A Multicenter Diagnostic Accuracy Study on Prehospital Stroke Screening Scales.

BACKGROUND: Stroke is one of the most common debilitating diseases. Although effective treatment is available, a golden time has been defined in this regard. Therefore, prompt action is needed to identify patients with stroke as soon as possible, even in the pre-hospital stage. In recent years, several clinical scales have been introduced for this purpose. We performed the present study to examine the accuracy of eight clinical scales in terms of stroke diagnosis. METHODS: This multicenter diagnostic accuracy study was conducted in 2019. All patients older than 18 years who were admitted to the emergency department (ED) and underwent brain magnetic resonance imaging (MRI) for a suspected stroke were eligible. All data were gathered through a pre-prepared checklist consisting of three sections, using the clinical records of the patients. The first section of the checklist included basic characteristics and demographic data. The second part included physical examination findings of 19 items related to the 8 scales. The third part was dedicated to the final diagnosis based on the interpretation of brain MRI, which was considered the gold standard for the diagnosis of acute ischemic stroke (AIS) in the current study. RESULTS: The data from 805 patients suspected of stroke were analyzed. In all, 463 patients (57.5%) were male. The participants' age was 6-95 years with a mean age of 66.9 years (SD = 13.9). Of all the registered patients, 562 (69.8%) had an AIS. The accuracy of screening tests was 63.0% to 84.4%. The sensitivity and specificity were 71.9% to 95.7% and 46.5% to 82.8%, respectively. Among all the screening tests, Los Angeles Pre-Hospital Stroke Screening (LAPSS) had the lowest sensitivity, and Medic Prehospital Assessment for Code Stroke (Med PACS) had the highest sensitivity. In addition, Pre-Hospital Ambulance Stroke Test (PreHAST) had the lowest specificity and LAPSS had the highest specificity. CONCLUSION: Based on the findings of the present study, highly sensitive tests that can be used in this regard are Cincinnati Prehospital Stroke Scale (CPSS), Face-Arm-Speech-Time (FAST), and Med PACS, all of which have about 95% sensitivity. On the other hand, none of the studied tools were desirable (specificity above 95%) in any of the examined cut-offs.

Medical treatment for paradoxical and saddle pulmonary embolism in a young man with patent foramen ovale and coronavirus disease 2019.

Here, we reported a 32-year-old male presenting to the emergency department with respiratory symptoms and coronavirus disease 2019 (COVID-19) diagnosis. Multiple thrombi were detected in his heart and inferior vena cava, probably due to former deep-vein thrombosis. The presence of patent foramen ovale and high pressure of the right heart caused the clots to enter the heart's left side. He received fibrinolytics, and his condition improved with no need for surgery. Hence, patients with impending paradoxical embolism may take advantage of medical treatment, such as fibrinolytics. Moreover, COVID-19 appears to be associated with a strong thrombotic tendency, and anticoagulants might be helpful.

The validity of recognition of stroke in the emergency room (ROSIER) scale in the diagnosis of Iranian patients with acute ischemic stroke in the emergency department.

OBJECTIVES: In this study, we aimed to investigate the accuracy of recognition of stroke in the Emergency Room (ROSIER) Scale in the diagnosis of patients with acute ischemic stroke (AIS) transferred to the emergency department (ED). METHODS: The present study was a multicenter study. Records from patients suspected of stroke, who referred to the ED were reviewed. Demographic, clinical, and diagnostic data were extracted and then entered in checklists. ROSIER Scale was used to evaluate the possible diagnosis in this study. The definitive diagnosis of a stroke was made based on neurologist's assessment and clinical and neuroimaging findings, mainly brain magnetic resonance imaging (MRI). Receiver operating characteristic (ROC) curve analysis was conducted for assessing the accuracy of ROSIER in discrimination of stroke. RESULTS: The data of 356 suspected stroke patients were analyzed. Of all, 186 patients (52.2%) were male, and the mean age was 65.2 (standard deviation = 14.0) years ranging from 26 to 95 years. One hundred and fifty-one patients (42.4%) had AIS based on the final diagnosis. The area under the ROC curve was 0.85. The best cutoff point for ROSIER scale was ≥1 with a sensitivity of 85.4% (95% confidence interval [CI]: 78.8, 90.6%) and specificity of 65.8% (95% CI: 58.9, 72.3%). CONCLUSION: Based on the findings, although the best cutoff point was the same as the original (derivation) study, its sensitivity (85.4% vs. 92%) and specificity (65.8% vs. 86%) were considerably lower.

Accuracy of prehospital ambulance stroke test in terms of diagnosis of patients with acute ischemic stroke: A multi-center study.

Background: Andsberg et al. have recently introduced a novel scoring system entitled "PreHospital Ambulance Stroke Test (PreHAST)", which helps to early identification of patients with acute ischemic stroke (AIS) even in prehospital setting. Its validity has not been assessed in a study yet, and the purpose of this study was to assess this scoring system on a larger scale to provide further evidence in this regard. Methods: This was a cross-sectional multi-center accuracy study, in which, sampling was performed prospectively. All patients over 18 years of age admitted to the emergency department (ED) and suspected as AIS cases were included. All required data were recorded in a form consisting of 3 parts: baseline characteristics, neurological examination findings required for calculating PreHAST score, and the ultimate diagnosis made from interpretation of their brain magnetic resonance imaging (MRI). Results: Data from 805 patients (57.5% men) with the mean age of 67.1 ± 13.6 years were analyzed. Of all the patients presenting with suspected AIS, 562 (69.8%) had AIS based on their MRI findings. At the suggested cut-off point (score ≥ 1), PreHAST had a specificity of 46.5% [95% confidence interval (CI): 40.1%-53.0%) and a sensitivity of 93.2% (95% CI: 90.8%-95.2%). Conclusion: According to the findings of our study, at the suggested cut-off point (score ≥ 1), PreHAST had 93.2% sensitivity and 46.5% specificity in detection of patients with AIS, which were somewhat different from those reported in the original study, where 100% sensitivity and 40% specificity were reported for this scoring system.

Comparing the Therapeutic Effects of Dexamethasone-Metoclopramide with Ketorolac in Relieving Headache in Patients with Acute Migraine Attacks Presenting to the Emergency Department.

INTRODUCTION: Migraine is a frequent chief complaint of patients in the emergency department. A wide range of treatments are used for acute migraine. OBJECTIVE: This study aimed to compare the therapeutic effects of a combination of metoclopramide + dexamethasone with those of ketorolac for treatment of acute migraine in the emergency department. METHOD: This quasi-experimental study enrolled patients identified as migraine headache cases admitted to the emergency departments of Shohadaye Tajrish and Sina hospitals, Tehran, Iran. The patients were divided into two groups and treated with either 8 mg Dexamethasone + 10 mg Metoclopramide or 60 mg ketorolac, and then compared regarding the rate of pain control based on visual analogue scale (VAS) on arrival and 1 and 2 hours afterward. RESULTS: Overall, 86 patients were recruited, of whom 50 were male (58.1%). Their mean age was 37.6 ± 10.3 years. Thirty-five (40.7%) were in the ketorolac group and 51 (59.3%) were in the dexamethasone + metoclopramide group. Treatment success was defined as a reduction of at least 3 points in pain severity in comparison to the admission time. One hour after administration of medications, the reported pain intensity was 4.7 ± 2.0 and 6.2 ± 2.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. By the second hour, pain intensity was 3.4 ± 1.2 and 2.9 ± 1.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. The two groups did not show a significant difference in terms of the reported pain at this time (p= 0.04). CONCLUSION: Based on our findings, the pain reduction time was relatively shorter for ketorolac in acute migraine, but the final response was identical in the two groups.

Social media; resolving tunnel vision in practicing medicine.

BACKGROUND: With the emergence of social media, physicians who use social media, including emergency medicine physicians, have shared their experiences with their colleagues instead of working alone and keeping their experiences to themselves. OBJECTIVE: This study aimed to evaluate the rate and type of use of electronic online sources and social media, in order to improve learning and education among emergency medicine residents. METHODS: This was a cross-sectional study carried out from September 2015 until August 2016 on emergency medicine residents of two main medical universities of Tehran, Iran. A questionnaire was prepared by reviewing the existing studies and asking emergency medicine professors inside and outside Iran for opinions. Census sampling method was applied and all emergency medicine residents were included. The gathered data were analyzed using statistical tests of chi square, Independent-samples t-test and Pearson's correlation coefficient via SPSS version 21. RESULTS: Seventy three residents with the mean age of 34.2±5.2 years participated in this study (60.3% female). Smart phone is the most important tool they use for connecting to the Internet. About 30% use the Internet for about 1-2 hours a day. In half of these participants less than 25% of this time is spent on something related to their academic field of study. The correlation of sex (p=0.034) and age (p=0.049) with extent of using social media related to the academic field of study were significant. Other analytical analyses were not statistically significant (p>0.05). CONCLUSION: In summary, the findings of current study showed that despite sufficient access to proper technology, use of social media and online sources by high majority of the studied EM residents regarding improvement of their learning and educational level is very limited.

The Cost of Leaving the Emergency Department without Notice; a Cross-sectional Study.

INTRODUCTION: Leaving the hospital without notice is among the problems that can inflict financial and non-financial burdens on the health care system of a country. OBJECTIVE: The present study was carried out with the aim of evaluating the prevalence of leaving without notice cases in the emergency department (ED) of one of the major teaching hospitals of Tehran affiliated with Shahid Beheshti University of Medical Sciences and calculating the direct costs resulting from it. METHODS: This study was a retrospective cross-sectional one carried out during 1 year from 2016 to 2017 in one of the teaching hospitals of Tehran affiliated with Shahid Beheshti University of Medical Sciences. Sampling was performed via census method and the study population consisted of the profiles of all the patients who had left the hospital without notice or checking out after being admitted to the hospital. To gather the required data for this study, a checklist consisting of questions regarding sex, age, insurance coverage, and the amount of money they owed the hospital was used. Statistical analysis was performed using the software IBM Statistics for Windows v22 and P-value<0.05 was considered significant. RESULTS: Out of the total of 39946 patients visiting the ED of the studied hospital during 1 year, 1692 (4.2%) had left the hospital without checking out. Below 30 years age range was the most common age range with 46.9% (794 patients) and 72.9% of the patients leaving without notice were men. Based on the findings obtained, male patients without insurance coverage had attempted to leave the hospital without notice more than others (p<0.001). The total cost inflicted by leaving without notice throughout the studied year was 1,755,286,279 Rials, which is equal to 0.0059 of the total annual income of the ED. CONCLUSION: Throughout the year this study was performed, a total of 1.2% of all the visitors of the ED of a hospital affiliated with Shahid Beheshti University of Medical Sciences left the hospital without notice or checking out, which inflicted a considerable cost on the ED.

Upper Gastrointestinal Bleeding as Delayed Presentation of Traumatic Diaphragmatic Hernia; a Case Report.

INTRODUCTION: Traumatic diaphragmatic hernia (TDH) is one of the critical complications resulting from penetrating chest trauma. The rate of undiagnosed TDH equivocates 12-60%. The significant part of complications happens 1-4 years after the primary damage. Here, we report a case of delayed TDH presented with upper gastrointestinal bleeding (GIB) as an excuse to discuss this issue. CASE PRESENTATION: The patient was a 35-year-old man, admitted with objection of abdominal pain. A nasogastric tube was inserted and fixed that resulted in drainage of about 500cc dark blood. He was candidate for emergent endoscopy due to upper GIB. During resuscitation measures, he suddenly developed respiratory distress that could not be justified by upper GIB alone. Therefore, bedside sonography discovered some soft tissue apart from lung tissue in the left hemithorax. After performing diagnostic measures, with diagnosis of diaphragmatic herniation and strangulation he underwent emergent surgery. CONCLUSION: Small diaphragmatic lesions, which usually result from stab wounds, may develop into larger injuries if left untreated and they might lead to a diaphragmatic hernia with a potential risk of early or late complications and mortality. One of the rare complications is GIB, which should be considered in a patient with past history of trauma and presentation of GIB.

An Epidemiologic Study on Emergency Department Mortality.

INTRODUCTION: Epidemiologic evaluation generally starts with recording the raw data regarding mortality, and healthcare managers should have a national plan executed for this purpose. OBJECTIVE: The present study was planned and performed with the aim of epidemiologically evaluating mortality cases among patients admitted to the emergency department (ED) of a major hospital in Tehran, Iran in order to plan and provide proper equipment for decreasing the mortality of patients. METHOD: This cross-sectional study was performed in Shohadaye Tajrish Hospital, Tehran, Iran. All cases of mortality, recorded in the ED of the studied hospital from 20 March 2016 until 21 June 2016, were included in the study. A checklist was prepared for gathering data and the clinical profiles of all the considered patients were reviewed. Using this checklist, demographic data, chief complaint, history of underlying disease, pathologic findings of imaging modalities, and cause of death were extracted from the patients' profiles. RESULT: Over the mentioned period of time, in total, the data of 8420 admissions to the ED were recorded. Out of these patients, 76 (0.9%) had died, the mean age of whom was 67.66 ± 21.40 years. Based on these findings, among patients who had presented to the ED, 42.1% died due to the complications of heart attack and 13.2% died from complications caused by cancer. CONCLUSION: Based on the findings of the present study, cardiovascular complications were the most leading cause of mortality in the studied ED and complications resulting from malignancy were in the second place. Trauma and accidents leading to intracranial hemorrhage were in the next places.

Pregnancy Screening before Diagnostic Radiography in Emergency Department; an Educational Review.

In modern medical practice, there is an increasing dependence on imaging techniques in most medical specialties. Radiation exposure during pregnancy may have serious teratogenic effects to the fetus. Therefore, checking the pregnancy status before imaging women of child bearing age can protect against these effects. Lack of international regulations and standard protocols exposes the patient to unexpected fetal radiation effects and the health professionals to medicolegal suits. Recently, the American Academy of Radiology and the European community of Medical Ionizing Radiation Protection released national guidelines regarding pregnancy screening before imaging potentially pregnant females. However, different methods of pregnancy screening exist among different radiology centers. This review aims to discuss the most recent guidelines for imaging females of childbearing age and highlight the need for an international regulation to guide pregnancy screening before diagnostic radiation exposure.

Intravenous caffeine citrate vs. magnesium sulfate for reducing pain in patients with acute migraine headache; a prospective quasi-experimental study.

BACKGROUND: Current evidence suggests that intravenous magnesium sulfate might be effective for reducing migraine pain. In a recent pilot study, we showed that intravenous caffeine citrate could reduce the severity of migraine headache. The objective of this study is to investigate the efficacy of intravenous caffeine citrate vs. magnesium sulfate for management of acute migraine headache. METHODS: We conducted a prospective quasi-experimental study from January until May 2016 in two educational medical centers of Shahid Beheshti University of Medical Sciences (Shoahadaye Tajrish Hospital and Imam Hossein Hospital), Tehran, Iran. The study included patients who were referred to the emergency department and met the migraine diagnosis criteria of the International Headache Society. Patients were allocated into 2 groups receiving either 60 mg intravenous caffeine or 2 g intravenous magnesium sulfate. The pain scores, based on the visual analog scale, were recorded on admission, as well as one and two hours after receiving the drug. A Chi-Square test and student t-test were used for analysis of baseline characteristics. A Mann-Whitney U test and Wilcoxon singed rank test were used to analyze differences in the visual analogue scale (VAS) score between and within the groups respectively. RESULTS: In total, 70 patients (35 patients in each group) with the mean age of 33.1 ± 11.3 years were included (64.3% female). For the Caffeine citrate group, the median pain score decreased from 9.0 (2.0) to 5.0 (4.0) after one hour and to 3.0 (4.0) after two hours. For the magnesium sulfate group, the pain score decreased from 8.0 (2.0) to 2.0 (2.0) after one hour and to 0.0 (1.0) after two hours. Both intravenous caffeine citrate and intravenous magnesium sulfate reduced pain scores significantly but the magnesium sulfate group showed more improvement than the Caffeine citrate group after one hour (P < 0.001) and after two hours (P < 0.001). CONCLUSIONS: It is likely that both intravenous caffeine and intravenous magnesium sulfate can reduce the severity of migraine headache. Moreover, intravenous magnesium sulfate at a dose of 2 g might be superior to intravenous caffeine citrate 60 mg for the short term management of migraine headache in emergency departments.

The Prevalence of Personality Disorders among Emergency Nurses Based on MMPI-2 Questionnaire; a Cross-sectional Study.

INTRODUCTION: The prevalence of behavioral disorders is substantially higher in stressful working environments such as emergency departments. The present study aimed to evaluate the prevalence of personality disorders among emergency nurses. METHODS: In the present epidemiologic study, the prevalence of personality disorders among emergency nurses of three educational hospitals, Tehran, Iran, were evaluated based on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) test. After the questionnaires were filled, data were entered to a special software for MMPI-2 test and the final result was interpreted based on the opinion of a clinical psychologist. Findings were reported using descriptive statistics. RESULTS: 102 emergency nurses with the mean age of 30.2 ± 5.6 years were enrolled (100% female; 100% with master's degree in nursing). The mean working time and experience of studied nurses were 210.8 ± 47.9 hours/month (130-370) and 4.1 ± 3.6 years (1-20), respectively. 32 (31.4%) cases showed symptoms of personality disorders The most common personality disorder detected in this study was somatization with 8.8%, hysteria with 6.9% prevalence, and pollyannaish with 4.9%. Among the studied factors only recent history of unpleasant event has significant correlation with existence of personality disorders (p = 0.015). CONCLUSION: The present study showed that somatization, hysteria, and pollyannaish were the most common personality disorders among the emergency nurses. History of an unpleasant event in the past year was the only effective factor in existence of personality disorders in the studied nurses.

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.

Effectiveness of the Concurrent Intravenous Injection of Dexamethasone and Metoclopramide for Pain Management in Patients with Primary Headaches Presenting to Emergency Department.

INTRODUCTION: Headache is a common reason for visiting emergency departments, and pain control is a major therapeutic goal in patients with headaches. OBJECTIVE: The present study was conducted to examine the effectiveness of the concurrent intravenous administration of dexamethasone and metoclopramide in pain control in patients presenting to emergency departments with complaints of primary headache. METHODS: This quasi-experimental study examined patients with moderate to severe headache attacks presenting to emergency departments. An 8-mg dose of dexamethasone and a 10-mg dose of metoclopramide were intravenously administered to the patients. The degree of headache was measured and recorded using the Numeric Rating Scale (NRS) upon admission and one hour and two hours after the injection. RESULTS: A total of 51 patients with a mean age of 38.3±10.5 years participated in the study. The patients' mean pain score was 8.4±1.3 upon admission and reduced to 6.2±2.3 one hour after the administration of the medication and to 3.1±2.9 two hours after the administration, suggesting significant reductions on both occasions (P<0.05). The therapeutic success was 39.2% one hour after the administration of the medication and 84.3% two hours after the administration. CONCLUSION: Based on these findings, the concurrent administration of dexamethasone and metoclopramide appears to affect the control of headache intensity in patients with primary headaches presenting to emergency departments.

Atypical Presentation of Massive Pulmonary Embolism, a Case Report.

The lack of pathognomonic signs and symptoms makes the diagnosis of pulmonary embolism (PE) difficult. Here, we report a case of a 42-year-old man presented to the emergency department with worsening epigastric pain, hypotension, frank bradycardia, and final diagnosis of PE. Although previous studies have indicated that abdominal pain was observed in 6.7% of patients with PE, the exact reason for abdominal pain in PE still remains unknown. Tension on the sensory nerve endings, hepatic congestion, and distention of Gilson's capsule are some of the possible mechanisms of abdominal pain in PE. We conclude that emergency physicians should pay more attention to PE, which is an important differential diagnosis of shock state. In this context, rapid ultrasound in shock (RUSH) should be considered as a vital sign that needs to be evaluated when recording the history of patients presented to the emergency department with signs and symptoms of shock.