Validity of SMART-COP score in prognosis and severity of community acquired pneumonia in the emergency department.

BACKGROUND: Determining prognosis in community acquired pneumonia (CAP), is very important. Many scores are introduced up to now for prediction of pneumonia prognosis like SMART-COP. OBJECTIVE: To evaluate validity of SMART-COP score in prognosis and severity of CAP in emergency department (ED). METHODS: All patients older than 18 years old with clinical suspicion of CAP (meeting the inclusion criteria), were enrolled in our study. In this prospective study, patients were admitted to the ED of a tertiary referral center. Hospital length of stay, rate of intensive care unit (ICU) admission, mortality rate, number of intensive respiratory or vasopressor support (IRVS) use, patients' SMART-COP scores and all demographic data were recorded. Validity of SMART-COP in the prediction of IRVS rate and its correlation with other variables were determined. RESULTS: In this study, 47.6% and 52.4% of patients were females and males respectively. The mean age of patients was 68.13 ±â€¯16.60 years old. The mean hospital length of stay was 13.49 ±â€¯5.62 days. Of all patients entered in our study, 55 cases (38.5%) needed ICU admission, 29 cases (20.3%) were expired within 1 month and 44 cases (30.8%) needed IRVS during their treatment. SMART-COP ≥5 (high risk CAP) accurately predicted the rate of ICU admission, one-month mortality and IRVS need (p-value = 0.001). CONCLUSIONS: SMART-COP≥5 had a high sensitivity and specificity in the prediction of patients' prognosis with severe CAP in the ED.

Validity of ultrasound in diagnosis of tendon injuries in penetrating extremity trauma.

BACKGROUND: Tendon ruptures are common musculoskeletal injuries all around the world. Correct and timely diagnosis of tendon injuries is obviously important for improving the treatment and minimizing the community costs. Ultrasound is now being considered as one of useful modalities in this area. OBJECTIVE: The preset study is going to validate the diagnostic ability of ultrasound in tendon injuries induced by penetrating extremity trauma. METHODS: In this prospective, observational study, patients with penetrating extremity trauma and suspicion of tendon injuries were enrolled in our study. A team of emergency medicine (EM) residents performed ultrasound examination in these cases after attending the specific workshop and acquiring necessary skills in normal and abnormal tendon ultrasound examination. Then another team of either EM or orthopedic residents explored patients' wounds and determined intact or injured tendons under direct visual observation. The results were analyzed to validate sensitivity and specificity of ultrasound as an alternative diagnostic test. RESULTS: Seventy-one patients were enrolled in our study and 11 patients were excluded during one year in 2014. Sixty patients, 11 with lower extremity and 49 with upper limb injuries were evaluated, among them 32 patients had extensor zone and 28 patients had flexure zone injuries. The overall sensitivity and specificity were calculated 94.4% (95% CI 72.7-99.8%) and 100% (95% 91.5-100.0%) respectively. CONCLUSIONS: Our results were similar to previous findings. Ultrasound can effectively differentiate injured from intact tendons in penetrating extremity trauma.

Comparison of intranasal ketamine versus IV morphine in reducing pain in patients with renal colic.

BACKGROUND: Various drugs have been used to relieve abdominal pain in patients with renal colic. Ketamine is a popular choice as an analgesic. OBJECTIVE: To compare the effectiveness of intranasal (IN) ketamine versus intravenous (IV) morphine in reducing pain in patients with renal colic. METHODS: A randomized double-blind controlled trial was performed in 53 patients with renal colic recruited from the emergency department (ED) in 2015. Finally, 40 patients were enrolled in this study. Patients in the ketamine group received IN ketamine 1 mg/kg and IV placebo while patients in the control group received IV morphine 0.1mg/kg and IN placebo. Our goal was to assess visual analogue scale (VAS) changes between the 2 groups. Patients' VAS scores were reported before and 5, 15, 30min after drug injection. RESULTS: Before drug administration, the mean±SD VAS score was 7.40±1.18 in the morphine group (group A) and 8.35±1.30 in the ketamine group (group B) (P-value=0.021). After adjustment by the appropriate analysis, the mean±SD VAS score in group (A) and (B) at 5min were (6.07±0.47 vs 6.87±0.47; mean difference -0.79, 95% confidence interval (CI) -1.48 to -1.04) (P-value=0.025), at 15 and 30min, the mean±SD VAS score in group (A) and (B) were (5.24±0.49 vs 5.60±0.49; mean difference -0.36, 95% CI -1.08 to 0.34) and (4.02±0.59 vs 4.17±0.59; mean difference -0.15, 95% CI -1.02 to 0.71) (P-value=0.304 and 0.719) respectively. CONCLUSIONS: IN ketamine may be effective in decreasing pain in renal colic.

Comparison of local anesthetic effect of lidocaine by jet injection vs needle infiltration in lumbar puncture.

BACKGROUND: Usual routes of drug administration are often painful and invasive. Nowadays, using jet injection has been introduced successfully, as a noninvasive and painless method of anesthetic delivery in performing different procedures. OBJECTIVE: The objective of the study is to compare the local anesthetic effect of lidocaine by jet injection vs needle infiltration in performing lumbar puncture in the emergency department (ED). METHODS: A randomized single-blind controlled study was performed in 65 patients needing lumbar puncture recruited from the ED from July to November 2014. We enrolled 44 patients and excluded 21 patients by the exclusion criteria. Local lidocaine was delivered in 1 group by jet injector (group B), whereas in the other group conventional method, needle infiltration was used (group A). In both groups, intravenous midazolam 1 mg was administered as an anxiolytic drug before the procedure. Patients' pain score (visual analog scale [VAS]) from 0 to 10 was recorded both during drug delivery and performing the procedure itself. The observer who collected patients' data and fulfill the questionnaire was blinded to the study. RESULTS: During lidocaine injection, the mean ± SD VAS score was 5.27 ± 1.77 in group A and 2.95 ± 1.81 in group B (mean difference, 2.31; 95% confidence interval, 1.22-3.41) (P= .000). During performing the procedure, the mean ± SD VAS score in groups A and B was 3.77 ± 1.77 vs 2.18 ± 1.50 (mean difference, 1.59; 95% confidence interval, 0.59-2.58) (P= .003). CONCLUSIONS: Injecting lidocaine by jet injector is less painful than infiltrating it by needle and syringe.

Comparison of intravenous lidocaine versus morphine in alleviating pain in patients with critical limb ischaemia.

BACKGROUND: Numerous drugs have been proposed to alleviate ischaemic limb pain, but none have been successful in relieving ischaemic pain thoroughly and rapidly. OBJECTIVE: To compare the effectiveness of intravenous lidocaine and intravenous morphine in decreasing pain in patients with critical limb ischaemia. METHODS: A randomised double-blind controlled trial was performed in 63 patients with critical limb ischaemia recruited from the emergency department between October 2012 and December 2013; 23 patients were excluded and the remainder were randomly divided into two groups of 20 patients. Patients in the lidocaine group received lidocaine infusion (2 mg/kg) while patients in the morphine group received morphine (0.1 mg/kg). Patients' visual analogue pain scores (VAS), from 0 to 10, were reported before and 15 and 30 min after the infusion. RESULTS: Before the infusion the mean±SD VAS score was 7.50±1.93 in the lidocaine group and 7.65±1.92 in the morphine group. At 15 min the mean±SD VAS score in the lidocaine group was lower than in the morphine group (5.75±1.77 vs 7.00±1.83; mean difference 1.25, 95% CI 0.095 to 2.405) and, at 30 min, the mean±SD VAS score in the lidocaine group was again lower (4.25±1.48 vs 6.50±1.73; mean difference 2.25, 95% CI 1.218 to 3.282). CONCLUSIONS: Lidocaine may be helpful in decreasing ischaemic pain in patients with critical limb ischaemia. TRIAL REGISTRATION NUMBER: http://www.irct.irIRCT201210148872N2.

Haloperidol-Midazolam vs. Haloperidol-Ketamine in Controlling the Agitation of Delirious Patients; a Randomized Clinical Trial.

Introduction: Agitation management in delirious patients is crucial in a crowded emergency department (ED) for both patient and personnel safety. Benzodiazepines, antipsychotics, and newly derived ketamine are among the most commonly used drugs in controlling these cases. This study aimed to compare the effectiveness of haloperidol-midazolam with haloperidol-ketamine combination in this regard. Methods: In this double-blind randomized clinical trial, delirious patients with agitation in ED were randomly assigned to a group: group A: haloperidol 2.5 mg IV and midazolam 0.05 mg/kg IV or group B: haloperidol 2.5 mg IV and ketamine 0.5 mg/kg IV. Sedative effects as well as side effects at 0, 5, 10, 15, 30 minutes and 1, 2, 4 hours after the intervention were compared between the 2 groups. Results: We enrolled 140 cases with Altered Mental Status Score (AMSS)≥+2 and mean age of 52.819.4 years (78.5% male). Agitation was significantly controlled in both groups (p<0.05). In group B, AMSS score was more significantly and rapidly reduced 5 (p = 0.021), 10 (p = 0.009), and 15 (p = 0.034) minutes after drug administration. After intervention, oxygen saturation was significantly decreased in group A 5 (p = 0.031) and 10 (p = 0.019) minutes after baseline. Time required to the maximum effect was significantly lower in group B versus group A (p=0.014). Less patients in group B had major side effects (p=0.018) and needed physical restraint (p=0.001). Conclusions: Haloperidol-ketamine can control agitation in delirium more rapidly than haloperidol-midazolam. This combination had lower adverse events with lower need for physical restraint.

Effectivness of Nebulized Budesonide for COPD Exacerbation Management in Emergency Department; a Randomized Clinical Trial.

INTRODUCTION: Nebulized budesonide has been long used in chronic obstructive pulmonary disease (COPD) exacerbation. This study aimed to compare the effectiveness of nebulized budesonide (NB) versus oral prednisolone (OP) in increasing peak expiratory flow rate (PEFR) of COPD patients in emergency department (ED). METHODS: Patients with COPD exacerbation, referring to ED were enrolled in this randomized trial study. In the first group, NB 0.5 mg every 30 minutes till three doses, placebo tablet, and standard treatment was administered. In the second group, nebulized normal saline, OP tablet 50 mg, and standard treatment were administered. Patients' demographic data, vital signs, PEFR, venous blood gas (VBG) analysis, disposition, and patient and physician satisfaction were all collected and compared between the two groups. RESULTS: 43 patients in the NB group and 41 patients in the OP group were evaluated. The two groups had similar age (p=0.544) and gender (p=0.984) distribution, duration of illness (p=0.458), and baseline PEFR (p=0.400). 12 and 24 hours after treatment, significant increase in PEFR in the NB and OP groups were observed (p=0.032 and 0.008; respectively). The upward trend of PEFR in NB group was significantly better than that of OP group during 24 hours of treatment (p=0.005). Vital signs and VBG results showed no significant differences between the two groups during the studied time interval. CONCLUSION: NB, compared to OP, could more effectively increase PEFR and ameliorate disease severity of patients with COPD exacerbation at 12 and 24 hours after treatment in ED.

Peripheral Cytotoxic T Cell Lymphoma of the Appendix Presenting as Acute Appendicitis.

INTRODUCTION: Lymphoma of the appendix is a rare cause of acute appendicitis; however, acute appendicitis is a common first manifestation of appendiceal lymphomas. Cytotoxic peripheral T cell lymphoma (PTCL) is a type of aggressive non-Hodgkin lymphoma that portends a generally poor outcome. Cytotoxic PTCL of the appendix is extremely rare with few cases reported in the literature. Case Presentation. This is the report of a 23-year-old man who had experienced lower abdominal pain for three months before presenting to the emergency department with severe right lower abdominal pain, nausea, vomiting, and anorexia since the day prior to admission. The patient was diagnosed with acute appendicitis, and the pathology report confirmed cytotoxic PTCL of the appendix. CONCLUSION: Patients with appendiceal PTCL commonly present with signs and symptoms of acute appendicitis due to luminal obstruction by the tumor. Therefore, appendiceal tumors such as PTCL should be considered in the differential diagnosis of patients presenting as acute appendicitis. In addition, since there is no standard chemotherapy regimen for cytotoxic PTCL, this and other case reports hopefully help in providing the clinical evidence needed for establishing appropriate treatment guidelines.

The effect of prehospital telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction patients undergoing primary percutaneous coronary intervention: A cross-sectional study.

OBJECTIVES: The sooner the primary percutaneous coronary intervention (PPCI) is performed, the better prognosis is expected in patients with acute myocardial infarction. The objective is to evaluate the effect of prehospital triage based on electrocardiogram (ECG) and telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction (STEMI) patients undergoing PPCI. METHODS: This cross-sectional study was conducted based on the data extracted from the hospital information system (HIS) of one general hospital, which had the capability of performing PPCI 24 h a day, 7 days a week. All patients with STEMI who undergone PPCI during 1 year, transferred by emergency medical service (EMS) and their data were registered in the HIS were eligible. Besides the baseline characteristics, first medical contact (FMC)-to-balloon time was recorded. Morbidity based on predischarge left ventricular ejection fraction (LVEF) and mortality based on Global Registry of Acute Cardiac Events (GRACE) score were also recorded. Patients who were referred to the hospital by EMS with prehospital ECG and telecardiology were compared with those without prehospital ECG. RESULTS: Totally, 298 patients with STEMI were enrolled, of whom 183 patients (61.4%) had prehospital ECG (telecardiology), and 115 patients (38.6%) had not. The means of predischarge LVEF of the patients in the first and the second groups were 40.7 ± 10.4 and 40.6 ± 11.2, respectively (P = 0.946). The mean of the probability of 6-month mortality based on GRACE score in the first group was significantly less than that of the second group (P = 0.004). Analyses of multivariable ordinal logistic regression showed that 6-month mortality severity risk in the second group was 1.5 times more than the first group (95% confidence interval 0.8-2.6), although this difference was not statistically significant (P = 0.199). CONCLUSIONS: It is likely that prehospital telecardiology, with shortening FMC to balloon time result in reducing probability 6-month mortality in STEMI patients who undergone PPCI. However, the process of telecardiology had no effect on predischarge LVEF in the current study.

How the COVID-19 Epidemic Affected Prehospital Emergency Medical Services in Tehran, Iran.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has substantially impacted the healthcare delivery system in Tehran, Iran. The country's first confirmed positive test for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was on February 18, 2020. Since then, the number of cases has steadily increased in Iran and worldwide. Emergency medical services (EMS) quickly adapted its operations to accommodate a greater number of patients, and it worked to decrease the risk of COVID-19 spread among EMS personnel, given the disease's high transmissibility. METHODS: We evaluated the chief complaint as well as the pattern and number of EMS calls and dispatches during the 28-day intervals before and after the February 18, 2020, COVID-19 outbreak in Iran. RESULTS: EMS calls increased from 355,241 in the pre-outbreak period to 1,589,346 in the post-outbreak period, a 347% increase (p<0.001). EMS dispatches rose more modestly from 82,282 to 99,926, a 21% increase (p<0.001). The average time on telephone hold decreased from 10.6 ± 12.7 seconds pre-outbreak to 9.8 ± 11.8 seconds post-outbreak, a 7% decrease (p<0.001). The average length of call also decreased from 1.32 ± 1.42 minutes pre-outbreak to 1.06 ± 1.28 minutes post-outbreak, a 20% decrease (p<0.001). The highest number of daily dispatches occurred during the second and third weeks of the four-week post-outbreak period, peaking at 4557 dispatches/day. After the first reported case of SARS-CoV-2, there were significant increases in chief complaints of fever (211% increase, p<0.001) and respiratory symptoms (245% increase, p<0.001). CONCLUSION: The number of EMS calls and dispatches in Tehran increased 347% and 20%, respectively, after the outbreak of COVID-19. Despite this, the time on hold for EMS response decreased. The Tehran EMS system accomplished this by increasing personnel hours, expanding call-center resources, and implementing COVID-19-specific training.

Association of optic nerve sheath diameter in ocular ultrasound with prognosis in patients presenting with acute stroke symptoms.

BACKGROUND: Measurement of optic nerve sheath diameter (ONSD) by means of ocular ultrasound (US), can diagnose elevated intracranial pressure (ICP). Stroke accompanied by elevated ICP might have a worse prognosis. OBJECTIVE: To determine the relationship of ONSD in ocular US with prognosis in acute stroke in the emergency department (ED). METHODS: Patients with acute presentations of stroke, presenting to the ED in 2017 (during six months), were enrolled in our study. US exam was performed on all of them and ONSD was determined in two longitudinal and transverse dimensions. Demographic data, rate of patients' admission in the ward or intensive care unit, one-month patients' outcome and type of stroke were recorded. The relationship of mean ONSD was evaluated with study variables. RESULTS: In this study, 60 patients were enrolled. The mean ±â€¯SD ONSD in the deceased cases was 4.40 ±â€¯0.64 mm and in the survived patients was 3.83 ±â€¯0.56 mm. Youden index calculated ONSD>3.9 mm as the best cut-off point in mortality prognosis. It has a sensitivity of 83.3% and a specificity of 59.2%. CONCLUSIONS: Increased ONSD had a direct relationship with mortality rate in acute stroke.

Procalcitonin and D-dimer for Predicting 28-Day-Mortality Rate and Sepsis Severity based on SOFA Score; A Cross-sectional Study.

OBJECTIVE: To determine the possible relationship of procalcitonin (PCT) and D-dimer with the 28-day-mortality rate and severity of sepsis based on sequential organ failure assessment (SOFA) score. METHODS: In this cross-sectional study, patients were enrolled based on their signs and symptoms of sepsis confirmed by essential laboratory studies. Demographic data, Glasgow coma scale and vital signs, serum PCT and D-dimer levels, creatinine, bilirubin level, arterial blood gas analysis and platelet count were recorded. Disease severity index was assessed based on SOFA score. Patients' 28-day-mortality rate and hospital length of stay were compared with the study variables. RESULTS: Sixty-four patients with the mean age of 78.3±11.6 were included of whom 34 cases (53.1%) were male. The 28-day-mortality rate was 17%. The analysis showed that only patients' age (p=0.01) and platelet count (p=0.02) had a statistically significant association with the mortality rate. SOFA score had no statistically significant correlation with PCT or D-dimer; and these two markers didn't have any significant correlation in terms of predicting mortality due to the sepsis. CONCLUSION: In our study, PCT and D-dimer failed to show any significant correlation with 28-day-mortality rate of sepsis.

Oral Diclofenac Potassium Versus Intravenous Acetaminophen in Acute, Isolated, Closed-Limb Trauma.

Pain control is an important concern in limb trauma. The most ideal agent for this purpose varies among different hospitals. The objective of this study was to compare the analgesic effect of oral diclofenac potassium versus intravenous acetaminophen in patients with limb trauma. This was a double-blind randomized clinical trial conducted on 60 adult patients. Oral diclofenac potassium (50 mg) was given in Group D, and intravenous acetaminophen (1 g in 500 ml normal saline over 20 min) was administered in Group A. Patients' pain scores (visual analogue scale) were recorded and compared at baseline, 5, 15, 30, 60 min, and 4 hr after drug administration. The mean age was 42.62 ± 15.42 and 38.04 ± 17.48 years in Group A and Group D, respectively. No significant change was observed between the 2 groups (p = 0.11). In this study, both drugs could decrease the pain score effectively and safely in isolated limb trauma.

Nebulized Budesonide vs. Placebo in Adults with Asthma Attack; a Double Blind Randomized Placebo-Controlled Clinical Trial.

INTRODUCTION: Asthma is one of acute respiratory diseases leading to emergency department (ED) referral. Management of acute attack plays an important role in its outcome. OBJECTIVE: This trial was designed to evaluate the effectiveness of nebulized budesonide versus placebo in moderate to severe acute asthma attack in adults in the ED. METHOD: In this clinical trial, we enrolled patients with acute exacerbation of asthma and standard treatment of acute asthma attack was administered to all of them. 41 patients in our study were randomly entered into 2 groups. In one group, we prescribed nebulized budesonide and in the other group nebulized placebo (normal saline) was administered. Patients' demographic data, vital signs, symptoms' acuity and the time of symptom relief, patient and physician satisfaction were all recorded and compared between the 2 groups. All cases were followed and disease outcome, readmission, mortality and morbidity rates were documented. RESULTS: In this study, 20 patients were entered the budesonide group and 19 patients were enrolled in the placebo group. The mean age ranges were 55.70±15.30 and 60.32±18.41 years old respectively. Heart rate, respiratory rate and O2 saturation in the first group were improved significantly after the treatment in comparison to the second group (p<0.05). The mean time of recovery and length of hospital stay were better in the first group than the second group but this difference was not significant (p>0.05). CONCLUSION: The addition of nebulized budesonide to standard asthma treatment might result in more improvement in O2 saturation and less patient's distress.

Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury.

BACKGROUND: Rapid and effective pain relief in acute traumatic limb injuries (ATLI) is one of the most important roles of emergency physicians. In these situations, opioid addiction is an important concern because of the dependency on opioids. The study aims to compare the effectiveness of intravenous (IV) fentanyl versus morphine in reducing pain in patients with opioid addiction who suffered from ATLI. METHODS: In this double-blind randomized clinical trial, 307 patients with ATLI, who presented to the emergency department (ED) from February 2016 to April 2016, were randomly divided into two groups. One group (152 patients) received 0.1 mg/kg IV morphine. The other group (155 patients) received 1 mcg/kg IV fentanyl. Patients' demographic data, pain score at specific intervals, vital signs, side effects, satisfaction and the need for rescue analgesia were recorded. RESULTS: Eight patients in the morphine group and five patients in the fentanyl group were excluded. Pain score in the fentanyl group had a significant decrease at 5-minute follow-up (P value=0.00). However, at 10, 30, and 60-minute follow-ups no significant differences were observed between the two groups in terms of pain score reduction. The rescue analgesia was required in 12 (7.7%) patients in the fentanyl group and in 48 (31.6%) patients in the morphine group (P value=0.00). No significant difference was observed regarding side effects, vital signs and patients' satisfaction between the two groups. CONCLUSION: Fentanyl might be an effective and safe drug in opioid addicts suffering from ATLI.

Association of Lymphopenia with Short Term Outcomes of Sepsis Patients; a Brief Report.

INTRODUCTION: Studies have claimed that low lymphocyte count is independently correlated with 28-day survival of sepsis patients. Therefore, this study aimed to evaluate the value of lymphopenia in predicting the short-term outcome of sepsis patients. METHODS: This cross-sectional study was performed on sepsis patients referred to the emergency department during an 8-month period and relationship of lymphopenia with 28-day mortality and probability of septic shock and readmission due to sepsis was assessed. RESULTS: 124 cases with the mean age of 66.12 15.82 (21-90) years were studied (54.8% male). 81 (65.3%) cases had lymphopenia (59.3% male). Lymphopenic patients had a significantly higher mean age (p = 0.003), higher need for ICU admission (p < 0.001), higher prevalence of 28-day septic shock (p < 0.001), higher 28-day mortality (p < 0.001), higher probability of readmission due to sepsis (p = 0.048), and higher SOFA score (p < 0.001). During 28 days of follow up, 57 (46%) patients were expired. They had a higher prevalence of septic shock (p < 0.001) and higher SOFA score (p < 0.001). Multivariate analysis showed that septic shock (OR=364.6; 95% CI: 26.3 to 5051.7; p = 0.001) and lymphopenia (OR=19.2; 95% CI: 1.7 to 211.3; p = 0.016) were the independent predictors of 28-day mortality. CONCLUSIONS: Based on the findings, lymphopenia was independently associated with higher 28-day mortality and lymphopenic patients were older than the control group and had a significantly higher need for ICU admission, higher probability of 28-day septic shock and readmission due to sepsis, and higher SOFA score.

Accuracy of ultrasound exam performed by emergency medicine versus radiology residents in the diagnosis of acute appendicitis.

BACKGROUND: Although the traditional approach to the diagnosis of acute appendicitis (AA) is using clinical methods, experience has shown that strict reliance on clinical data can lead to mismanagement or unnecessary surgery. OBJECTIVE: The objective of this study was to determine the total agreement of ultrasound (US) results in AA performed by emergency medicine (EM) versus radiology residents in emergency department. PATIENTS AND METHODS: In this cross-sectional study, 121 patients with AA suspicion underwent an US exam by both trained EM and radiology residents in emergency department. The training course for EM residents consisted of attending an 8-h-workshop and then practicing an US exam on real patients within a 2-month period. The gold standards were either histopathologic or follow-up results. Total agreement of the results in both specialties was compared. RESULTS: There were 67 men and 54 women, with a mean age of 33.6 ± 16.1 years (18.2-88.7 years). Fifty-four (44.6%) patients underwent surgery with the initial diagnosis of AA and the rest were evaluated by follow-ups. On the basis of our gold standards, the diagnosis was finally confirmed in 46 (38%) cases. There was a high total agreement in AA diagnosis [96% agreement, κ = 0.90; 95% confidence interval (CI) = 0.81-0.99] between the two groups. The specificity and sensitivity of EM and radiology groups were 99% (95% CI = 93-100), 63% (95% CI = 48-77), 97% (95% CI = 91-100), and 72% (95% CI = 57-84), respectively. CONCLUSION: US has a high diagnostic specificity in patients suspected of having AA and EM residents can perform this modality as accurately as radiologists after training in the emergency setting.

Determining the Value of Cerebrospinal Fluid Lactate Dehydrogenase Level in Differentiating Subarachnoid Hemorrhage From Traumatic Lumbar Puncture.

Context Lumbar puncture (LP) is still an important modality in the diagnosis of subarachnoid hemorrhage (SAH). Rapid and correct fluid analysis can provide patients with a better prognosis by appropriate intervention. Objective To determine the value of cerebrospinal fluid lactate dehydrogenase level in differentiation between SAH and traumatic LP. Design This was a cross-sectional observational study. Patients with a diagnostic suspicion of SAH who were admitted to the emergency department were enrolled in our study based on the inclusion criteria. All patients underwent head computed tomography scan without contrast. Patients with SAH confirmed on computed tomography scan and those who needed surgical intervention underwent LP by the neurosurgical service in the operation room (group 1). Other patients who fulfilled the inclusion criteria but had a traumatic LP in the emergency setting were also enrolled in our study (group 2). The fluid samples of all LPs were sent to the laboratory to be analyzed. Finally, we compared the results of the 2 groups with each other. Results Fifty-two patients were enrolled in our study, 26 patients (50%) from each group. The cerebrospinal fluid lactate dehydrogenase level was significantly higher in group 1 than it was in group 2 ( P < .001), and based on receiver operating characteristic curve analysis, the significant level of cerebrospinal fluid lactate dehydrogenase to differentiate SAH from traumatic LP was estimated to be 185. The red blood cell and white blood cell counts were significantly higher in group 1 than they were in group 2 ( P < .001). Conclusions Cerebrospinal fluid lactate dehydrogenase can effectively differentiate SAH from traumatic tap in LP samples.

Impact of an educational intervention on medical records documentation.

BACKGROUND: Inaccurate and incomplete documentation can lead to poor treatment and medico-legal consequences. Studies indicate that teaching programs in this field can improve the documentation of medical records. The study aimed to evaluate the effect of an educational workshop on medical record documentation by emergency medicine residents in the emergency department. METHODS: An interventional study was performed on 30 residents in their first year of training emergency medicine (PGY1), in three tertiary referral hospitals of Tehran University of Medical Sciences. The essential information that should be documented in a medical record was taught in a 3-day-workshop. The medical records completed by these residents before the training workshop were randomly selected and scored (300 records), as was a random selection of the records they completed one (300 records) and six months (300 records) after the workshop. RESULTS: Documentation of the majority of the essential items of information was improved significantly after the workshop. In particular documentation of the patients' date and time of admission, past medical and social history. Documentation of patient identity, requests for consultations by other specialties, first and final diagnoses were 100% complete and accurate up to 6 months of the workshop. CONCLUSION: This study confirms that an educational workshop improves medical record documentation by physicians in training.

Comparison of sedative effectiveness of thiopental versus midazolam in reduction of shoulder dislocation.

BACKGROUND: Various sedative drugs have been proposed to control anxiety and agitation in shoulder dislocation, but none of them has been diagnosed as the best sedative and relaxant agent. The study aimed to compare the sedative effectiveness of thiopental versus midazolam in reduction of shoulder dislocation. METHODS: A randomized double-blind controlled trail was performed in 80 patients with shoulder dislocation recruited from the emergency department. Ten patients were excluded and 70 patients were enrolled in the study. Case group received intravenous thiopental 2 mg/kg+2 µg/kg fentanyl while control group received intravenous midazolam 0.1 mg/kg+2 µg/kg fentanyl. Number of times, patients and physician's satisfaction, difficulty of procedure, degree of muscle relaxation, time of sedation and complete recovery, number of patients with apnea episode, O2 saturation, patient's pain score and adverse events were all recorded. RESULTS: Muscular tone had significant difference between the two groups (P-value=0.014) and thiopental was more muscle relaxant than midazolam. Replacement of shoulder dislocation in thiopental group was easier than midazolam group (P-value=0.043). There was no need to use multiple methods of reduction in either group. Before drug infusion the mean±SD VAS scores were 8.37±2.21 in the midazolam group (A) and 8.94±1.78 in the thiopental group (B); mean difference 0.57, 95% CI= -0.38 to 1.52. After completion of the procedure, the mean±SD VAS scores in group (A) and (B) were 3.20±1.30 vs. 3.65±1.30; mean difference -0.45, 95% CI= -1.07 to 0.16. CONCLUSION: Thiopental might be more effective and relaxant than midazolam for reduction of shoulder dislocation.