Atomized intranasal vs intravenous fentanyl in severe renal colic pain management: A randomized single-blinded clinical trial.

OBJECTIVES: Renal colic is one of the most common painful disorders in patients referred to the emergency department. The main purpose of this study was to compare the efficiency of two methods of intravenous (IVF) and intranasal (INF) fentanyl administration in pain management in patients with severe renal colic. MATERIALS & METHODS: This was a single-blind randomized clinical trial performed on patients with severe renal colic. The severity of pain was ≥8 based on the Numerical Rating Scale (NRS). The efficacy of pain management was compared within and between the IVF (intramuscular Ketorolac + intravenous fentanyl) and INF (intramuscular Ketorolac + intranasal fentanyl) groups at different times points. Oral consent was obtained from all the patients. RESULTS: Of 220 individuals, 96 (43.60%) were women and 124 (56.40%) were men. There were no significant differences between the two groups regarding the baseline pain severity, age, sex, history of urolithiasis and body mass index (BMI). The pain severity showed a significant reducing trend in both groups (p < 0.0001). There was also a significant difference comparing the mean pain severity between groups at different times (p < 0.0001). In each group, the severity of pain showed significant reduction compared with its prior measurement (P < 0.0001). CONCLUSION: Fentanyl is highly effective in controlling pain in patients with severe renal colic referring to the emergency department. Intranasal administration of fentanyl combination with ketorolac can be an appropriate, non-invasive, easy-to-use and fast alternative to the intravenous method to manage pain in these patients.

Blood sugar changes and hospital mortality in multiple trauma.

OBJECTIVES: Hyperglycemia with unknown mechanism plays a predictive role in determining the prognosis of multiple trauma patients. The exact time of blood sugar measurement and the role of blood sugar changes in the monitoring of these patients have not been well established. METHODS: This follow-up study was done on multiple trauma patients (>18years) with an Injury Severity Scores (ISS)>16. These patients didn't have any history of diabetes, underlying disease, or drug or alcohol use. Data collection was done by the questionnaire (checklist), and the patients were followed by the medical records. Cox regression was used to measure the effect of independent variables on the patients' hospital mortality. RESULTS: Of a total of 963 patients, 280 patients were enrolled. Of those, 202 were male (72.1%) and 78 were female (27.9%). Hospital mortality was 18 (6.4%). Cox regression analysis suggested that those who had high blood sugar 3h after admission had higher hospital mortality (P=0.04). Changes in blood sugar, ΔBS (BS 3h after admission - BS on admission), in these patients was also significantly correlated with hospital mortality (P<0.001). The multivariate model using the backward conditional method showed that ΔBS (P<0.001), international normalized ration (INR) (P<0.001), and heart rate (P=0.036) were significantly correlated with hospital mortality. CONCLUSIONS: In multiple trauma patients, blood sugar changes in the early hours of admission to the emergency department may help predict hospital mortality, but further studies are needed. Blood sugar monitoring in these patients during this time frame may be helpful in predicting these patients' outcomes. In addition, coagulopathy and tachycardia were significantly associated with hospital mortality.

Prevalence and predictors associated with severe pulmonary hypertension in COPD.

BACKGROUND: Pulmonary hypertension (PH) is one of the most common complications of COPD (chronic obstructive pulmonary disease), but its severe form is uncommon. Various factors play an important role in the occurrence and severity of pulmonary hypertension in patients. METHODS: This cross-sectional study was performed on patients with COPD referred to an emergency department over a one-year period. The tests-including complete blood count (CBC) and arterial blood gas (ABG), pulmonary functional test (PFT) and echocardiography-were performed for all patients to measure mPAP (mean pulmonary artery pressure), ejection fraction (EF) and body mass index (BMI). The prevalence of severe pulmonary hypertension and its associated factors were investigated in these patients. RESULTS: A total of 1078 patients was included in the study, of whom 628 (58.3%) were male and 450 (41.7%) were female. The mean age of the patients undergoing the study was 70.1±12.2. A total of 136 (13.7%) of them had mPAP (mm Hg)≥40mm Hg as severe pulmonary hypertension. Following multivariable analysis by using the backward conditional method, it was shown that seven variables had a significant correlation with severe PH. CONCLUSIONS: The results showed that there is an independent correlation between hypoxia, hypopnea and compensatory metabolic alkalosis, polycythemia, left ventricular dysfunction, emaciation, and cachectic with severe pulmonary hypertension. The prevalence of severe PH in these patients was 13.7%.

Shock index, modified shock index, and age shock index for prediction of mortality in Emergency Severity Index level 3.

OBJECTIVES: To elucidate the predictive capability of shock index (SI), modified SI (MSI), and age SI for mortality in patients assigned to Emergency Severity Index (ESI) level 3 patients. METHODS: This was a retrospective medical record review performed in an academic internal medicine emergency department in Kerman, Iran. All patients older than 14 years triaged to ESI level 3 were enrolled in the study. Triage time vital signs were used to calculate SI, MSI, and age SI. The primary outcome was in-hospital mortality. RESULTS: A total number of 3375 patients were enrolled in the study, in which 84 (2.5%) died during hospital stay. In the adjusted multivariate analysis, age SI, systolic blood pressure (SBP), and sex were independently associated with mortality, with P values (odds ratio [95% confidence interval]) of <.001 (1.03 [1.01-1.04]), .003 (0.97 [0.96-0.99]), and .04 (1.61 [1.01-2.59]), respectively. Receiver operating characteristic curve showed an area under curve of 0.717 for the 3-variable final model and an area under curve of 0.678 for age SI in mortality prediction. CONCLUSIONS: In ESI level 3 patients, age SI and SBP showed to be better than SI or MSI in predicting mortality. However, because their predictive capability was modest, age SI or SBP should be considered adjuncts to sort actions in favor of patients with higher risk for mortality.

Association of triage time Shock Index, Modified Shock Index, and Age Shock Index with mortality in Emergency Severity Index level 2 patients.

BACKGROUND: Shock Index (SI) is considered to be a predictor of mortality in many medical and trauma settings. Many studies have shown its superiority to conventional vital sign measurements in mortality prediction. OBJECTIVES: The objectives were to compare mortality and intensive care unit admission prediction of triage time SI, Modified SI (MSI), and Age SI with each other and with triage time blood pressure in Emergency Severity Index (ESI) level 2 patients. METHODS: A retrospective medical record review was performed in the internal medicine emergency department of a general hospital in Kerman, Iran. Triage time vital signs were used to calculate the indices. Multivarible regression analysis was used to create the final model. RESULTS: A total of 1285 patients triaged to ESI level 2 were enrolled in the study. In the multivariate analysis, SI, MSI, and Age SI were found to be the only variables independently associated with mortality, whereas none of them were associated with intensive care unit admission. Sensitivity, specificity, and area under curve in the receiver operating characteristic curve for the model including SI, MSI, and Age SI were 60.8%, 65.4%, and 0.675, respectively. Sensitivity, specificity, and area under curve did not change significantly by excluding SI, MSI, or Age SI from the final model. CONCLUSION: In nontrauma adult patients, triage time SI, MSI, and Age SI are superior to blood pressure for mortality prediction in ESI level 2. They can be used alone or in combination with similar results, but their low sensitivity and specificity make them usable only as an adjunct for this purpose.

The role of repeated brain computed tomography based on ultrasound monitoring of optic nerve sheath diameter after moderate traumatic brain injury.

OBJECTIVE: This study was conducted to evaluate the association between changes in repeated brain computed tomography (CT) findings and the optic nerve sheath diameter (ONSD) determined by ocular ultrasonography in patients with moderate blunt traumatic brain injury (TBI). METHODS: This cross-sectional study was performed on patients with moderate blunt TBI (Glasgow Coma Scale, 9-12) who were referred to the emergency department during a 1-year period. Initially, all patients underwent a brain CT scan and primary ocular ultrasonography. Patients who were candidates for a second brain CT scan under observation in the emergency department also underwent a second ocular ultrasound. The primary outcome was the progression of brain lesions on repeated brain CT scans. Logistic regression and the area under receiver operating characteristic curve (AUC) were used. RESULTS: Overall, 204 patients with a mean age of 43±13.4 years were enrolled in the study. The study detected expanding changes in brain CT scans from 29 patients (14.2%). The progression of lesion on CT scan were significantly associated with changes in the Glasgow Coma Scale. In the second brain CT scan, there were significant associations between the progression of lesion on CT scan and the increased size of the ONSD measured on both axial and coronal sections (odds ratio, 17.3-47.5; AUC, 0.88-0.93). CONCLUSION: Among patients with moderate TBI, an increase in ONSD on ocular ultrasound seems to be an appropriate criterion for repeating a brain CT scan to select a suitable therapeutic intervention.

Blood Glucose Level as a Predictor of Abnormal Brain Computed Tomography Scan Findings in Patients with Mild Traumatic Brain Injury.

Objective: This study aimed to investigate blood glucose levels in patients with brain injury caused by mild traumatic brain injury (TBI) as a foundation for determining whether these patients need a brain CT scan or not. Methods: This cross-sectional study was conducted on patients with mild TBI, who were referred to the emergency department from March 1, 2022, to September 1, 2022. After the confirmation of mild TBI by an emergency medicine specialist, blood samples were taken from the patients to measure blood glucose levels. Then a brain CT scan was performed, and blood glucose levels were compared between patients with and without CT indications of brain injury. A checklist was used to collect data, and the data were analyzed using SPSS software (version 23). Results: In the CT scans of the 157 patients included in the study, 30 patients (19.2%) had a brain injury in the CT scan. The mean blood glucose level was significantly higher in patients with brain injury, especially in the presence of vertigo and ataxia, than patients without brain injury in the CT scan (p<0.0001). There was a significant positive correlation between age and blood glucose level (r=0.315, p<0.0001). Conclusion: Patients with mild TBI who had signs of brain injury in the CT scan had significantly higher blood glucose levels than patients with normal CT scan findings. Although indications for performing a brain CT scan are usually based on clinical criteria, blood glucose levels can be helpful in determining the requirement for a brain CT scan in patients with mild TBI.

Reverse shock index (RSI) as a predictor of post-intubation cardiac arrest (PICA).

BACKGROUND: Endotracheal intubation (ETI) in critically ill patients is a high-risk procedure due to the increased risk of cardiac arrest, and several factors may predict poor outcomes in these patients. The aim of this study was to investigate the role of some factors, especially newly introduced vital signs such as the reverse shock index (RSI), in predicting post-intubation cardiac arrest (PICA) in critically ill adult patients. METHODS: This cross-sectional study was conducted on critically ill patients over 18 years of age who were admitted to the emergency department (ED) and underwent ETI within 1 year. Patients who developed PICA and those without this event were included in the study, and their features were compared. The primary outcome was cardiac arrest. RESULTS: Of 394 patients, 127 patients were included, of whom 95 (74.8%) developed PICA, and 32 (25.2%) did not experience cardiac arrest after intubation. In multivariate analysis, age, RSI, oxygen saturation, and total bilirubin were significantly associated with PICA. In addition, patients with RSI < 1 had a significantly higher risk of developing PICA (odds ratio = 5.22, 95% CI 1.83-14.86, p = 0.002). The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for predicting PICA were 51.11%, 83.33%, 90.2%, 36.23%, and 59.17%, respectively. The ROC curve for RSI showed an area under the curve (AUC) of 0.66. CONCLUSION: RSI may be useful in predicting PICA with higher diagnostic accuracy compared to the shock index. Furthermore, advanced age, hypoxia, and hyperbilirubinemia may increase the risk of PICA in patients admitted to the ED.

Assessment of the relationship between miR-499C/T (rs3746444) polymorphism and lung carcinoma in Iranian population; a case-control study.

Introduction: Lung carcinoma is characterized by uncontrollable division of respiratory system cells with detrimental and lethal consequences on human health. Critical roles of microRNAs (miR) are scientifically approved in biological and pathological pathways, such as the role of miR-499 (rs3746444) in lung carcinomas. Thus, in this case-control investigation, we aimed to assess the probable relationship between miR-499C/T variant and the occurrence of lung carcinoma in Iranian population for the first time. Methods: Genotype of miR-499 polymorphism was described by the Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP) assay in patients and healthy individuals. Following definite diagnosis of lung carcinoma, the blood samples were collected, and the DNA extraction was performed by Salting-Out method. Finally, data were analysed by SPSS (v. 20) and the significant level was considered p-value<0.05. Results: Statistically, the frequency of combined genotypes of CC+CT were 83.33% and 35% and TT+CT were 100% and 92% in case and control individuals, respectively. Also, individuals with genotypes of TC (OR: 3.08, CI95%: 3.03-3.17, p<0.0001), TC+CC (OR: 0.10, CI95%: 0.05-0.23, p<0.0001), CC (OR: 0, CI95%: 0.00-0.60, p=0.0214), and TC (OR: 0.07, CI95%: 0.030.15, p<0.0001) represented statistically significant (p<0.05) differences lung carcinoma than those with TT, TT, TT+TC, and TT+CC genotypes, respectively. The frequency of miR-499C (78.5%) and miR-499T (21.5%) alleles were also statistically significantly (p<0.05) difference associated with lung carcinoma in patients than controls. Conclusion: In this study, a possible relationship among miR-499C/T polymorphism and lung carcinoma was detected in Iranian population. Since this study was conducted for the first time, thus other supplementary assessments are needed for definite conclusion.

Do Avoid Unnecessary Procedure in A Trauma Patient? A Case Report.

Endotracheal intubation is more commonly performed in the right main bronchus; however, it may rarely be performed in the left side. A 52-years-old man was brought to the emergency department by emergency medical services (EMS) after multiple trauma injury. There was a decrease in the right lung's sound. Lung computed tomography (CT) scan revealed total pulmonary atelectasis. This scan was at the time that patient did not mention any recent history or complaint of pulmonary problems or diseases. In CT scan, we observed the white lung in the right side, the trachea which was deviated to the right, and the collapse-consolidation of the right lung was seen. The endotracheal tube image was observed in the left main bronchus which is a rare phenomenon. Decreasing of the right lung sound may not always be due to pneumothorax or hemothorax in trauma patients. In these patients, the rare phenomenon of left lung intubation should be considered as well. Left lung intubation may occur because of the lesion presence in the right lung.

Relationship between End-Tidal CO2 (ETCO2) and Lactate and their Role in Predicting Hospital Mortality in Critically Ill Trauma Patients; A Cohort Study.

OBJECTIVE: To investigate the relationship between end-tidal CO2 (ETCO2) and serum lactate and their predictive role in hospital mortality of intubated multiple trauma patients. METHODS: In a cohort study, intubated multiple trauma patients who referred to the emergency department for two years were enrolled. After orotracheal intubation using Rapid Sequence Intubation (RSI) method, ETCO2 was immediately measured by capnography. Blood samples for serum lactate measurements were sent to the laboratory, immediately after intubation. Data collection was done using the questionnaire, and the patients were followed using their medical records. RESULTS: Totally, 250 patients were included with hospital mortality of 14.8% (n=37). Using Pearson correlation, an inverse relationship was noticed between serum lactate and ETCO2, immediately (p<0.0001, r=-0.65). In adjusted multivariate analysis, three variables including heart rate (HR), serum lactate and ETCO2 showed a significant relationship with hospital mortality, respectively (p=0.007, p=0.009, p=0.023, respectively). Receiver operating characteristic curve illustrated an area under the curve (AUC) of 0.93, 0.96, and 0.97 for HR, lactate, and ETCO2, respectively. CONCLUSION: ETCO2 post-intubation and serum lactate may be considered as prognostic factors for intubated multiple trauma patients referring to the emergency department, which can give the clinician an important clue in early prediction of the hospital mortality.

A comparative study on the diagnostic validity of three scoring systems in the diagnosis of acute appendicitis in emergency centres.

BACKGROUND: Considering the inconsistencies on the validity scoring systems in the diagnosis of acute appendicitis, our aim was to compare the accuracy of the three Anderson, Alvarado and Alvarado + CRP scoring systems in the diagnosis of patients with suspected acute appendicitis. METHODS: This was a prospective observational study performed on patients 15-65 years complained of abdominal pain in the RLQ with a high clinical suspicion of acute appendicitis within two years. The scoring systems of Anderson, Alvarado, and Alvarado + CRP were recorded using a pre-prepared questionnaire by a senior emergency medicine assistant. Acute appendicitis was confirmed based on the histopathologic findings. Written informed consent was obtained from all the patients before entering the study. RESULTS: 200 patients were enrolled in the study. In 159 cases diagnosed with appendicitis based on histopathological findings, Anderson, Alvarado, and Alvarado scoring systems were able to identify 121, 152, and 147 cases respectively. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 77%, 19%, 78%, 17 and 64% in Anderson, 95%, 7%, 75%, 30% and 77% in Alvarado, and 92%, 7%, 79%, 20%, and 75% in Alvarado + CRP scoring systems, respectively. CONCLUSION: Anderson scoring system had lower diagnostic accuracy than the Alvarado system. The role of CRP as an adjunct test to increase the accuracy of the Alvarado scoring system in the diagnosis of acute appendicitis has been under question. Given the inconsistent results of the scoring systems in the diagnosis of acute appendicitis, there is a need to develop a more precise clinical-paraclinical scoring system for this condition.

The Correlation of Serum Chloride Level and Hospital Mortality in Multiple Trauma Patients.

INTRODUCTION: Electrolyte disorder is a prevalent complication in multiple trauma patients; nevertheless, the role of chloride has been rarely addressed in literature when evaluating serum electrolytes. OBJECTIVE: The present study was conducted to determine the correlation between serum chloride changes and hospital mortality in multiple trauma patients. METHOD: The present cross-sectional study measured serum chloride levels in 100 multiple trauma patients upon their admission to the emergency department and 24 hours later. All these patients were followed up in terms of hospital mortality using their medical records. Exact logistic regression was used to measure the effects of independent variables on hospital mortality in the patients. RESULTS: Hospital mortality was found to be 15 (15%), and the mean serum chloride level to be 106.37±4.53 mmol/l upon admission and 112.18±6.16 mmol/l 24 hours later. Although the univariate analysis suggested that serum chloride levels were independently associated with mortality 24 hours after admission (P=0.005), this correlation was insignificant in the multivariate analysis. CONCLUSION: The present study rejected the hypothesis suggesting the potential role of serum chloride levels in predicting hospital mortality in multiple trauma patients.

The Value of Red Cell Distribution Width (RDW) and Trauma-Associated Severe Hemorrhage (TASH) in Predicting Hospital Mortality in Multiple Trauma Patients.

OBJECTIVE: To investigate the role of red cell distribution width (RDW) in comparison with Trauma-Associated Severe Hemorrhage (TASH) system in predicting the mortality of multiple trauma patients, referred to the hospital emergency department. METHODS: This follow-up study was conducted on multiple trauma patients (age ≥ 18 years) with Injury Severity Scores (ISS) of ≥ 16, who were referred to the emergency department from March 1, 2017, to December 1, 2017. First, all patients were evaluated based on the Advanced Trauma Life Support (ATLS) guidelines, and then, their blood samples were sent for RDW measurements at baseline and 24 hours after admission. The ISS, Revised Trauma Score (RTS), and TASH were measured in the follow-ups and recorded by third-year emergency medicine residents. Hospital mortality was considered as the outcome of the study. RESULTS: In this study, 200 out of 535 multiple trauma patients were recruited. The frequency of hospital mortality was 19 (9.5%). In the univariate analysis, there was no significant relationship between hospital mortality and RDW at baseline, RDW on the first day, and ΔRDW (RDW at baseline - RDW on the first day), unlike ISS, RTS, TASH (p=0.97, P= 0.28, and p=0.24, respectively). On the other hand, in the multivariate analysis, ISS, RTS, and TASH showed a significant relationship with hospital mortality. The greatest area under the ROC curve (AUC) was attributed to TASH and RTS systems (0.94 and 0.93, respectively). CONCLUSION: TASH scoring system, which was mainly designed to predict the need for massive transfusion, may be of prognostic value for hospital mortality in multiple trauma patients, similar to ISS and RTS scoring systems.

The relationship between blood lead level and the severity of abdominal pain in opioid-addicted patients during a hospital outbreak.

An increase in the incidence of abdominal pain in opioid abusers over a period of time increased the suspicion of lead poisoning. The severity of abdominal pain and its relationship with blood lead level (BLL) were investigated during a hospital outbreak. This was a descriptive, cross-sectional study on opioid-addicted patients presenting with abdominal pain. Pain severity was measured based on the numerical rating scale (NRS). Blood lead and serum uric acid levels were determined. The presence of basophilic stippling was sought in the peripheral blood smear. Also, the X-ray was performed to assess abdominal cavity. Of 239 patients, 160 opioid addicts presenting with abdominal pain participated in the study. There were significant associations between the severity of abdominal pain and the type of opioid, the route and, duration of opioid consumption, the presence of basophilic stippling in peripheral blood smear and radio-opaque opioids in abdominal X-ray, as well as BLL and serum uric acid level (P < 0.0001). Opium abuse is a common cause of lead poisoning in Iran. The patients with lead poisoning may present with abdominal pain. The severity of abdominal pain significantly correlated with BLL. Continuous screening of BLL is recommended in opioid abusers.