, as signs and symptoms of local and systemic envenomations. Victims, companions, and healthcare providers perform many futile and maybe harmful measures and there is a need to educate all about all of these details.

Focused cardiac ultrasound (FOCUS) by emergency medicine residents in patients with suspected cardiovascular diseases.

INTRODUCTION: Few studies have assessed the value and accuracy of focused cardiac ultrasound (FOCUS) performed by emergency physicians. The aim of the present study was to evaluate the diagnostic accuracy of FOCUS performed by emergency medicine residents compared to echocardiography performed by a cardiologist in emergency department (ED) patients suspected of cardiovascular disease. METHODS: The research involved a prospective observational cross-sectional study enrolling patients over 18-years old suspected of having cardiovascular disease who required an echocardiograph. For each patient, a FOCUS test was conducted by a trained emergency medicine resident. The diagnostic accuracy of ED performed FOCUS was compared to echocardiography performed by a cardiologist (gold standard) in the ED. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios were calculated for FOCUS. The agreement of EM residents and cardiologists on each finding was evaluated using Cohen's kappa coefficient with 95% CI. RESULTS: Two hundred and five patients, with a mean age of 61.0 ± 17 years (50% male), were included in this study. Agreement between FOCUS performed by an emergency medicine resident and echocardiography performed by a cardiologist in measuring ejection fraction of the left ventricle was 91% (κ = 0.85; 95% CI = 0.79-0.91). Reports of the two groups for identifying right ventricular enlargement showed 96% agreement (κ = 0.86; 95% CI = 0.82-0.90). The agreements for right ventricular pressure overload, wall motion abnormality and pericardial effusion were 100% (κ = 0.83; 95% CI = 0.77-0.89), 92% (κ = 0.83; 95% CI = 0.76-0.90), and 96% (κ = 0.83; 95% CI = 0.77-0.89), respectively. CONCLUSION: FOCUS performed by emergency medicine residents is comparable to echocardiography performed by cardiologists. Therefore, it could be a reliable tool and screening test for initial testing of patients suspected of cardiac abnormalities.

Effects of Pre-Injury Anti-Platelet Agents on Short-Term Outcome of Patients with Mild Traumatic Brain Injury: A Cohort Study.

OBJECTIVE: To determine the effects of pre-injury consumption of anti-platelet agents on the 30-day outcomes of patients with mild traumatic brain injury (TBI). METHODS: This prospective cohort study was conducted at three general hospitals in Tehran, Iran between July 2013 and July 2014. The study population included all patients with mild TBI aged over 18 years that medicated with aspirin or clopidogrel before occurring trauma. Within hospitalization, all patients were assessed with respect to in-hospital conditions especially complications and adverse events. After discharge, the individuals were followed for 30 days by telephone to assess mortality and disability using the Glasgow outcome scale (GOS). RESULTS: Of 1140 patients with mild TBI, only 135 had previously received aspirin and/or clopidogrel. The mean age was dramatically higher in those who were taking aspirin or clopidogrel (p<0.001). The patients with previously use of anti-platelets were more transferred by ambulance when compared to another group (p=0.006). The patients on anti-platelets had significantly lower GCS on admission when compared to others (p<0.001). Length of hospitalization was significantly longer in those receiving anti-platelets (p=0.003). In follow-up, 30-day mortality and disability was revealed in 2.8% of patients that received only aspirin and 7.5% in aspirin with clopidogrel and in 1.6 % of those who did not receive drugs without any significant difference between aspirin and control group (p=0.208) and significant difference in aspirin with clopidogrel group (p<0.001). CONCLUSION: The premedication by anti-platelets (aspirin and/or clopidogrel) in patients with mild TBI leads to prolonged hospital stay, and increase rate of disability. Age and on admission GCS are the independent risk factors for predicting the outcome in patients with mild TBI receiving anti-platelet agents.

Effectiveness of an interprofessional education model based on the transtheoretical model of behaviour change to improve interprofessional collaboration.

This study aimed to assess the effectiveness of an interprofessional education model (IPE) based on the transtheoretical model to improve the participants' interprofessional collaborative practice. The study was conducted in Iran using a controlled before-and-after study design. The participants (n = 91) were the residents of emergency medicine and nurses of the emergency units from two teaching hospitals affiliated to Iran University of Medical Sciences. The participants in the intervention group (n = 40) were 22 residents and 18 nurses. The control group (n = 51) consisted of 20 residents and 31 nurses. The participants were classified based on their stage of readiness to change. The interventions were two-day workshops for each stage (i.e., attitude and intention). We used the Interprofessional Collaborator Assessment Rubric (ICAR) to assess the effectiveness of the developed model. The interprofessional collaboration of the participants in the intervention and control groups was assessed at four time points before and after the intervention in the real emergency unit environment. Student's t-test and repeated measures analysis of variance (RM-ANOVA) were used to analyse the data. We used partial eta-squared (η2) for effect size calculations. The mean values of ICAR scores in the intervention and control groups were 95.63 ± 19.14 and 89.19 ± 16.11 before the intervention. The mean values of ICAR scores at 3 months after the intervention were 99.82 ± 22.32 and 88.29 ± 16.87 in the intervention and control groups, respectively. After 6 months, the mean values of ICAR scores of the intervention and control groups were 98.6 ± 23.40 and 87.98 ± 16.01, respectively. The results showed that the intervention had a medium educational effect size (partial η2 = 0.06) on performance of the participants. Our results showed that an IPE model that is tailored to the learners' stage of readiness to change improves interprofessional collaboration in the participants. The developed model could be applied for improving interprofessional collaborative performance in other IPE programmes.

Jolt accentuation and its value as a sign in diagnosis of meningitis in patients with fever and headache.

OBJECTIVES: Meningitis is an important disease among the patients being visited in Emergency Departments (EDs). There are many signs to diagnose it with different sensitivity and specificity reported in previously done studies. Current study tries to evaluate diagnostic accuracy of "Jolt accentuation" in the diagnosis (Dx.) of meningitis in patients with fever and headache. MATERIALS AND METHODS: 48 adult patients, who were referred to two teaching EDs for fever and headache and were diagnosed as suspected meningitis, were included in this prospective observational study. Demographic characteristics of patients were recorded in data sheets, as well as the results of exams including nuchal rigidity, Kernig and Brudzinski signs, and Jolt accentuation. Then, lumbar puncture (LP) was done and cerebrospinal fluid (CSF) was analyzed for each patient; pleocytosis (more than five white blood cells in high power field) were considered as meningitis. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (LR+ and LR-) of the above mentioned signs were compared to each other. RESULTS: Meningitis was proved in 33 patients (68.8% of them), according to CSF analysis. Jolt accentuation had sensitivity, specificity, PPV, NPV, LR+, and LR- of 69.6%, 33.3%, 69.6%, 33.3%, 1.02, and 0.91, respectively. Jolt accentuation had the highest sensitivity rate all of the signs mentioned above; although, it was not significant. CONCLUSION: Jolt accentuation alone cannot rule in or out the Dx. of meningitis in patients with fever and headache; LP is still recommended for these patients.

Can intravenous acetaminophen reduce the needs to more opioids to control pain in intubated patients?

AIMS: To evaluate the effect of intravenous (IV) acetaminophen on reducing the need for morphine sulfate in intubated patients admitted to the Intensive Care Unit (ICU). SETTINGS AND DESIGN: Current study was done as a clinical trial on the patients supported by mechanical ventilator. SUBJECTS AND METHODS: Behavioral pain scale (BPS) scoring system was used to measure pain in the patients. All of the patients received 1 g, IV acetaminophen, every 6 h during the 1(st) and 3(rd) days of admission and placebo during the 2(nd) and 4(th) days. Total dose of morphine sulfate needed, its complications, and the BPS scores at the end of every 6 h interval were compared. RESULTS: Totally forty patients were enrolled. The mean pain scores were significantly lower in the 2(nd) and 4(th) days (4.33 and 3.66, respectively; mean: 4.0) in which the patients had received just morphine sulfate compared to the 1(st) and 3(rd) days (7.36 and 3.93, respectively; mean: 5.65) in which the patients had received acetaminophen in addition to morphine sulfate too (P < 0.001). Cumulative dose of morphine sulfate used, was significantly higher in the 1(st) and 3(rd) days (8.92 and 3.15 mg, respectively; 12.07 mg in total) compared to the 2(nd) and 4(th) days (6.47 mg and 3.22 mg, respectively; 9.7 mg in total) (P = 0.035). CONCLUSION: In our study, IV acetaminophen had no effect on decreasing the BPSs and need of morphine sulfate in intubated patients admitted to ICU.

Direct ultrasound methods: a confirmatory technique for proper endotracheal intubation in the emergency department.

BACKGROUND AND OBJECTIVE: Early confirmation of incorrect endotracheal tube (ETT) placement is of vital importance when performing emergency airway management. No ideal confirmation technique has been proposed under all circumstances. Recently, ultrasonography was suggested as a useful tool for confirmation of correct positioning of the ETT. The aim of this study is to assess the diagnostic accuracy of ultrasonography for detection of proper ETT placement. MATERIALS AND METHODS: This prospective study was carried out in the emergency department from February to October 2012. The ultrasonography was performed by a trained senior resident in two phases: (a) as the intubation was being performed (dynamic phase) and (b) after the intubation had been completed (static phase). A linear probe was placed transversely over the cricothyroid membrane during the intubation process (dynamic phase) and on the anterior neck just superior to the suprasternal notch in the static method. Operating characteristics were calculated for both dynamic and static determination of ETT placement. RESULTS: Sixty patients were enrolled in each study group. The sensitivity, specificity, positive predictive value, and negative predictive value of the dynamic technique for determining correct endotracheal intubation were 98.1% [95% confidence interval (CI), 88.8-99.9%], 100% (95% CI, 51.6-100%), 100% (95% CI, 91.5-100%), and 85.7% (95% CI, 42-99.2%), respectively. Using the static technique, all testing characteristics listed previously were 100%. CONCLUSION: In this study, we found acceptable sensitivity, specificity, positive predictive value, and negative predictive value for prediction of tracheal ETT placement with the use of dynamic and static ultrasonography.

Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial.

OBJECTIVE: We compared the efficacy and safety of ultrasound-guided haematoma block with that of procedural sedation and analgesia in patients with acute distal radial fracture reduction pain control. METHODS: This was a randomised clinical trial on adult patients conducted in two teaching hospitals. Patients received intravenous midazolam plus fentanyl in the procedural sedation and analgesia group, and fracture site injection of lidocaine 10% in the ultrasound guided haematoma block group. We measured pain scores before reduction, during reduction and 5, 10 and 15 min after reduction by a numeric rating scale, and patient and physician satisfaction by a four-level Likert scale. Time to discharge, early adverse effects and late complications were also compared. RESULTS: We enrolled 160 patients with distal radial fracture and randomised 143 patients into two groups (after excluding 17 patients). Pain was effectively controlled in both groups. Pain scores had no statistically significant difference before and during reduction and 5 and 15 min after reduction in the procedural sedation and analgesia and ultrasound guided haematoma block groups. Patient and physician overall satisfaction were similar in the two groups. Time to discharge was significantly lower in the ultrasound guided haematoma block group. Four patients (5.5%) in the procedural sedation and analgesia group showed early adverse effects. No patient in either group showed any late complications. CONCLUSIONS: Ultrasound guided haematoma block may be a safe and effective alternative to procedural sedation and analgesia. TRIAL REGISTRATION NUMBER: 201112308104N5.

Oral oxycodone plus intravenous acetaminophen versus intravenous morphine sulfate in acute bone fracture pain control: a double-blind placebo-controlled randomized clinical trial.

OBJECTIVES: Bone fracture is a common cause of acute pain in emergency and orthopedics departments. Targeting the multifaceted mechanisms of pain with combinations of multiple analgesics (multimodal analgesia) can increase the pain control efforts efficacy and decrease the adverse effects of each medication. METHODS: One hundred and fifty-three patients with acute bone fracture were randomly allocated to two groups receiving intravenous morphine sulfate (74 patients) or oral oxycodone plus intravenous acetaminophen (79 patients). Pain scores and drugs' adverse effects were assessed 10, 30 and 60 min after treatment. RESULTS: Pain scores were similar between groups before, 30 and 60 min after medication but patients in morphine sulfate group experienced less pain 10 min after medication. Eight (10.8%) patients in morphine sulfate group and 26 (32.9%) patients in acetaminophen/oxycodone group experienced nausea that was statistically significant higher (P value = 0.001). Itching was seen in 12 (15.1%) patients of acetaminophen/oxycodone group and three (4.0%) patients of patients in morphine sulfate group (P value = 0.02). CONCLUSION: Intravenous acetaminophen plus oral oxycodone is as effective as intravenous morphine sulfate in acute pain control in emergency department but with a less desirable safety profile.

Acute pain management with intravenous 0.10 mg/kg vs. 0.15 mg/kg morphine sulfate in limb traumatized patients: a randomized double-blinded placebo-controlled trial.

BACKGROUND: We aimed to compare pain relief and safety of two doses of morphine in adult emergency department (ED) patients with acute limb trauma pain. METHODS: A total of 200 adult ED patients over 20 years of age requiring opioid analgesia were randomly allocated to two groups. Following a first dose of intravenous morphine sulfate at 0.10 mg/kg, a randomized double-blind placebo-controlled trial of intravenous morphine sulfate at 0.05 mg/kg versus the same amount of placebo was performed. Measurement of visual analogue scale pain intensity and assessment of adverse effects were performed at baseline (before morphine at 0.10 mg/kg), 30 minutes from baseline (just before study drug administration), and at 60 minutes from baseline (30 minutes after study drug). RESULTS: No significant difference was found between groups at 30 minutes from baseline. There was significant reduction in final pain after 1 hour in the 0.15 mg/kg compared to 0.10 mg/kg group (p<0.05). In addition, there was a significant improvement in the mean score of pain in the same group (p<0.05). The percent of pain reduction in the intervention and control group relative to the basic measures was 52.70% and 35.82%, respectively. Adverse effects were present in both groups; however, there was no statistically significant difference between groups. CONCLUSION: Using two doses of morphine instead of one is a safe and effective method for pain reduction in isolated limb trauma. We recommend performing a second injection of 0.05 mg/kg morphine 30 minutes after the initial standard dose of 0.10 mg/kg to decrease pain in these patients.

Ultrasound guided lumbar puncture in emergency department: Time saving and less complications.

BACKGROUND: Lumbar puncture (LP) is an essential procedure in the diagnosis and treatment of several critical situations. This procedure is routinely performed by palpating external landmarks to find the most appropriate inter-spinous space. In the current study, we compared surface landmark and ultrasound (US) guided LP in different aspects. MATERIALS AND METHODS: This clinical trial study was conducted at the emergency department (ED) of a teaching hospital from March 2009 to March 2010. Eighty patients were allocated randomly in two equal groups. In first group, LP was performed by US-guided method and in the control group by palpation of external landmarks of spinal column. Pain score, number of attempts for successful dural penetration, numbers of traumatic LP, and procedure time were compared between two groups. The performance of US-guided LP was assessed with regard to body mass index (BMI) of patients too. RESULTS: The mean of procedure time and pain scores were markedly higher in land mark group in comparison to US group (6.4 ± 1.2 and 7.4 ± 1.1 vs. 3.3 ± 1.2 and 4.4 ± 1.4 respectively). Number of attempts and number of traumatic LPs were significantly lower in US group too. In patients with different subgroups of BMI, US-guided LP showed better results and less complication when compared with surface landmark guided technique. All of these results were statistically significant. CONCLUSION: This study showed that US was able to find pertinent landmarks to facilitate the LP in patients admitted to ED and resulted in less pain and less time wasting. Moreover, patients who have high BMI may benefit more than others.

Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department.

STUDY OBJECTIVE: Emergency physicians frequently encounter shoulder dislocation in their practice. The objective of this study is to assess the diagnostic accuracy of ultrasonography in detecting shoulder dislocation and confirming proper reduction in patients presenting to the emergency department (ED) with possible shoulder dislocation. We hypothesize that ultrasonography could be a reliable alternative for pre- and postradiographic evaluation of shoulder dislocation. METHODS: This was a prospective observational study. A convenience sample of patients suspected of having shoulder dislocation was enrolled in the study. Ultrasonography was performed before and after reduction procedure with a 7.5- to 10-MHz linear transducer. Shoulder dislocation was confirmed by taking radiographs in 3 routine views as a criterion standard. The operating characteristics of ultrasonography to detect dislocation in patients with possible shoulder dislocation and to confirm reduction in patients with definitive dislocation were calculated as the primary endpoints. RESULTS: Seventy-three patients were enrolled. The ultrasonography did not miss any dislocation. The results of ultrasonography and radiography were identical and the sensitivity of ultrasonography in detection of shoulder dislocation was 100% (95% confidence interval 93.4% to 100%). The sensitivity of ultrasonography for assessment of complete reduction of the shoulder joint reached 100% (95% confidence interval 93.2% to 100%) in our study as well. CONCLUSION: We suggest that ultrasonography be performed in all patients who present to the ED with a clinical impression of shoulder dislocation on admission time. The results of this study provide promising preliminary support for the ability of ultrasonography to detect shoulder dislocation. However, further investigation is necessary to validate the results and assess the ability of ultrasonography in detecting fractures associated with dislocation.

Operating characteristics of a qualitative troponin assay for the diagnosis of acute coronary syndrome.

The troponin I serum level is widely used in acute coronary syndrome patients for their classification. The qualitative assay is faster and more available than the quantitative assay. The objective was to determine the operating characteristics of a qualitative troponin I assay compared with a quantitative method. This is a prospective observational study and patients suspected to have acute coronary syndrome were enrolled. A rapid troponin I test and a quantitative assay were carried out for each patient on arrival and 6 h after admission. A total of 262 patients were enrolled. The degree of agreement between the second rapid qualitative and quantitative troponin I was excellent (κ=0.946; 95% confidence interval, 0.903-0.989). The sensitivity, specificity, negative predictive value, and positive predictive value of the rapid qualitative troponin I test were 92.6, 100, 96.8, and 100%, respectively. In conclusion, this study reveals an excellent agreement between quantitative and qualitative bedside assays 6 h after admission in a sample of Iranian patients in the emergency department.

Accuracy of emergency physician-performed ultrasound in detecting traumatic pneumothorax after a 2-h training course.

BACKGROUND: Pneumothorax is one of the leading causes of preventable death in trauma patients. Chest radiograph has a lower sensitivity than a computed tomography (CT) scan for the diagnosis of pneumothorax. OBJECTIVES: The objective of this study is to assess the accuracy of ultrasound (US) in diagnosing post-traumatic pneumothorax using a simplified diagnostic algorithm. METHODS: This prospective study was carried out in two academic emergency departments with a combined annual emergency department census of 70 000 visits per year by convenient sampling. Emergency physicians underwent a 2-h training course using a two-step diagnostic algorithm. The trauma patients included suspected of having post-traumatic pneumothorax were evaluated by thoracic US and chest CT scan. The accuracy of US in identifying pneumothorax was measured by calculating the sensitivity, specificity, positive predictor value, and negative predictor value using CT scan as the gold standard. The performance of US was compared with chest radiograph, which was also done as a part of standard trauma care for all patients. RESULTS: From June 2009 until July 2009, a total of 153 patients were included. US had a sensitivity of 86.4%, a specificity of 100%, a positive predictor value of 100%, and a negative predictor value of 95.6%. Chest radiograph showed a sensitivity of 48.6%, a specificity of 100%, a positive predictor value of 100%, and a negative predictor value of 85.1%. The mean time to perform chest radiograph was 12 min, which was significantly higher than US, with a mean time of 2 min. All missed pneumothoraces in US evaluation were small in size. CONCLUSION: After just a 2-h training course, emergency physicians showed a good success rate in finding pneumothoraces. Thoracic US can be an easy to learn and an accurate diagnostic modality for the detection of traumatic pneumothorax in emergency departments.

Comparison of diagnostic value of conventional ultrasonography by emergency physicians with Doppler ultrasonography by radiology physicians for diagnosis of deep vein thrombosis.

OBJECTIVES: To determine sensitivity, specificity and other operating characteristics of bedside three-point compression ultrasonography performed in emergency department by emergency physicians in comparison with duplex ultrasonography. METHODS: The cross-sectional study at Rasoul-e-Akram Hospital in Tehran, Iran, prospectively evaluated 81 suspected patients of lower extremity deep vein thrombosis between March 2006 and March 2007. A trained second-year resident and one attending physician of emergency medicine evaluated the veins of all the patients with through compression ultrasonography. Then, a second-year resident of radiology assessed the patients with duplex ultrasonography. Finally, data were compared and quantitative and categorical variables were worked out along with other statistical analysis through SPSS version 16. RESULTS: The mean age of the patients was 47.2 +/- 18.6 years. When cases who lost the compressibility of at least one of their femoral or popliteal veins were considered to be positive, there were 80.2% diagnosed by compression ultrasonography and 79% by the duplex variety. Sensitivity, specificity and accuracy of the former in comparison with the latter were 85.9%, 41.2% and 84.6% respectively. CONCLUSION: Compression ultrasonography has relatively an acceptable sensitivity and accuracy level, but has low specificity in the diagnosis of deep vein thrombosis in the hands of Iranian emergency physicians. It is better to implement duplex ultrasonography whenever accessible. Otherwise, compression ultrasonography results should be compared with the results of duplex ultrasonography as soon as possible.