Intranasal Lidocaine for Primary Headache Management in Emergency Department; a Clinical Trial.

INTRODUCTION: Most of the headache cases only require pain management in emergency department (ED). The present study aimed to evaluate the efficacy of intranasal lidocaine in this regard. METHOD: In this clinical trial, adult patients with primary headache were randomly treated with 7.5 mg intravenous (IV) chlorpromazine and 1 ml intranasal lidocaine 2% (treatment) or normal saline 0.9% (placebo), and were compared 5, 15, and 30 minutes later regarding success rate using SPSS 21. RESULT: 100 patients were assigned to either treatment or placebo group. Number needed to treat of intranasal lidocaine at 5, 15, and 30 minutes were 4 (95% CI: 2.2 - 6.6), 3 (95% CI: 1.7 - 3.5), and 4 (95% CI: 2.3 - 15.9), respectively. These measures for absolute risk reduction were 30 (95% CI: 15.2 - 44.8), 44 (95% CI: 28.7 - 59.3), and 26 percent (95% CI: 6.3 - 44.3), respectively. Pain relapse occurred in 16% of treatment and 11% of control group within 1 hour of treatment (p = 0.402). CONCLUSION: It seems that, intranasal lidocaine along with IV chlorpromazine could result in more successful and faster management of primary headaches in ED.

Intravenous Lidocaine versus Morphine Sulfate in Pain Management for Extremity Fractures; a Clinical Trial.

INTRODUCTION: Considering the existing contradictions regarding effectiveness of intravenous (IV) lidocaine, especially in emergency department (ED), the present study was designed to compare the analgesic effect of IV lidocaine and morphine sulfate in pain management for extremity bone fractures. METHOD: In this triple blind clinical trial, 15 to 65 year-old patients with extremity fractures and in need of pain management were randomly allocated to either IV lidocaine or morphine sulfate group and were compared regarding severity of pain 5, 10, 15, 20, 25, and 30 minutes after infusion via intention to treat analysis. The absolute risk reduction, number needed to treat and relative risk of IV lidocaine after 30 minutes were 0.40 (95%CI: 0.25 - 0.64), 7 (95%CI: 3.7 - 23.1), and 20.71 (95%CI: 10.91 - 30.51), respectively. RESULTS: 280 patients with the mean age of 32.50 ± 12.77 years were randomly divided into 2 equal groups of 140 (73.9% male). The 2 groups had similar baseline characteristics. 15 minutes after injection success rate was 49.28% in lidocaine and 33.57% in morphine sulfate group (p = 0.011), and after 30 minutes it reached 85.71% and 65.00%, respectively (p < 0.001). CONCLUSION: Based on the results of the present study, IV lidocaine could be considered as a reasonable alternative choice for pain management in ED.

Comparing Two Different Doses of Intravenous Midazolam in Pediatric Sedation and Analgesia.

INTRODUCTION: Midazolam has turned into a common drug for pediatric procedural sedation and analgesia. However, there is not much data regarding its proper dose and potential side effects in the Iranian children population. Therefore, the present study was done to compare 2 doses of IV midazolam in this regard. METHODS: The present clinical trial was performed to compare 0.1 and 0.3 mg/kg doses of IV midazolam in induction of sedation for head trauma infant patients in need of brain computed tomography (CT) scan. Conscious infants under 2 years old, with stable hemodynamics were included. Onset and duration of action as well as probable side effects were compared between the two groups using SPSS version 22. RESULTS: 110 infants with the mean age of 14.0 ± 5.9 months (range: 4 - 24) and mean weight of 9.7 ± 2 kg (range: 5 - 15) were randomly allocated to one of the 2 study groups (54.6% female). Success rate in 0.1 and 0.3 mg/kg groups were 38.2% (21 patients) and 60% (33 patients), respectively (p = 0.018). Overall, 56 (50.9%) patients did not reach proper sedation and were sedated receiving ketamine (22 patients) or another dose of midazolam (34 patients, mean additional dose needed was 2.1 ± 1.1 mg). CONCLUSION: The results of the present study demonstrated the higher success rate and longer duration of action for 0.3 mg/kg midazolam compared to 0.1 mg/kg. The groups were equal regarding onset of action, effect on vital signs and probable side effects.

Proper Angle of Sono-guided Central Venous Line Insertion.

INTRODUCTION: Determining the proper angle for inserting central venous catheter (CV line) is of great importance for decreasing the complications and increasing success rate. The present study was designed to determine the proper angle of needle insertion for internal jugular vein catheterization. METHODS: In the present case series study, candidate patients for catheterization of the right internal jugular vein under guidance of ultrasonography were studied. At the time of proper placing of the catheter, photograph was taken and Auto Cad 2014 software was used to measure the angles of the needle in the sagittal and axial planes, as well as patient's head rotation. RESULT: 114 patients with the mean age of 56.96 ± 14.71 years were evaluated (68.4% male). The most common indications of catheterization were hemodialysis (55.3%) and shock state (24.6%). The mean angles of needle insertion were 102.15 ± 6.80 for axial plane, 36.21 ± 3.12 for sagittal plane and the mean head rotation angle was 40.49 ± 5.09. CONCLUSION: Based on the results of the present study it seems that CV line insertion under the angles 102.15 ± 6.80 degrees in the axial plane, 36.21 ± 3.12 in the sagittal plane and 40.49 ± 5.09 head rotation yield satisfactory results.

Effective Factors in Severity of Traffic Accident-Related Traumas; an Epidemiologic Study Based on the Haddon Matrix.

INTRODUCTION: Traffic accidents are the 8(th) cause of mortality in different countries and are expected to rise to the 3(rd) rank by 2020. Based on the Haddon matrix numerous factors such as environment, host, and agent can affect the severity of traffic-related traumas. Therefore, the present study aimed to evaluate the effective factors in severity of these traumas based on Haddon matrix. METHODS: In the present 1-month cross-sectional study, all the patients injured in traffic accidents, who were referred to the ED of Imam Khomeini and Golestan Hospitals, Ahvaz, Iran, during March 2013 were evaluated. Based on the Haddon matrix, effective factors in accident occurrence were defined in 3 groups of host, agent, and environment. Demographic data of the patients and data regarding Haddon risk factors were extracted and analyzed using SPSS version 20. RESULTS: 700 injured people with the mean age of 29.66 ± 12.64 years (3-82) were evaluated (92.4% male). Trauma mechanism was car-pedestrian in 308 (44%) of the cases and car-motorcycle in 175 (25%). 610 (87.1%) cases were traffic accidents and 371 (53%) occurred in the time between 2 pm and 8 pm. Violation of speed limit was the most common violation with 570 (81.4%) cases, followed by violation of right-of-way in 57 (8.1%) patients. 59.9% of the severe and critical injuries had occurred on road accidents, while 61.3% of the injuries caused by traffic accidents were mild to moderate (p < 0.001). The most common mechanisms of trauma for critical injuries were rollover (72.5%), motorcycle-pedestrian (23.8%), and car-motorcycle (13.14%) accidents (p < 0.001). CONCLUSION: Based on the results of the present study, the most important effective factors in severity of traffic accident-related traumas were age over 50, not using safety tools, and undertaking among host-related factors; insufficient environment safety, road accidents and time between 2 pm and 8 pm among environmental factors; and finally, rollover, car-pedestrian, and motorcycle-pedestrian accidents among the agent factors.

Comparison of Oral Midazolam and Promethazine with Oral Midazolam alone for Sedating Children during Computed Tomography.

INTRODUCTION: Both midazolam and promethazine are recommended to be used as sedatives in many studies but each have some side effects that limits their use. Combination therapy as an alternative method, may decreases these limitations. Therefore, this study aimed to compare midazolam with midazolam-promethazine regarding induction, maintenance, and recovery characteristics following pediatric procedural sedation and analgesia. METHODS: Children under 7 years old who needed sedation for being CT scanned were included in this double-blind randomized clinical trial. The patients were randomly divided into 2 groups: one only received midazolam (0.5 mg/kg), while the other group received a combination of midazolam (0.5 mg/kg) and promethazine (1.25 mg/kg). University of Michigan Sedation Scale (UMSS) was used to assess sedation induction. In addition to demographic data, the child's vital signs were evaluated before prescribing the drugs and after inducing sedation (reaching UMSS level 2). The primary outcomes in the present study were onset of action after administration and duration of the drugs' effect. RESULTS: 107 patients were included in the study. Mean onset of action was 55.4±20.3 minutes for midazolam and 32.5±11.1 minutes for midazolam-promethazine combination (p<0.001). But duration of effect was not different between the 2 groups (p=0.36). 8 (7.5%) patients were unresponsive to the medication, all 8 of which were in the midazolam treated group (p=0.006). Also in 18 (16.8%) cases a rescue dose was prescribed, 14 (25.9%) were in the midazolam group and 4 (7.5%) were in the midazolam-promethazine group (p=0.02). Comparing systolic (p=0.20) and diastolic (p=0.34) blood pressure, heart rate (p=0.16), respiratory rate (p=0.17) and arterial oxygen saturation level (p=0.91) showed no significant difference between the 2 groups after intervention. CONCLUSION: Based on the findings of this study, it seems that using a combination of midazolam and promethazine not only speeds up the sedation induction, but also decreases unresponsiveness to the treatment and the need for a rescue dose.

The efficacy of intranasal desmopressin as an adjuvant in the acute renal colic pain management.

The aim of this study was to compare analgesic effect of intramuscular (IM) sodium diclofenac and intranasal desmopressin combination with IM sodium diclofenac alone in patients with acute renal colic. In this randomized double-blind clinical trial, all patients aged 18 to 55 years who were diagnosed as acute renal colic and met the inclusion and exclusion criteria were randomized into two groups to receive 40 µg intranasal desmopressin spray and 75 mg IM sodium diclofenac combination (Group A) or 75 mg IM sodium diclofenac alone (Group B). The pain score of patients was assessed using a visual analogue scale (VAS) at baseline, 15, 30, 45, and 60 minutes after administration. Of all 159 patients who were assessed for eligibility finally, the results of 120 patients were analyzed. There was no significant difference regarding age and gender between two groups. The baseline VAS score was not significantly different between two groups (P = 0.44). The Mean ± SD scores of two groups reduced 15 minutes after drug administration, but this decrease was significantly more in Group A compared with Group B (P = 0.02). This pattern continued in minutes 30, 45, and 60 of drug administration. Our results showed that desmopressin could be used as an effective adjuvant in acute renal colic pain management.

Comparison of clinical efficacy of intravenous acetaminophen with intravenous morphine in acute renal colic: a randomized, double-blind, controlled trial.

The aim of this study was to compare the clinical efficacy of intravenous acetaminophen with intravenous morphine in acute renal colic pain management. In this double-blind controlled trial, patients aged 18-55 years, diagnosed with acute renal colic, who met the inclusion and exclusion criteria, were randomized into two groups. First, using the visual analogue scale (VAS), intensity of pain was assessed in both groups. Then, one gram of intravenous acetaminophen or 0.1 mg/kg morphine was infused in 100 mL normal saline to either acetaminophen or morphine group. Intensity of pain was reassessed in 15, 30, 45, and 60 minutes according to VAS criteria. Finally, data from 108 patients were analyzed, 54 patients in each group. No significant difference was observed between the two groups in regard to sex (P = 0.13), mean age (P = 0.54), and baseline visual analogue score (P = 0.21). A repeated measure analysis of variance revealed that the difference between the two treatments was significant (P = 0.0001). The VAS reduction at primary endpoint (30 min after drug administration) was significantly higher in the acetaminophen group than in the morphine group (P = 0.0001). This study demonstrated that intravenous acetaminophen could be more effective than intravenous morphine in acute renal colic patients' pain relief.