Intranasal ketamine versus intranasal fentanyl on pain management in isolated traumatic patients.

Background: Given the inadequate control of pain in patients with the trauma that refer to the emergency departments, the rapid onset of action of intranasal administration in pain management, and the avoidance of administering opioid medications, the present study aimed at evaluating the effect of intranasal ketamine versus intranasal fentanyl on pain management in isolated traumatic patients. Materials and Methods: The current study was performed on 125 patients that were divided into the following three groups: control group (n = 41), 1 mg/kg intranasal ketamine group (n = 40), and 1 µg/kg intranasal fentanyl group (n = 44). Then pain scores, heart rate, respiratory rate, blood pressure, and oxygen saturation were recorded at baseline, 5, 10, 15, 30, and 40 min after the intervention. Results: Visual analog scale (VAS) scores of patients in the intranasal ketamine group 5 and 10 min after the intervention were 61.50 ± 20.45 and 55.00 ± 21.96, respectively. The mentioned scores were significantly lower than the VAS scores of patients in the control group with the mean of 72.44 ± 22.11 and 66.59 ± 24.25 and the VAS scores of patients in the intranasal fentanyl group with the mean of 71.59 ± 22.09 and 65.00 ± 22.87 at 5 and 10 min after the intervention, respectively (P < 0.05). Conclusion: Given the onset of action in < 10 min, intranasal ketamine can be proposed as an appropriate analgesic medication in pain reduction of patients with isolated limb injuries. Moreover, the incidence rate and severity of adverse effects were insignificantly higher in the intranasal ketamine group as compared with the intranasal fentanyl group.

Topical ketamine as a local anesthetic agent in reducing venipuncture pain: A randomized controlled trial.

AIM: Pain control is an important aspect of ED patient management, and there are many different protocols used around the world influenced by both availability of local resources as well as staff competency and experience. This study aims to evaluate the use of topical ketamine in acute pain reduction by directly comparing it to lidocaine-prilocaine (EMLA) cream. MATERIALS AND METHODS: In this randomized clinical trial, 300 adult patients classified as level 4 or 5 by ESI triage system were enrolled. These patients were divided randomly into three groups. The site of venipuncture was covered with 2 g of topical ketamine cream 10% in group one, 2 g of 5% EMLA cream in group two, and finally, in group 3 (control group), was covered with placebo (2 g of cold cream). The primary end point of the study was reported pain severity with secondary end points being onset of local anesthesia as well as any side effects noted. RESULTS: The data gathered showed pain score during venipuncture in both intervention groups were significantly lower when compared to the control group (P < 0.05). However, pain score did not differ between the 2 intervention groups (P = 0.395). There was no statistically significant difference between the ketamine or EMLA in onset of local anesthesia (P = 0.419). We noted itching and irritation was significantly higher in the EMLA group when compared to ketamine(P < 0.05). CONCLUSION: This study showed that local cutaneous ketamine is as effective as EMLA in relieving pain during venipuncture.

Mini-dose Bier's block vs systemic analgesia in distal radius fractures: a promising reduction in emergency department throughput time.

Aim: This study compared the effect of the conventional technique of procedural sedation and the mini-dose intravenous regional anesthesia (IVRA). Patients & methods: 45 patients received IVRA, and 47 received iv. ketamine. The pain score, emergency department (ED) length of stay and patients' satisfaction were compared. Results: The study revealed that not only the levels of hemodynamic parameters but also their stability, and the patient's satisfaction in the IVRA group were significantly better. The patients' pain score and ED length of stay were also significantly decreased in those who received IVRA. Conclusion: Mini-dose IVRA technique contributes to better hemodynamic stability, without prominent adverse events, and leads to significant pain control and improved ED throughput time. Clinical Trial Registration: NCT03349216 (ClinicalTrials.gov).

Effects of the COVID-19 pandemic on healthcare delivery to an immigrant population in the Islamic Republic of Iran.

Background: Healthcare inequity has widely affected marginalized and immigrant communities globally during the COVID-19 pandemic. Aims: This study assessed the effect of COVID-19 pandemic on health care delivery to immigrant populations in Isfahan Province, Islamic Republic of Iran. Methods: All 67 hospitals across Isfahan Province were included in this study conducted from 1 March to 31 May 2020. Data on clinical manifestations, comorbidities, patient management, and outcomes of patients during hospital admission were extracted from medical records and analysed using SPSS for chi-square and odds ratio (OR). Results: One hundred and sixty-eight (3.3%) of 5128 PCR-confirmed COVID-19 cases during the study period were immigrants and were included in the study. There were no differences in sex, clinical presentation, comorbidities, and length of hospital stay between the non-immigrant and immigrant groups. Immigrant patients were significantly younger and had poorer outcomes, including tracheal intubation [OR = 1.9, 95% confidence interval (CI): 1.2-3.1); P = 0.009] and in-hospital mortality (OR = 1.6; 95% CI: 1.1-2.4; P = 0.02). Conclusion: Adverse health outcomes among immigrant communities may be an indication of health inequity and should be addressed by the relevant policymakers.

Effects of Adding Oral Clonidine to Standard Treatments on Pain Intensity of Patients with Acute Renal Colic: A Randomized Clinical Trial.

Background: The aim of this study was to compare the effect of adding oral clonidine to standard treatments on pain intensity in patients with acute renal colic. Materials and Methods: This is a randomized clinical trial that was performed in 2020 in Isfahan. The study population consisted of 200 patients with renal colic. Pain of the patients was assessed using Visual Analog Scale. Patients were then randomized into 4 groups of 50 patients. Group A received 0.1 mg/kg morphine and clonidine tablets (0.2 mg). Group B received morphine and placebo. Group C received 30 mg ketorolac and clonidine tablets. Group D received 30 mg ketorolac and placebo tablets. Pain of patients was assessed. 0.05 mg/kg morphine was administered and repeated every 40 min if the pain was not reduced. Results: Our data showed that there was a significant difference between pains of patient by the time of admission in groups (P = 0.04). However, no significant differences were observed between pains of patients in different measuring times (P > 0.05). Using general linear model, we showed that the decreases in pain scores of each group were significant (P < 0.05) but there were no significant differences in pains of patients in different measuring times (P > 0.05). Our data showed that Group A and Group C had lowest frequencies of morphine administrations while Groups B and D had the highest frequencies (P < 0.001). Conclusion: We showed that administration of clonidine in patients with renal colic resulted in better pain control and lower morphine injections.

Point-Of-Care Ultrasonography for Diagnosis of Medial Collateral Ligament Tears in Acute Knee Trauma; a Diagnostic Accuracy Study.

Introduction: The use of point-of-care ultrasonography (POCUS) for identifying medial collateral ligament (MCL) tears has increased in recent years. This study aimed to evaluate the diagnostic accuracy of POCUS in the diagnosis of acute MCL tears of the knee. Methods: This prospective cross-sectional study was performed on patients with suspected MCL tear of the knee in the emergency department (ED). After history taking and primary physical examination, radiographic imaging of the knee was done. If there was no fracture in the knee X-ray, the POCUS examination was done. All of the patients were asked to refer to an orthopedic clinic, 7-10 days after discharge from ED, for Magnetic Resonance Imaging (MRI) evaluation. The second POCUS was done in the orthopedic clinic. Finally, the findings of POCUS and MRI were compared in diagnosing MCL injury. Results: Two hundred and fifty patients with a mean age of 25.05 ± 9.12 years were analyzed (86.8% male). According to the MRI findings, as the gold standard, 55(22.0%) patients had MCL injury. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), and accuracy of ultrasound in detection of MCL injury, in comparison with MRI were 83.64 (95% CI, 71.20 to 92.23), 94.36% (95% CI, 90.13 to 97.15), 80.70% (95% CI, 69.95 to 88.25), 95.34% (95% CI, 91.83 to 97.38), and 92.00% (95% CI, 87.92 to 95.05), respectively. The area under the receiver operating characteristic (ROC) curve of POCUS was 0.890 (95% CI, 0.844 to 0.926). Conclusion: It seems that POCUS can be applied in screening patients with MCL tears following blunt knee trauma.

Differential Diagnosis of Seizure and Syncope by the Means of Biochemical Markers in Emergency Department Patients.

Background: Seizure and syncope have similar clinical symptoms but different etiologies. Hence, differential diagnosis is crucial prior to intervention. This study evaluates the diagnostic importance of neuron specific enolase (NSE), creatine phosphokinase (CPK), and serum lactate dehydrogenase (LDH) for admitting patients with seizure medical history to emergency department (ED) in order for differential diagnosis between syncope and seizure. Methods: Patients with a short-lasting loss of consciousness admitted to the ED were recruited. All patients with a short-lasting loss of consciousness were eligible and EEG was conducted several times and was taken over a long period. Patients were then divided into two groups of seizure and syncope. The biochemical markers levels of all the eligible patients were measured by a reputable laboratory. Results: In order to define specificity and sensitivity of different levels of biomarkers and the optimal cut-off points, ROC curves for each biomarker of syncope and seizure patients admitted to ED were performed. AUC for NSE, CPK, and LDH were 0.973 ± 0.023, 0.827 ± 0.047, and 0.836 ± 0.043 respectively in 95% confidence level. Cut-off points for NSE, CPK, and LDH were determined 25.12, 218.09, and 193.88 respectively. Conclusions: It was concluded that NSE, CPK and LDH levels were different significantly in seizure patients compared to syncope ones. The seizure group showed an increase in NSE, CPK and LDH level.

Role of point-of-care ultrasonography (POCUS) in the diagnosing of acute medial meniscus injury of knee joint.

BACKGROUND: In recent years, musculoskeletal ultrasound has increasingly become the common method for diagnosis for many medical specialties. Therefore, the present study was performed to evaluate the diagnostic value of point-of-care ultrasonography (POCUS) as a primary triage tool in the diagnosis of the acute medial meniscus injury of the knee. MATERIALS AND METHODS: The present cross-sectional study was performed on patients with a suspected medial meniscus injury of the knee in the emergency department (ED). After history taking and primary physical examination, radiographic imaging of the knee was done. If there was no fracture in the knee X-ray, the POCUS examination on the knee was carried out. All the patients were asked to refer to an orthopedic clinic 2 weeks after discharge from ED for the Magnetic Resonance Imaging (MRI) evaluation. Finally, the POCUS findings were compared with the MRI findings in diagnosing medial meniscus injury. RESULTS: Fifty-five patients with a mean age of 35.48 ± 11.58 years were analyzed in the study (69.1% male). In comparison with MRI scan, the sensitivity and specificity of POCUS in the detection of medial meniscus injury were 85.0 [95% confidence interval (CI), 54.0 to 98.9] and 65.7% [95% CI 42.2 to 85.7], respectively. Its positive and negative predictive values were 58.6% [95% CI 33.8 to 81.5] and 88.5% [95% CI 62.1 to 99.3], respectively. (Area under the ROC curve = 0.726, P value = 0.003). CONCLUSION: The present study demonstrated that POCUS can reasonably be applied in comparison with MRI to evaluate medial meniscus injury. POCUS is an effective initial diagnostic modality in patients with suspected medial meniscus injuries.

Evaluation of the effect of shift cycle time on chest compression quality during cardiopulmonary resuscitation.

OBJECTIVE: Considering the potential role of shift cycle time on chest compression quality during cardiopulmonary resuscitation (CPR) and the available contradictory results in this regard, the present study aimed at evaluating the effect of 1-min versus 2-min shift cycle time on the quality of CPR. MATERIALS AND METHODS: In this randomized crossover study, 80 rescuers performed CPR on a manikin in two scenarios with a rotation of 1 and 2-min cycles. The quality of CPR was evaluated and compared based on the information obtained regarding the chest compression depth, recoil, and rate of chest compression. In addition, rescuer fatigue was recorded in 1-min versus 2-min shift cycles. RESULTS: In the 1-min group, the number of chest compressions per minute, complete recoil, and good rate with the mean of 114.89 ± 3.62, 54.34 ± 3.86, and 76.06 ± 8.00 were significantly higher than those of the 2-min group with the mean of 113.78 ± 4.94, 53.49 ± 5.27, and 73.98 ± 7.87 (P < 0.05), respectively. In addition, the quality of CPR provided by males was significantly higher than females in both groups. The score of rescuer fatigue was higher in the 2-min group as compared with the 1-min group (P < 0.001). CONCLUSION: According to the results of the present study, the difference in the quality of CPR in terms of the number of chest compressions, complete recoil, and good rate was higher in the 1-min group as compared with the 2-min group. In addition, the quality of CPR in terms of chest compression depth and number in both 1-and 2-min rotation cycles was higher for male rescuers than females. Furthermore, rescuer fatigue was higher in the 2-min group as compared with the 1-min group. The mentioned finding may be a factor in reducing, albeit slightly, the quality of CPR in the group with a longer time.

Ketamine improves nasogastric tube insertion.

OBJECTIVES: Nasogastric (NG) intubation is one of the most common procedures performed in the emergency department (ED) and other hospital settings. The aim of this study was to compare the level of pain during NG tube insertion in groups receiving local ketamine plus water-soluble lubricating gel and water-soluble lubricating gel alone (the latter is the common practice in our hospital). It was hypothesised that ketamine has local anaesthetic effects in reducing the pain of NG tube insertion in the ED. METHODS: This prospective double-blind randomised clinical trial was performed on alert haemodynamically stable subjects aged >18 years who required NG tube placement for diagnostic or therapeutic purposes in the ED of a teaching hospital during January and June 2008. The subjects were divided into two groups using randomised allocation software. The ketamine group received intranasal ketamine, while an equivalent volume of sterile water was instilled into the nasal cavity in the control group. The same amount of lubricating gel was used in both groups. The pain of NG tube placement was measured using a standard 100 mm visual analogue scale (VAS). The physician was asked to evaluate the difficulty of the procedure using a 5-point Likert scale. RESULTS: Seventy-two subjects were enrolled in the study (36 subjects in each group). There was a significant difference between the pain score of the ketamine and control groups (19.03+/-3.56 vs 33.33+/-5.31), while the difficulty score was not statistically different between the two groups (2.39+/-1.25 vs 2.78+/-1.56). CONCLUSION: Intranasal ketamine is an effective agent in reducing pain during NG tube insertion among patients without serious underlying illness.

Comparing Sedative Effect of Dexmedetomidine versus Midazolam for Sedation of Children While Undergoing Computerized Tomography Imaging.

BACKGROUND: Pediatric anxiety and restlessness may create issues and difficulties in performing accurate diagnostic studies even noninvasive ones, such as radiological imaging. There are some agents that will help to get this goal. This study aimed to compare the intranasal effect of dexmedetomidine (DEX) and midazolam (MID) for sedation parameters of children undergoing computerized tomography (CT) imaging. MATERIALS AND METHODS: A double-blind clinical trial was conducted on 162 eligible children who underwent CT imaging. These patients were divided into two groups including MID (n = 81) with dose of 0.3 mg.kg and DEX (n = 81) with dose of 3 µg.kg, which was consumed intranasally. The mean blood pressure (MBP), respiratory rate (RR), heart rate (HR), and oxygen saturation (O2Sat) in children were recorded. Then, time of initiation, level of sedation, and duration effect of medication were measured at 0, 10, 20, and 30 min. Parents and clinician satisfaction score was asked. All data were analyzed using the Statistical Package for the Social Sciences (SPSS) software by t test and chi-square test. RESULTS: Decreasing in MBP and HR was higher in DEX group than MID group (P < 0.001), whereas decrease of O2Sat in MID group was higher than DEX group (0.009). Starting time of sedation (22.72 ± 11.64 vs. 33.38 ± 10.17, P = 0.001) was lower in DEX group. Parents (P < 0.001) and physician (P < 0.001) satisfaction score was higher in DEX group than the MID group. CONCLUSION: Using 3 µg/kg intranasal DEX for sedation of 1-6-year-old children was a suitable method to undergo noninvasive studies such as CT imaging. Intranasal DEX is superior to MID due to higher sedation satisfactory, faster starting effect of sedation, and lower side effects and complications. Nevertheless, in children with hemodynamic instability DEX is not an appropriate choice.

Diagnostic Value of Copeptin in Patients with Suspected Pulmonary Embolism in Emergency Departments.

BACKGROUND: Pulmonary thromboembolism (PTE) is a serious and life-threatening condition. Diagnosis of PTE can be challenging in emergency departments, as there is no absolutely reliable biomarker for the diagnosis of PTE. Copeptin (COP) is a new biomarker, which may be valuable in the diagnosis of PTE; however, its role has not been well studied. In this study, we aimed to investigate the diagnostic value of COP in the diagnosis of PTE. MATERIALS AND METHODS: This study was carried out on 102 patients suspected of PTE. The serum levels of D-dimer and COP were measured, and diagnosis of PTE was confirmed by CT angiography. Next, the prognostic value of D-dimer and COP was examined. RESULTS: The area under the curve (AUC) of D-dimer was 0.581 with a standard error (SE) of 0.07 (P=0.34). Estimation of the validity of D-dimer showed that it is a highly sensitive (100%), but poorly specific (15.8%) test. Evaluation of the predictive value of this test showed that it has a positive predictive value of 20% and a negative predictive value of 100%. The AUC of COP was 0.423 with SE of 0.1 (P=0.44). Measurement of the validity of COP test showed that it is a poorly sensitive (50%) and specific (22.9%) test. CONCLUSION: COP is a new cardiovascular biomarker. However, the present findings did not confirm the prognostic value of this biomarker for the diagnosis of PTE.

Bedside Ultrasonography versus Brain Natriuretic Peptide in Detecting Cardiogenic Causes of Acute Dyspnea.

INTRODUCTION: Acute dyspnea is a common cause of hospitalization in emergency departments (ED).Distinguishing the cardiac causes of acute dyspnea from pulmonary ones is a major challenge for responsible physicians in EDs. This study compares the characteristics of bedside ultrasonography with serum level of blood natriuretic peptide (BNP) in this regard. METHODS: This diagnostic accuracy study compares bedside ultrasonography with serum BNP levels in differentiating cardiogenic causes of acute respiratory distress. Echocardiography was considered as the reference test. A checklist including demographic data (age and sex), vital signs, medical history, underlying diseases, serum level of BNP, as well as findings of chest radiography, chest ultrasonography, and echocardiography was filled for all patients with acute onset of dyspnea. Screening characteristics of the two studied methods were calculated and compared using SPSS software, version 20. RESULTS: 48 patients with acute respiratory distress were evaluated (50% female). The mean age of participants was 66.94 ± 16.33 (28-94) years. Based on the results of echocardiography and final diagnosis, the cause of dyspnea was cardiogenic in 20 (41.6%) cases. Bedside ultrasonography revealed the cardiogenic cause of acute dyspnea in 18 cases (0 false positive) and BNP in 44 cases (24 false positives). The area under the ROC curve for bedside ultrasonography and BNP for differentiating the cardiogenic cause of dyspnea were 86.4 (95% CI: 74.6-98.3) and 66.3 (95% CI: 49.8-89.2), respectively (p = 0.0021). CONCLUSION: It seems that bedside ultrasonography could be considered as a helpful and accurate method in differentiating cardiogenic causes of acute dyspnea in emergency settings. Nevertheless, more study is needed to make a runaway algorithm to evaluate patients with respiratory distress using bedside ultrasonography, which leads to rapid therapeutic decisions in a short time.

Diagnostic validity of ultrasonography in evaluation of pulmonary thromboembolism.

BACKGROUND: Diagnosis of pulmonary embolism (PE) remains difficult due to its nonspecific symptoms and signs. Therefore, many patients die undiagnosed or untreated. We decided to study the sensitivity, specificity, and accuracy of ultrasonography in the diagnosis of pulmonary thromboembolism. MATERIALS AND METHODS: In this prospective study, 77 patients with clinically suspected PE in the emergency department of Isfahan Al-Zahra Hospital were enrolled from September 2011 to September 2012. At first, they were evaluated by thoracic ultrasonography (TUS) and then divided into four groups based on their TUS findings. Multi-slice computed tomography (MSCT) was the reference method in this study performed within 24 h from admission. MSCT scans were interpreted by a radiologist who was unaware of the TUS results. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPVs) of thoracic ultrasonography were determined. RESULTS: PE diagnosis was confirmed by MSCT in 25 patients and 54 hypoechoic lesions were detected by TUS with the average size of 16.4 mm × 11.1 mm. In our study, sensitivity, specificity, PPV, NPV, and accuracy of TUS for PE diagnosis were 84%, 94.2%, 87.5%, and 92.5%, respectively. CONCLUSION: TUS is an inexpensive, safe and easily available method for timely diagnosis and treatment of PE in emergency department and its NPV is high for cases with low scores for Wells criteria who had a normal or possible TUS findings. It is also specific in the diagnosis of PE in cases with high scores Wells criteria who have confirmed or probable TUS findings.

Rectal Thiopental versus Intramuscular Ketamine in Pediatric Procedural Sedation and Analgesia; a Randomized Clinical Trial.

INTRODUCTION: Physicians frequently deal with procedures which require sedation of pediatric patients. Laceration repair is one of them. No study has been performed regarding the comparison between induction of sedation with sodium thiopental and ketamine in laceration repair. Therefore, the present study was aimed to comparison of induced sedation by rectal sodium thiopental and muscular injection of hydrochloride ketamine in pediatric patients need laceration repair. METHODS: The presented study is a single-blinded clinical trial performed through 2013 to 2014 in Ayatollah Kashani and Alzahra Hospitals, Isfahan, Iran. Patients from 3 months to 14 years, needed sedation for laceration repair, were entered. Patients were sequentially evaluated and randomly categorized in two groups of hydrochloride ketamine with dose of 2-4 milligram per kilogram and sodium thiopental with dose of 25 milligram per kilogram. Demographic data and vital signs before drug administration and after induction of sedation, Ramsey score, time to onset of action, and sedation recovery time were evaluated. Chi-squared, Mann-Whitney, and Non-parametric analysis of covariance tests were used. P<0.05 was considered as a significant level. RESULTS: In this study 60 pediatric patients were entered. 30 patients with mean age of 42.8±18.82 months were received sodium thiopental and the rest with mean age of 30.08±16.88 months given ketamine. Mann-Whitney test was showed that time to onset of action in sodium thiopental group (28.23±5.18 minutes) was significantly higher than ketamine (7.77±4.13 minutes), (p<0.001). The sedation recovery time in ketamine group (29.83±7.70) was higher than sodium thiopental. Depth of sedation had no significant difference between two groups based on Ramsey score (p=0.87). No significant difference was seen between two groups in the respiratory rate (df=1, 58; F=0.002; P=0.96) and heart rate (df=1, 58; F=0.98; P=0.33). However, arterial oxygen saturation level (df=1, 58; F=6.58; P=0.013) was significantly higher in ketamine group. CONCLUSION: The findings of the present study show that Although the recovery time from sedation by ketamine is more than sodium thiopental, it's fast-acting function without effecting on the oxygen saturation level causes that ketamine is considered as the better choice for induction of sedation in pediatric patients need laceration repair. In addition, long-term effect of ketamine provides more time for the physician to do the procedure and this issue decreases the need probability to the repeated-dose. However, effectiveness of both drugs to decrease the agitation was equal, based on the Ramsey score.

Diagnostic Accuracy of Optic Nerve Ultrasonography and Ophthalmoscopy in Prediction of Elevated Intracranial Pressure.

INTRODUCTION: Elevated intracranial pressure (ICP) is a major and potentially lethal disorder in patients admitted to the emergency department (ED). Several methods are being used to investigate for elevated ICP. Here we assessed and compared the diagnostic accuracy of two existing tools of ophthalmoscopy and optic nerve ultrasonography in detection of elevated ICP. METHODS: 131 participants with probable elevation of ICP referred to the emergency department of Al-Zahra Hospital, Isfahan, Iran, from 2012 to 2014, were enrolled. Brain computed tomography (CT) scan, ultrasonography of optic nerve sheath, and ophthalmoscopy were performed for them. The optic nerves sheath with diameter more than 5 millimeters was considered as elevated ICP. Widening of optic nerve, ocular venous engorgement, blurring, hemorrhage over optic disk, elevation of optic disk, and retinal venous tortuosity were recorded as evidences of ICP rising in ophthalmoscopy. Diagnostic accuracy of the two tools in prediction of ICP rising were compared with the results of brain CT scan as a gold standard. RESULTS: The mean age of participants was 46.29 ± 10 years (77% male). The number of diagnosed elevated ICPs with ophthalmoscopy and ultrasound were 98 (74.8%) and 102 (77.9%) cases, respectively. The calculated sensitivity and specificity of ophthalmoscopy and ultrasonography in detection of ICP rising were 100.0% (95% CI: 88.6-100.0) and 35.4% (95% CI: 26.0-46.2), 100.0% (95% CI: 84.0-100.0) and 31.9% (95% CI: 23.0-41.7), respectively. CONCLUSION: The present study revealed that bedside ultrasonography of optic nerve sheath and ophthalmoscopy have enough accuracy for the screening of patients with probable elevation of ICP. Of course, it should be considered that despite the high sensitivity of both tools, their specificity is low.

Oral Chloral Hydrate Compare with Rectal Thiopental in Pediatric Procedural Sedation and Analgesia; a Randomized Clinical Trial.

INTRODUCTION: The increasing use of diagnostic imaging in pediatric medicine has resulted in growing need for procedural sedation and analgesia (PSA) to minimize motion artifacts during procedures. The drug of choice in pediatric PSA was not introduced until now. The aim of the present study was comparison of oral chloral hydrate (OCH) and rectal sodium thiopental (RST) in pediatric PSA. METHODS: In the present randomized clinical trial, 2-6 years old pediatrics who referred for performing brain computed tomography scan was enrolled and were randomly divided in to two groups. OCH (50mg/kg) and RST (25mg/kg) were prescribed and a trained nurse recorded the time from drug prescription to receiving the conscious sedation (onset of action), the total period which the patient has the Ramsay score≥4 (duration of action), and adverse effect of agents. Mann-Whitney U test and chi-squared test, and Non-parametric analysis of covariance (ANCOVA) were used for comparisons. RESULTS: One hundred and forty children were entered to two groups of OCH and RST, randomly. The patients of two groups had similar age, sex, weight, and baseline vital signs except for diastolic blood pressure (p<0.001). The onset of action in OCH and RST groups were 24.5±6.1and 28.7±5.2 minutes, respectively (p<0.001). Duration of action in OCH and RST groups were 12.9±2.8 minutes and 13.7±2.6 minutes, respectively (p=0.085). Non-parametric ANCOVA revealed that only diastolic blood pressure was affected by drug prescription (p=0.001). In 11(15.7%) patients in RST group, diarrhea was observed during 24 hours (p=0.001). Oxygen desaturation was observed only in two patients, both in OCH group. CONCLUSION: Each of the sedative has advantages and disadvantages that should be considered when selecting one for inducing short-term sedation. It seems that rectal sodium thiopental and oral chloral hydrate are equally effective in pediatric PSA and based on patient's condition we can administrate one of these agents.

Ketamine/propofol versus midazolam/fentanyl for procedural sedation and analgesia in the emergency department: a randomized, prospective, double-blind trial.

OBJECTIVES: The authors performed a prospective, double-blinded, randomized trial with emergency department (ED) patients requiring procedural sedation and analgesia (PSA) for repair of deep traumatic lacerations and reduction of bone fractures, to compare the ketamine/propofol (ketofol) combination with the midazolam/fentanyl (MF) combination. METHODS: Sixty-two patients scheduled for PSA who presented between January 2009 and June 2009 were enrolled prospectively. Thirty-one were randomly assigned to the ketofol group, and 31 were assigned to the MF group. RESULTS: The median starting doses were 0.75 mg/kg of both ketamine and propofol (interquartile range [IQR] = 0.75 to 1.5 mg/kg), 0.04 mg/kg midazolam (IQR = 0.04 to 0.06 mg/kg), and 2 µg/kg fentanyl (IQR = 2 to 3 µg/kg). There were no significant differences in sedation time between the groups. There were no differences in physician satisfaction (p = 0.065). Perceived pain in the ketofol group, as measured by the Visual Analog Scale (VAS), was significantly lower than in the MF group (median ketofol = 0, IQR = 0-1 vs. median MF = 3, IQR = 1-6; p < 0.001). Only one patient in each group required bag-mask ventilation, and neither of them were intubated. CONCLUSIONS: The ketamine/propofol combination provides adequate sedation and analgesia for painful procedures and appears to be a safe and useful technique in the ED.