Epidemiological Aspects of Opioid Poisoning in Northern Iran: A Registry-Based Clinical Study.

Opioids are a class of drugs that are commonly used to manage pain due to their analgesic and sedative effects. However, the high consumption of opioids in the community has led to an increase in the incidence of overdoses and poisonings caused by various types of these drugs, whether intentional or unintentional. Therefore, comprehending the epidemiological features of patients experiencing opioid poisoning is crucial. We decided to investigate various epidemiological aspects of patients with opioid poisoning in the Mazandaran province, located in northern Iran, during the period of 2020 to 2021. The present investigation was conducted as a descriptive cross-sectional study, wherein we collected data on patients registered in the Mazandaran Registry Center of Opioid Poisoning (MRCOP) who had a history of using any kind of opioid. We collected information on various parameters, including patient demographics, the type of opioid consumed, the mode of consumption, and clinical outcomes. A total of 240 patients were initially registered at the registry center. However, 17 cases were excluded with personal consent, and eventually, a total of 223 patients were included in the investigation. The majority of the patients 70.9% (n = 158) were male, and the average age was 34.4 ± 16.55 years. The most common cause of poisoning reported in our study was intentional, which was mainly due to a suicide attempt. Furthermore, the most prevalent type of opioid consumed was methadone. The most frequently observed symptoms of poisoning among the patients were drowsiness, a decreased level of consciousness, and reduced arterial oxygen saturation levels. Based on the results of our study, several factors were found to be significant in methadone poisoning, including addiction, age, gender, suicide attempt, and a history of psychiatric disorder. These findings highlight the need for public education and awareness campaigns on the risks associated with opioid use, particularly methadone.

C-Reactive Protein and D-dimer as Prognostic Markers for Clinical Outcomes in Patients with Mild Traumatic Brain Injury: A Cross-Sectional Study.

Objective: To investigate the use of prognostic markers such as C-reactive protein (CRP) and D-dimer for clinical outcomes in patients with mild traumatic brain injury (TBI). Methods: This cross-sectional study was conducted on patients with mild head trauma who were admitted to the Emergency Department of Imam Khomeini Hospital (Sari, Iran). Data were collected from 2018 to 2019. Age, sex, the time of injury hospitalization, length of hospitalization, length of unconsciousness, blood pressure, heart rate, respiratory rate, and concomitant symptoms were all recorded using a pre-designed checklist. The patient's Glasgow Coma Scale (GCS), CRP, and D-dimer were also measured. Moreover, all patients underwent CT scan. Results: This study included 74 patients with TBI. The mean age of the participants was 36.92±3.54. The mean CRP and D-dimer values were 5.69±0.77 and 0.58±0.11 in these patients, respectively. At the cut-off point of 11.50 for CRP, the sensitivity and specificity to detect the pathological lesions in CT scan were 75% and 95.50%, respectively (p<0.001). Additionally, with a D-dimer cut-off point of 0.90, the sensitivity and specificity for diagnosing pathological lesions in CT scan were 100% and 98.50%, respectively (p<0.001). Conclusion: In general, the CRP and D-dimer levels of patients with mild TBI (GCS≥13) can be assessed to protect against CT-induced radiation exposure and subsequent disorders; if they do not exhibit clinical signs to increase the risk of adverse brain damage, such as reduced level of consciousness, drowsiness, and prolonged periods of unconsciousness.

Aldolase C Profiling in Serum after Mild Traumatic Brain Injury: A Prospective Cohort Study.

BACKGROUND: After a traumatic brain injury (TBI), in addition to clinical indices, the serum level of neurological biomarkers may provide valuable diagnostic and prognostic information. The present study aimed to investigate the aldolase C (ALDOC) profile in serum for early diagnosis of brain damage in patients with mild TBI (mTBI) presented to the Emergency Department (ED). METHODS: A single-center prospective cohort study was carried out in 2018-2019 at Imam Khomeini Hospital affiliated with Mazandaran University of Medical Sciences, Sari, Iran. A total of 89 patients with mTBI were enrolled in the study. Blood samples were taken within three hours after head trauma to measure ALDOC serum levels. Brain CT scan was used as the gold standard. Statistical analysis was performed using the Kruskal Wallis, Mann-Whitney U, and Chi square tests. The receiver-operating characteristic (ROC) curve plot was used to determine the optimal cutoff point for ALDOC. The sensitivity and specificity of the determined cutoff point were calculated. P values less than 0.05 were considered statistically significant. RESULTS: Of the 89 patients, the CT scan findings showed a positive TBI in 30 (33.7%) of the patients and in 59 (66.3%) a negative TBI. The median ALDOC serum level in the patients with positive CT scan findings (8.35 ng/mL [IQR: 1.65]) was significantly higher than those with negative CT scan findings (5.3 ng/mL [IQR: 6.9]) (P<0.001). The optimal cutoff point for ALDOC serum level was 6.95 ng/mL, and the area under the curve was 99.6% (P<0.001). The sensitivity and specificity of the determined cutoff point were 100% and 98%, respectively. CONCLUSION: The ALDOC serum level in patients with mTBI significantly correlates with the pathologic findings of the brain CT scan. This biomarker, with 100% sensitivity, is a suitable tool to detect brain structural abnormalities in mTBI patients.

Clinical Predictors of Testicular Torsion in Patients with Acute Scrotum; a Cross-Sectional Study.

INTRODUCTION: Testicular torsion is an important and critical issue in patients with acute scrotum referring to emergency department (ED). Early detection is very important to save the testicles. This study aimed to determine the diagnostic accuracy of clinical variables in predicting the presence of testicular torsion. METHODS: This prospective cross-sectional study was done using the information of patients hospitalized from September 2015 to September 2020, with complaint of acute scrotum (ICD 10 code: N50.8), referring to ED for evaluation of the clinical predictors of testicular torsions, which were confirmed by surgery. RESULTS: 81 patients with the mean age of 20.07 ± 9.64 (3- 45) years were studied. After surgical exploration, 70 patients (86.4%) had testicular torsion. Patients with torsion had lower age (p < 0.0001), lower time from symptom to ED visit (p < 0.0001), sudden onset pain (p = 0.003), left side pain (p < 0.0001), and lower white blood cell (WBC) count (p = 0.001). The frequency of dysuria (p = 0.032), diarrhea/vomiting (p = 0.005), and fever (p = 0.002) was significantly lower in patients with torsion. The cremasteric reflex was absent in 57 (81.4%) cases who suffered from testicular torsion (p = 0.001). Based on the results of binary logistic regression analysis, age (B = -0.175, SE = 0.45; p < 0.0001) was the sole independent predictor of testicular torsion. The highest area under the receiver operating characteristics (ROC) curve in predicting the presence of torsion belonged to lower age [91.0 (95%CI: 83.2 - 98.7)], pain in left testis [0.931 (95%CI: 0.828-0.987)], and lower WBC count [0.805 (95%CI: 0.684-0.926)], respectively. CONCLUSION: It seems that clinical variables are not accurate enough to be considered as the sole predictor of testicular torsion and they should be used with caution and in combination with other available screening tools like Doppler ultrasonography in this regard.

Utilization of the Parenteral Morphine in Emergency Department using the Anatomical Therapeutic Chemical Classification/Defined Daily Doses (ATC/DDD) System.

OBJECTIVE: To evaluate the utilization of the parenteral morphine in Emergency Department (ED) using the Anatomical Therapeutic Chemical Classification/Defined Daily Doses (ATC/DDD) system. METHODS: In this retrospective cross-sectional study, morphine administration was recorded in 4-year time period from January 2013 to December 2016 in the ED of a referral center. The dose of the administered morphine was evaluated using the ATC/DDD system. The ATC/DDD of the parenteral morphine was calculated based on the world health organization (WHO). The data was evaluated based on the different diagnosis and conditions using the ATC/DDD protocol. RESULTS: In this study, 500 patients referred to ED with mean age of 48.29 ± 10.10 years were included. There were 306 (61.2%) men and 194 (38.8%) women among the patients. The lowest and highest DDD of parenteral morphine were 0.1 and 0.43, respectively. The utilization of parenteral morphine was significantly higher in men when compared to women (p<0.001). Those with history of tricyclic anti-depressant (TCA) consumption (p<0.001) and opium addiction (p<0.001) had significantly higher parenteral morphine utilization. Those with pain in the extremities and chest pain had significantly higher parenteral morphine utilization (p<0.001). CONCLUSION: The utilization of parenteral morphine in the ED of our center was higher than the WHO standard dosage. The morphine utilization was associated with male gender, opium addiction and TCA consumption.

The predictive role of amylase and lipase levels on pancreas injury diagnosis in patients with blunt abdominal trauma.

Objectives Despite the low incidence of pancreatic injury in the abdominal blunt trauma (BTA), its early diagnosis is very important; since pancreatic injury is associated with high rates of morbidity and mortality. However, due to the high association of pancreatic injury with injury of other abdominal organs, its diagnosis may be delayed and complicated. The use of imaging modalities is also subject to limitations for reasons such as cost, unavailability, and harmfulness. Consequently, the present study aimed to investigate the predictive role of amylase and lipase enzyme levels in the final diagnosis of pancreatic injury in patients with BTA. Methods In a prospective diagnostic study, 384 patients with BTA referring to Imam Khomeini hospital of Sari (north of Iran) were enrolled according to the inclusion and exclusion criteria. Initial patient data including age and sex were recorded. Blood samples were analyzed in the laboratory to measure complete blood count (CBC), amylase and lipase enzyme levels. Patients were followed up during hospitalization and focal ultrasound for abdominal trauma (FAST), CT-Scan and laparotomy results were recorded. Finally, the data was analyzed using SPSS version 22. Results The level of amylase enzyme was significantly higher in males (p = 0.04), but the level of lipase enzyme was not significantly different between two genders (p > 0.05). The most common symptoms and signs in patients were pain, tenderness, and hematoma, respectively. The frequency of pancreatic injury in all patients with blunt abdominal trauma was 7.5% based of FAST, 7% based on CT-Scan and 12.4% based on laparotomy. Comparison of laboratory findings based on FAST, CT-Scan and laparotomy results showed that the level of amylase and lipase enzymes in patients with internal organ and pancreatic damage were higher than in patients without internal organ injury (p < 0.05). But based on FAST results; patients with pancreatic injury and injury of other organs had no significant difference (p > 0.05). However, comparison of laboratory findings based on CT-Scan and laparotomy results showed a significant increase in the level of amylase and lipase enzymes in patients with pancreatic trauma compared to patients with injury of other organs (p < 0.001). Conclusions The results of this study showed that pancreatic injury in blunt trauma is associated with a significant increase in levels of amylase and lipase enzymes. In addition, an increase in levels of amylase and lipase enzymes is associated with internal organ damage. Serum amylase and lipase levels can be used as useful biomarkers to decide whether to perform CT-Scan or laparotomy.

Demographic and epidemiologic evaluation of mushroompoisoning: a retrospective study in 4-year admissions of Razi Hospital (Qaemshahr, Mazandaran, Iran).

Aim Wild mushroom intoxication is a public health problem, which causes a wide range of symptoms: from mild gastrointestinal symptoms to multiple organ failure and death. The present study aims to evaluate the epidemiology of mushroom intoxication in 4-year admissions of Razi Hospital, Qaemshahr, Mazandaran, Iran. Methods Medical records of all identified cases of mushroom poisoning admitted during the period between 2015 and 2018 were extracted and patients' demographic data including age, sex, latency period, season of poisoning, clinical presentations, laboratory findings, prognosis, duration of hospitalization and therapeutic interventions were recorded. Results A total of 65 mushroom poisoning cases were identified (mean age of 35.68 years), of which 32 (49.2%) were females. Latency of ≤ 6 hours was seen in 63 (96.4%) cases. The most prevalent season of intoxication was spring (60.7%). The most frequent symptoms were nausea and vomiting (86.5%) and abdominal pain (51.2%). No case required intensive care unit (ICU) care or mechanical ventilation. Mean hospital stay was 1.89 days without any mortality. Mean aspartate aminotransferase (AST) level was 21.89 (±9.55), but the disturbance of liver function tests (LFTs), coagulopathy, elevated level of bilirubin and/or platelet was not noted. In 93% of patients ranitidine, in 7% Penicillin G, and in 3.6% cefaclor and ceftriaxone was administrated. Conclusion People and health care providers must be educated about mushroom poisoning. Prompt transfer of suspicious cases with history of wild mushroom ingestion to the emergency department is crucial since patients showing toxicity symptoms after 6 hours might have worse and mortal prognosis despite treatment.

Minor Head Trauma and its Short-term Outcomes Among Elderly Patients: a Prospective Epidemiological Study in North of Iran.

INTRODUCTION: Traumatic brain injury (TBI) is of the most challenging public health problems. AIM: The aim of this study was to investigate the epidemiology of mild TBI, frequency of clinically important head injuries identifiable on computed tomography (CT) scans and also short-time outcomes of mild TBI in elderly population in north of Iran. PATIENTS AND METHODS: A prospective epidemiological study was conducted at the Emergency department of Imam Khomeini general hospital, Mazandaran, Iran. Inclusion criteria were age older than 60, Glasgow coma scale (GCS) score of 13-15, and a single head trauma. Data were collected by retrospective chart review, interview with patients or their caregivers and contact with them after a week from time of discharge or transferring to another wards. RESULTS: Response rate was estimated at 67.8% (n: 122/180). Mean age of patients was 65.54±6.42 years. 82% of patients were younger than 70. Mean time from head trauma to hospital admission was 270 minutes. In majority of patients, mechanism of trauma was fall (28%) and then interpersonal violence (25%). 6.6% (95% CI: 2.87 to 12.5%) of patients suffered from important radiologically head injuries and 2.5% (95% CI: 0.5-7.00) were readmitted to hospital within a week. CONCLUSION: Time to admission for minor TBI in elderly patients was too long and could be of clinical concern. Considering the lower prevalence of important radiologically head injury among elderly population, using any clinical guideline for indication of CT scan may be more cost-effective than routine use of CT scan. Although short term outcomes of minor TBI were less threatening and not lethal but these patients need follow-up.

The prevalence of post-traumatic stress disorder among emergency nurses: a cross sectional study in northern Iran.

BACKGROUND AND OBJECTIVE: Posttraumatic stress disorder (PTSD) is one of the anxiety disorders which occurs in response to facing events and accidents accompanied by fear, frustration, and terror. Nurses who worked in the emergency departments witness unpleasant accidents and are exposed to stress and violence more than others. The aim of this study was to investigate the prevalence of PTSD among Iranian nurses working in the emergency department. MATERIALS AND METHODS: In this cross-sectional study, all nurses working in the emergency department of educational hospitals affiliated with Mazandaran University of Medical Sciences were included through census method (n = 131). Each of the participants in this study responded to the questionnaires individually. The first part of the questionnaire captured demographics, while the second part was the Civilian Mississippi Scale for PTSD, which was used to investigate the extent of PTSD in this study. Data were analyzed using SPSS version 22. RESULTS: In this study, 131 respondents were included. In the classification of age, nurses with 20-30-year- old had the maximum frequency (41.2 %,). Most nurses in the study (93.1%, n = 122) had a bachelor's degree in nursing and 84 were married. The prevalence of PTSD in emergency nurses was 82.96%, which was higher in nurses with shorter working background and nurses with lower levels of education. Further, the average score of PTSD was higher in married nurses. CONCLUSION: The results of this study revealed the high prevalence of PTSD among nurses who worked in emergency department. Therefore, it seems that designing and providing supportive and educational services to emergency nurses can be effective for preventing and managing this disorder, which probably can improve their performance.

Investigation of Frequency of the Lethal Triad and Its 24 Hours Prognostic Value among Patients with Multiple Traumas.

BACKGROUND: Death in multiple trauma (MT) patients is one of the serious concerns of the medical service provider. Any prediction of the likelihood of death on the assessment of the patient's condition is performed using different variables, one of the tools in the triage of patients to determine their condition. AIM: We aimed to investigate the frequency and the predictive value of death in 24 hours triad of death in patients qualified with multiple traumas admitted to Imam Khomeini hospital. METHODS: This was a prospective cross-sectional study to determine the prevalence and predictive value of 24-hour triad of death among patients with MT referred to an emergency department. Three factors including acidosis, hypothermia and coagulopathy and predictive value of 24-hour death were evaluated. Arterial blood gas, oral temperature and blood samples for coagulation factors were analysed. Data were analysed using SPSS version 19. Multivariate analysis (logistic regression) was used to determine the predictive value of the triad of death. RESULTS: A group of 199 MT patients referring to Imam Khomeini hospital during the first 6 months of 2015 were evaluated for the first 24 hours of admission. Logistic regression analysis showed that using the following formula based on the triad of death can predict death in 96% of cases can be based on the triad of a death foretold death upon admission to the emergency room. It should be noted that this prediction tool as 173 people left alive after 24 hours as live predicts (100% correct). CONCLUSION: The triad of death is one of the tools in the triage of patients to determine their condition and care plan to be used, provided valuable information to predict the prognosis of patients with a medical team.

Does co-treatment with ultra-low-dose naloxone and morphine provide better analgesia in renal colic patients?

OBJECTIVE: This study attempted to evaluate the efficacy of ultra-low-dose intravenous (IV) naloxone combined with IV morphine, as compared to IV morphine alone, in terms of reducing pain and morphine-induced side effects in patients with renal colic. METHODS: In this double-blind clinical trial, 150 patients aged 34 to 60 years old who presented to the emergency department (ED) with renal colic were randomly allocated to either an intervention group that received ultra-low-dose IV naloxone combined with IV morphine or to a control group that received morphine plus a placebo. The severity of pain, sedation, and nausea were assessed and recorded for all patients at entrance to the ED (T1), then at 20 (T2), 40 (T3), 60 (T4), 120 (T5), and 180 (T6) minutes after starting treatment. The Numeric Rating Scale (NRS) was used for the assessment of pain and nausea intensities, and the Ramsay Sedation Scale (RSS) was used to assess sedation. RESULTS: A GEE model revealed that patients in the naloxone group had non-significantly reduced pain scores compared to those in the morphine group (coefficient = -0.68; 95% CI: -1.24 to -0.11, Wald X2 (1) = 5.41, p = 0.02). The sedation outcome demonstrated no statistically significant differences at T1 to T4 among patients with renal colic compared to the ones who only received morphine. At T5 and T6, 1.5% vs. 20% and 1.5% vs. 16.9% of subjects from the naloxone group versus the morphine group obtained RSS scores equal to 3, respectively (p = 0.001 and p = 0.004, respectively). CONCLUSIONS: Compared to patients who only received IV morphine, co-treatment of ultra-low-dose naloxone with morphine could not provide better analgesia and sedation/agitation states in renal colic patients.

Comparing the analgesic efficacy of morphine plus ketamine versus morphine plus placebo in patients with acute renal colic: A double-blinded randomized controlled trial.

OBJECTIVES: Renal colic (RC) is a common cause for emergency department visits. This study was conducted to compare the analgesic efficacy of morphine plus ketamine (MK) versus morphine plus placebo (MP) in patients with acute renal colic. METHOD: Using a single center, double-blind, two-arm, parallel-group, randomized controlled trial, 200 patients were equally and randomly divided to receive 0.1 mg/kg morphine plus normal saline and 0.1 mg/kg morphine plus 0.2 mg/kg ketamine. The severity of renal colic was assessed by VAS at baseline, 20 and 40 min after drug injection. The number of adverse events also was recorded. RESULTS: Totally, 200 patients completed the study. Mean age of the patients was 35.60 ±â€¯8.17 years. The patients were mostly men (68.5%). The severity of pain between the groups was not significantly different at baseline. Both groups showing a significant reduction in VAS scores across the three time points. The main effect comparing the two types of intervention was significant (F = 12.95, p = 0.000), suggesting a significant reduction in pain severity of patients in the MK group. The number of patients who suffered from vomiting was significantly higher in MP group than that of MK group (13 and 3, respectively (P = 0.009)). However, the risk of dizziness in the MK group was >2 times higher than MP group (relative risk: 2.282, 95% CI: 1.030-5.003, P = 0.039). The number of patients who needed rescue analgesia was significantly lower in the MK group (OR, 0.43 (0.22-0.83)). CONCLUSION: Adding 0.2 mg/kg ketamine to 0.1 mg/kg morphine can reduce the renal colic pain, nausea and vomiting more than morphine alone; however, it was associated with higher number of patients with dizziness.

Propofol-fentanyl versus propofol-ketamine for procedural sedation and analgesia in patients with trauma.

OBJECTIVE: Many procedures performed in emergency department are stressful and painful, and creating proper and timely analgesia and early and effective assessment are the challenges in this department. This study has been conducted in order to compare the efficacy of propofol and fentanyl combination with propofol and ketamine combination for procedural sedation and analgesia (PSA) in trauma patients in the emergency department. METHOD: This is a randomized prospective double-blind clinical trial conducted in the emergency department of Imam Khomeini Hospital, a tertiary academic trauma center in northern Iran. Patients with trauma presenting to the emergency department who needed PSA were included in study. Patients were divided into two groups of propofol fentanyl (PF) and propofol ketamine (PK). Pain score and sedation depth were set as primary outcome measures and were recorded. RESULTS: Out of about 379 patients with trauma, who needed PSA, 253 met the criteria to be included in the study, 117 of which were excluded. The remaining 136 patients were randomly allocated to either PF group (n = 70) or PK group (n = 66). Pain management after drug administration was significantly different between the groups and the analgesia caused by fentanyl was significantly higher than ketamine. The sedation score after 15 min of PSA in the group PF was significantly higher than the group PK. CONCLUSION: It seems that regarding PSA in the emergency department, PF caused better analgesia and deeper sedation and it is recommended to use PF for PSA in the emergency departments.

Efficacy and Safety of Morphine and Low Dose Ketamine for Pain Control of Patients with Long Bone Fractures: A Randomized, Double-Blind, Clinical Trial.

OBJECTIVE: To compare the effects of intravenous morphine and a low dose of ketamine on pain intensity of patients with traumatic fractures of the long bones. METHODS: This randomized, controlled, double-blinded, clinical trial was conducted in the adult emergency department (ED) of Emam Khomeini hospital, a tertiary general hospital affiliated with Mazandaran University of Medical Sciences, in Northern Iran, during a 6-month period. Patients were randomly assigned to receive intravenous morphine (0.1 mg/kg) or low dose ketamine (0.5 mg/kg) for control of the pain in the emergency room. The pain intensity was checked by a nurse using the visual analogue scale (VAS) at 30, 60, 90, 120, 180 and 240, minutes after the intervention. RESULTS: Overall we included a total number of 156 patients with mean age of 35.87±3.38 years. There were 111 (71.2%) men and 4 (28.8%) women among the patients. Patients were randomly assigned to receive intravenous morphine (n=78) or low dose ketamine (n=78). The pain intensity decreased significantly in both study groups after 240 minutes of intervention. However, there was no significant difference between the two study groups regarding the pain intensity at 30 (p=0.378), 60 (p=0.927), 90 (p=0.434), 120 (p=0.557), 180 (p=0.991) and 240 (p=0.829) minutes. The side effects were comparable while low dose ketamine was associated with higher need for rescue analgesic (p=0.036). CONCLUSION: The results of the current study demonstrates that the intravenous low dose ketamine leads to successful pain control in patients with long bone fractures and the effects are comparable with intravenous morphine.

Carbon monoxide poisoning in Iran during 1999-2016: A systematic review and meta-analysis.

BACKGROUND: Carbon monoxide (CO) poisoning is a common cause of emergency department (ED) visits worldwide with high levels of morbidity and mortality. No inclusive nationally statistics of CO poisoning in Iran is available. The present review aimed to describe and review the pattern of CO poisoning in Iran. METHODS: The search of Medline, SCOPUS, Cochrane library, Google Scholar, Magiran, IranDoc and SID (Scientific Information Database) yielded only 10 studies discussing the epidemiology of CO poisoning in Iran. Outcomes of interest were determining the demographic characteristics, prevalence and mortality rates, annual trends, main sources and mechanisms, location of incidents of CO poisoning as well as providing the safety awareness and precautions. RESULTS: Totally, 10 studies including 6372 victims of CO poisoning were reviewed. The estimated incidence rate of CO poisoning was 38.91 per 100,000, the proportionate mortality rate was 11.6 per 1000 death and the pooled case fatality rate of was 9.5% (95% CI 6.3%-14.30%). Of the total 5105 individuals with CO poisoning, 2048 (40.12%) were male and 3057 (59.88%) were female. In addition, of 5105 poisoned, 4620 (90.50%) were alive and 485 (9.50%) were dead. The number of fatal CO poisoning cases among men and women were 259 (5.07%) and 226 (4.43%) victims, respectively; while the number of non-fatal CO poisoning cases among men and women were 1790 (35.06%) and 2830 (55.44%) individuals, respectively. The mean age of victims was about 30 years. Most of the victims (36.37%) had the educational level of secondary school, marital status of single (52.74%), and occupational status of housekeeper (27.48%). CONCLUSION: The incidence, proportionate mortality and case fatality rates of CO poisoning is high in Iran, particularly in young individuals. It seems that preventive strategies should be taught by health care providers more thoroughly and implemented by policy makers more strictly as a mandatory law.

Diagnostic Accuracy of Quick Stick for Identifying Traumatic Patients in Need of Tetanus Prophylaxis; a Cross-sectional Study.

INTRODUCTION: Based on the existing studies, measuring serum level of immunoglobulin for making decisions regarding prescription of tetanus prophylaxis seems logical and cost effective. Therefore, the present study was done with the aim of evaluating the diagnostic accuracy of tetanus quick stick (TQS) in comparison with ELISA method in this regard. METHODS: The present diagnostic accuracy study was carried out on trauma patients presenting to emergency department, who were in need of receiving tetanus prophylaxis due to dirty wounds or injuries. Patients' blood was evaluated regarding presence of anti-tetanus antibody via TQS and ELISA methods and screening performance characteristics of TQS in identifying the cases in need of receiving prophylaxis was calculated compared to ELISA as the reference test. RESULTS: 148 patients with the mean age of 34.58 ± 15.86 years (4-86) were studied (87.8% male). Agreement rate between the results of TQS and ELISA was 0.78 based on calculation of kappa coefficient. Sensitivity, specificity and area under the ROC curve of TQS were estimated to be 100 (95% CI: 96.50 - 100), 66.66 (95% CI: 38.68 - 86.01), and 0.83 (95% CI: 0.68 - 0.98), respectively. If TQS was used, the cost of treatment regarding use of tetabulin could have a 91.7% reduction. CONCLUSION: Based on the findings of the present study, TQS has good diagnostic accuracy in comparison with ELISA and considering its 100% sensitivity and negative predictive value in cases with dirty wound, it can be considered as a reliable tool for screening patients that do not need to receive anti-tetanus prophylaxis.

Efficacy and Safety of Combination Therapy with Ketorolac and Morphine in Patient with Acute Renal Colic; A Triple-Blind Randomized Controlled Clinical Trial.

OBJECTIVE: To compare the efficacy of combination therapy with ketorolac and morphine with monotherapy with each in patients with acute renal colic. METHODS: This triple-blind, randomized clinical trial was conducted during a 6-month period from March to September 2014 in Northern Iran. We included 300 patients with clinical diagnosis of acute renal colic and pain score greater than 4 on 10 cm visual analogue scale (VAS) score. Patients were randomly assigned to three study groups to receive 0.1 mg/kg morphine in combination with 30 mg ketorolac (n=100), or only 0.1 mg/kg morphine (n=100) or only 30mg ketorolac (n=100). All the patients were evaluated at 0, 20 minute,40 minute later. Our outcomes were pain reduction and need for additive morphine in 20 and 40 minutes. We also recorded and compared the adverse effects between the study groups. RESULTS: There was no significant difference between the study groups. The pain intensity was comparable between three study groups after 20-min of intervention. However, we found that the pain intensity was significantly lower in balanced analgesia group when compared to morphine (3.01±0.98 vs. 3.66±1.02; p=0.012) or ketorolac alone (3.01±0.98 vs. 3.68±0.88; p=0.018). However, those receiving the balanced analgesia, required significantly less rescue analgesia when compared to morphine (16% vs. 20%; p=0.041) or ketorolac (16% vs. 24%; p=0.012) alone. CONCLUSION: Balanced analgesia with morphine and ketorolac is more effective compared to morphine or ketorolac alone determine by lower pain scores after 40-min of injection and lower need for rescue analgesia.

Determinants of Prolonged Length of Stay in the Emergency Department; a Cross-sectional Study.

INTRODUCTION: Timeliness has been considered as a key domain in quality of emergency department (ED) care and delay in care providing is influential determinants of patient's outcomes. The present study, aimed to evaluate the determinants of prolonged ED length of stay (LOS). METHODS: In this cross-sectional study, using adopted version of the latest form for external evaluation and accreditation of EDs introduced by Iranian Ministry of Health, determinants of prolonged LOS were evaluated in the ED of an educational Hospital. Using SPSS 11, multivariate binary logistic regression was applied to estimate adjusted odds ratios (OR) for determining factors associated with prolonged LOS. RESULTS: 162 (10.2%) cases with prolonged LOS were detected. Based on univariate analysis, female gender (OR: 1.42, 95% CI: 1.14-1.75, p = 0.001), older age (OR: 1.05, 95% CI: 1.02-1.08, p < 0.0001), admission on evening shifts (OR: 4.0; 95% CI: 1.84-8.68, p < 0.001), triage level I (OR: 1.76, 95% CI: 1.21-2.57, p = 0.003), lack of insurance support (OR: 1.56, 95% CI: 1.12-2.19, p = 0.010), higher number of ordered para-clinical tests (OR: 1.23, 95% CI: 1.11-1.37, p = 0.016), and disposition time > 6 hours (OR, 0.13, p < 0.0001), were significant risk factors of prolonged LOS. CONCLUSION: Older age, lack of insurance support, disposition time > 6 hours due to complexity of patients' complaint, and the necessity of repeated para-clinical measures were the most important reasons for failed provision of timely services. From the view point of ED personnel, a small part of prolonged LOS in ED was concerned with defective ED workflow, while, the most important cause of such delays was the delayed response of the consultancy services.

Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial.

OBJECTIVE: Renal colic (RC) is a common clinical presentation in the emergency department (ED). Prompt and effective pain control is one of the first responsibilities of emergency physicians. The aim of this study was to evaluate the analgesic effect of adding lidocaine to morphine compared to morphine alone in patients presenting to the ED with RC. METHODS: In a double-blind, randomized controlled trial, a total of 110 adult patients of both sexes, aged 18 to 50 years, who presented to the ED with signs and symptoms suggestive of RC were randomly assigned into 1 of 2 groups. Patients in group A received morphine (0.1 mg/kg) plus lidocaine (1.5 mg/kg), whereas those in group B received morphine (0.1 mg/kg) plus normal saline 0.9% as placebo. All patients were asked to rate the intensity of their pain and nausea on a 0- to 10-point visual analog scale before and at 5, 10, 30, 60, and 120 minutes after intervention. RESULTS: There was a statistically significant time trend decline in both groups for both pain and nausea scores (P < .01). Repeated-measures analysis showed a significant effect for the interaction between group and time of persistent pain (P = .034), but there was no significant group effect in this regard (P = .146). Median times to being pain free in the group receiving morphine plus lidocaine and in the group taking morphine alone were 87.02 minutes (95% confidence interval [CI], 74.23-94.82) and 100.12 minutes (95% CI, 89.95-110.23), respectively (P = .071). Repeated-measures analysis also showed a significant group effect for nausea (P = .038), but there was no interaction between group and time in this regard (P = .243). The median nausea-free times in the group receiving morphine plus lidocaine and the group receiving morphine alone were 26.6 minutes (95% CI, 14.16-39.03) and 58.33 minutes (95% CI, 41.85-74.82), respectively. This time difference was statistically significant (P < .001). CONCLUSIONS: Using lidocaine may be recommended as an effective, safe, and inexpensive adjuvant to morphine in improving nausea and reducing the time needed to achieve pain and nausea relief in patients visiting the ED with acute RC.