Dexmedetomidine versus propofol: An effective combination with ketamine for adult procedural sedation: A randomized clinical trial.

BACKGROUND: Recently, drug combination protocols have been preferred over single drugs in procedural sedation and analgesia (PSA). This study aimed to compare the effectiveness and hemodynamic profile of ketamine-dexmedetomidine (ketodex) and ketofol as drug combinations with ketamine as a single medication for PSA in the emergency department (ED). METHODS: This prospective, randomized, double-blind clinical trial was performed among adult patients (≥18 years) requiring PSA for a painful procedure in the ED. 135 patients were enrolled and assigned into three equal groups to receive either ketodex, ketofol, or ketamine. Additional ketamine was used as a rescue agent for inadequate sedation in three groups. Oxygen saturation, heart rate, and blood pressure were recorded from baseline until 120 min after induction of PSA. Adverse events, hemodynamic variables, induction, and recovery time were recorded and compared between groups. RESULTS: The mean age of the patients was 38.16 ± 19.09 years and no differences were observed between the three groups in terms of demographic variables, pain scores, and procedures between the three groups. Respiratory events had similar incidences between the three groups. The O2 reduction was less in the Ketodex group in comparison with Ketofol and Ketamine groups (1.9%, 6.5%, and 3.8%, P = 0.015). No patient needed endotracheal intubation. Changes in mean arterial pressure from the baseline in Ketamine and Ketofol groups compared to Ketodex was higher (difference was 12.9 mmHg [95% CI, 9.5 to 20.3] and 8.6 mmHg [95% CI, 3.4 to 13.7]. Tachycardia in the Ketamine group had a significantly higher incidence. The recovery time was statistically shorter in the Ketofol group in comparison with other groups. The differences between Ketofol with Ketamine and Ketodex groups were 9.8 min (95% CI, [2.5 to 17.1]) and 8.3 min (95% CI, [1.5 to 15.1]). CONCLUSION: Ketodex, as well as ketofol, were effective and safe combinations with good recovery profiles and hemodynamic stability for adult PSA in ED.

A comparative study of dexmedetomidine and propofol to prevent recovery agitation in adults undergoing procedural sedation with ketamine: A randomized double-blind clinical trial.

BACKGROUND: The present study was designed to evaluate the effect of dexmedetomidine and propofol on ketamine-induced recovery agitation in adults when used as co-administration with ketamine. METHODS: In this prospective, randomized, and double-blind clinical trial, 93 patients aged 18 years or older who were candidates for painful procedures in the emergency department (ED) were enrolled and assigned into three equal groups to receive either ketadex (dexmedetomidine 0.7 µg/kg and ketamine 1 mg/kg), ketofol (propofol 0.5 mg/kg and ketamine 0.5 mg/kg) or ketamine alone (1 mg/kg) intravenously. Incidence and severity of recovery agitation were evaluated using the Richmond Agitation-Sedation Scale and compared between groups. RESULTS: There were no significant differences in demographic characteristics, procedures, pain scores, pre-sedation agitation, and duration of procedure between the three groups. The incidence of recovery agitation was 26% in the Ketadex group, 29% in the Ketofol group, and 58% in the Ketamine group. The difference in incidence of recovery agitation between Ketadex group and Ketamine group was 32% (95% confidence interval (CI), 9 to 56]) and between Ketofol group and Ketamine group was 29% (95% CI, 6 to 53). The severe agitation was significantly higher in Ketamine group, with a difference between Ketamine and Ketadex group of 19% (95% CI, 6 to 33), and a difference between Ketamine and Ketofol group of 16% (95% CI, 1 to 31). CONCLUSIONS: In this study, a combination of ketamine-dexmedetomidine and ketamine-propofol reduced the incidence and severity of ketamine-induced recovery agitation in adults undergoing procedural sedation in the ED.

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.

Comparison of the effects of dexmedetomidine and propofol in reducing recovery agitation in pediatric patients after ketamine procedural sedation in emergency department.

BACKGROUND: Ketamine has been a safe and effective sedative agent commonly used for painful pediatric procedures in the emergency department (ED). This study aimed to compare the effect of dexmedetomidine (Dex) and propofol when used as co-administration with ketamine on recovery agitation in children who underwent procedural sedation. MATERIALS AND METHODS: In this prospective, randomized, and double-blind clinical trial, 93 children aged between 3 and 17 years with American Society of Anesthesiologists Class I and II undergoing short procedures in the ED were enrolled and assigned into three equal groups to receive either ketadex (Dex 0.7 µg/kg and ketamine 1 mg/kg), ketofol (propofol 0.5 mg/kg and ketamine 0.5 mg/kg), or ketamine alone (ketamine1 mg/kg) intravenously. Incidence and severity of recovery agitation were evaluated using the Richmond Agitation-Sedation Scale and compared between the groups. RESULTS: There was no statistically significant difference between the three groups with respect to age, gender, and weight (P > 0.05). The incidence of recovery agitation was 3.2% in the ketadex group, 22.6% in the ketofol group, and 22.6% in the ketamine group (P = 0.002, children undergoing short procedures were recruited). There was a less unpleasant recovery reaction (hallucination, crying, and nightmares) in the ketadex group compared with the ketofol and ketamine groups (P < 0.05). There was no difference in the incidence of oxygen desaturation between the groups (P = 0.30). CONCLUSION: The co-administering of Dex to ketamine could significantly reduce the incidence and severity of recovery agitation in children sedated in the ED.

The effect of nitrous oxide in comparison to oxygen combined with fentanyl on the hospitalization time and pain reduction in renal colic patients at emergency department.

BACKGROUND: Renal colic is a painful medical emergency, needs urgent intervention to reduce pain. Nonsteroidal anti-inflammatory drugs, opioids, and entonox are pain-relieving agents. This study was aimed to compare fentanyl + entonox (nitrous oxide + O2) versus fentanyl + oxygen. MATERIALS AND METHODS: One hundred and twenty patients with acute renal colic presenting to the emergency department were enrolled. First, 50 µg fentanyl was infused for all patients. Then, patients divided into two groups receiving masks of entonox and oxygen, respectively. Quantitative measurement of pain was performed by visual analog scale, before the intervention, after 3, 5, 10, and 30 min of that. If the pain was not relieved after 30 min, 50 µg fentanyl was infused. If the pain was still continued, ketorolac and ketamine were used. Hospitalization duration and severity of pain at specified times were compared between patients in two groups. RESULTS: The mean (standard deviation) time of hospitalization was 211 (59) and 236 (61) min in fentanyl + entonox and fentanyl + O2 groups, respectively (P = 0.024). The decrease in pain severity after 10 and 30 min in fentanyl + entonox group were significantly greater than fentanyl + O2 group (P = 0.002 and 0.001, respectively). Mean (standard error) of needed time for renal colic pain to get better was 11.27 (1.23) and 20.47 (1.71) min in fentanyl + entonox and fentanyl + O2 groups, respectively (P < 0.001). Proportion of patients relief from pain in fentanyl + entonox in the second, third, and fourth measurements were significantly more than fentanyl + O2 group (P = 0.036, P < 0.001, and P < 0.001, respectively). CONCLUSION: Entonox is more effective to decrease the duration of hospitalization and reduction of pain than O2 in renal colic patients.

A comparative study of intranasal desmopressin and intranasal ketamine for pain management in renal colic patients: a randomized double-blind clinical trial.

OBJECTIVE: Urolithiasis is one of the most common urological diseases worldwide, usually presenting as renal colic that leads to severe pain that requires analgesic treatment. This study aimed to compare the efficacy of ketamine and desmopressin in the pain management of renal colic patients. METHODS: This double-blind, randomized clinical trial was conducted on renal colic patients referred to the emergency department from June 2021 to July 2022. Patients were randomly assigned to three groups. In the desmopressin group, patients were treated with intranasal desmopressin and intravenous ketorolac. The ketamine group was treated with intranasal ketamine and ketorolac. The control group received ketorolac and an intranasal placebo. Vital signs were evaluated at baseline and 60 minutes; and pain scores were assessed at baseline, 10, 30, and 60 minutes after treatment. RESULTS: Enrollment included 135 patients, the mean (standard deviation) age was 44.1±11.4 years, and 82 (60.7%) were men. The mean visual analog scale scores were significantly lower at 10, 30, and 60 minutes in the ketamine group (5.6±1.2, 3.0±1.1, and 0.9±0.9, respectively) compared to the control (8.2±1.1, 5.1±2.0, and 2.3±2.6, respectively) and desmopressin (6.7±1.8, 4.2±2.2, and 1.3±1.4, respectively) groups (P<0.05). Although patients in the desmopressin group had lower mean pain scores than the control group at 10, 30, and 60 minutes, this difference was only significant at 10 minutes after the intervention (P<0.05). No significant differences in vital signs were found at 60 minutes after treatment. CONCLUSION: Ketamine showed more favorable analgesic effects in renal colic patients than desmopressin, although desmopressin showed efficacy in the first minutes posttreatment.

The predictive value of point-of-care ultrasonography versus magnetic resonance imaging in assessing medial meniscal tears in patients with acute knee injury.

OBJECTIVE: Musculoskeletal ultrasound is increasingly used as the modality of choice in diagnosing many medical situations. The present study aimed to compare the accuracy of point-of-care ultrasonography (POCUS) and magnetic resonance imaging (MRI) to detect acute medial meniscus tears in knee. METHODS: The prospective study was conducted on patients with suspected medial meniscus tears in knee. in the emergency department. In the absence of a knee fracture on x-ray, POCUS on the knee was performed. All patients underwent POCUS and MRI of the knee followed by arthroscopy. POCUS findings were then compared to MRI findings to diagnose medial meniscus tears. RESULTS: A final total of 157 patients with a mean age of 25.04±7.41 years was included. Out of 157 patients, 94 (59.9%) were male. Medial meniscus tears were detected in 89 patients (56.7%) using arthroscopy as the gold standard. The sensitivity, specificity, positive and negative predictive values, and accuracy of POCUS to detect medial meniscus tears were 88.8% (95% confidence interval [CI], 80.3%-94.5%), 89.7% (95% CI, 79.9%-95.8%), 91.9% (95% CI, 84.8%-95.8%), 85.9% (95% CI, 77.2%-91.7%), and 89.2% (95% CI, 83.3%-93.6%), respectively. The diagnostic accuracy of MRI to detect medial meniscus injury was 93.0% (95% CI, 87.8%- 96.4%). CONCLUSION: The present study demonstrated that POCUS is an accurate and reliable diagnostic tool alternative to MRI in detecting medial meniscal tears. POCUS had acceptable sensitivity, specificity, and accuracy in detecting meniscal injuries and could be performed as an effective immediate investigation to guide further modalities in patients with acute knee trauma.

Diagnostic Value of Epigastric Ultrasound and Suprasternal Notch Ultrasound in Comparison with Standard Capnography in Confirmation of Endotracheal Tube Placement after Intubation.

Background: Endotracheal intubation is the basic method of providing a safe cross-sectional airway area and the incorrect placement can be dangerous and causes complications. So this study aimed to access the diagnostic value of color Doppler epigastric ultrasound and linear probe suprasternal notch ultrasound in comparison with standard capnography in confirmation of endotracheal tube (ETT) placement after intubation. Materials and Methods: This diagnostic value study was conducted on 104 patients requiring intubation who were referred to the Emergency Department. After the intubation, color Doppler epigastric ultrasound and suprasternal notch ultrasound as well as the standard capnography were used to confirm the placement ETT. Results: The sensitivity and specificity of color Doppler epigastric ultrasound were 97.96% and 100%, for suprasternal notch ultrasound were 98.98% and 66.67%, and for combination of the both methods were 96.94% and 100% respectively that showed the significant diagnostic value in the confirmation of ETT placement (P < 0.001). The mean of elapsed time to confirm the ETT placement by the standard capnography method (17.95 ± 2.45 s) was significantly more than the two methods of epigastric ultrasound (10.38 ± 4.65 s) and suprasternal notch ultrasound (5.08 ± 4.45 s) as well as the combined method with the mean of 15.46 ± 8.31 s (P < 0.001). Conclusion: The results of this study showed that although ultrasound is a potentially accurate, fast, and reliable method to confirm the endotracheal tube placement, but suprasternal notch ultrasound is considered to be a more appropriate diagnostic technique due to its higher sensitivity and less detection time compared to epigastric ultrasound and combined method.

Predictive performance of qSOFA in confirmed COVID-19 patients presenting to the emergency department.

Objectives: It is critical to quickly and easily identify coronavirus disease 2019 (COVID-19) patients who become severely or even critically ill. Thus, this study was conducted to determine the accuracy of the quick Sequential Organ Failure Assessment (qSOFA) score in predicting the severity and mortality of COVID-19 patients. Materials and Methods: This was a prospective observational study of COVID-19 patients admitted to the emergency department (ED) between June 22, 2021, and November 21, 2021. The clinical characteristics of the participants were collected by the emergency physicians. The correlation of the qSOFA, Systemic Inflammatory Response Syndrome criteria (SIRS), Pneumonia Severity Index (PSI), and confusion, urea, respiratory rate, blood pressure, 65 years of age and older (CURB-65) scores for 14-day mortality were evaluated. The area under a receiver operating characteristic (AUROC) curve analysis was calculated to compare the effectiveness of qSOFA, SIRS, PSI, and CURB-65 to predict severe disease. Results: Eight hundred and ninety-four subjects were included. Of them, 721 patients (80.6%) survived after 14 days of admission. The mean age was 58.92 ± 17.80 years, and 551 subjects (61.6%) were male. Nonsurvived patients were significantly older (51.09 ± 23.60 vs. 38.10 ± 18.24, P = 0.004) and had more comorbidities (diabetes mellitus, respiratory, cardiovascular, and cerebrovascular disease) in comparison with survived patients. For COVID-19 mortality prediction, the AUROCs of qSOFA, CURB-65, PSI, and SIRS score were 0.799 (95% confidence interval [CI 0.771-0.825]), 0.829 (95% CI [0.803-0.853]), 0.830 (95% CI [0.804-0.854]), and 0.759 (95% CI [0.730-0.787]), respectively. All scores were good predictors of COVID-19 mortality. Conclusion: The qSOFA was more successful than SIRS in predicting mortality for COVID-19 patients and was similar to CURB-65 and PSI. Therefore, the qSOFA score can be considered a simple and rapid screening tool for identifying high-risk patients.

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.

Diagnostic accuracy of ultrasonography for diagnosis of elbow fractures in children.

BACKGROUND: Elbow injuries and fractures are a common pathology in the pediatric emergency unit. X-ray and CT scan of the elbow are the standard diagnostic procedures, which increase exposure to radiation in children. Previous studies have shown that fractures can also be visualized by ultrasound (US); thus, this study aimed to evaluate the diagnostic accuracy of elbow US compared with radiography for the diagnosis of elbow fracture in children. MATERIALS AND METHODS: This was a prospective observational study of patients aged 2-14 years that presented to emergency departments with a suspected elbow fracture requiring radiographic evaluation. Elbow US for diagnosing elevated posterior fat pad or lipohemarthrosis was performed. All patients underwent elbow radiography and received clinical follow-up. Initial or follow-up X-ray or CT scan was used as the reference standard for fracture diagnosis. RESULTS: Seventy-five patients with a mean age of 6.51 ± 3.68 years were enrolled in the study. Twenty-eight (37.3%) patients had positive results for fracture. The sensitivity, specificity, and accuracy of US in the diagnosis of elbow fractures were 92.9% (95% CI 76.5-99.1%), 89.4% (95% CI 76.9-96.5%) and 90.7% (95% CI 81.7-96.2%). In patients with fracture, US demonstrated a lipohaemarthrosis in 20 patients (71.4%), elevated posterior fat pad in 19 patients (67.9%), cortical disruption in 10 patients (35.7%), and effusion in three patients (10.7%). CONCLUSION: Our results showed high diagnostic accuracy for the ultrasonography diagnosis of an elbow fracture, which allows us to confirm ultrasonography imaging of the elbow as a safe alternative in the primary evaluation of pediatric elbow injuries.

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.

D-dimer Levels in Predicting Severity of Infection and Outcome in Patients with COVID-19.

COVID-19 disease began to spread all around the world in December 2019 until now; and in the early stage it may be related to high D-dimer level that indicates coagulation pathways and thrombosis activation that can be affected by some underlying diseases including diabetes, stroke, cancer, and pregnancy and it also can be associated with Chronic obstructive pulmonary disease (COPD). The aim of this article was to analyze D-dimer levels in COVID-19 patients, as D-dimer level is one of the measures to detect the severity and outcomes of COVID-19. According to the results of this study, there is a higher level of D-dimer as well as concentrations of fibrinogen in the disease onset and it seems that the poor prognosis is linked to a 3 to 4-fold increase in D-dimer levels. It is also shown that 76% of the patients with ≥1 D-dimer measurement, had elevated D-dimer and were more likely to have critical illness than those with normal D-dimer. There was an increase in the rates of adverse outcomes with higher D-dimer of more than 2000 ng/mL and it is associated with the highest risk of death at 47%, thrombotic event at 37.8%, and critical illness at 66%. It also found that diabetes and COPD had the strongest association with death in COVID-19. So, it is necessary to measure the D-dimer levels and parameters of coagulation from the beginning as well as pay attention to comorbidities that can help control and management of COVID-19 disease.

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.

Physiologic Scoring Systems in Predicting the COVID-19 Patients' one-month Mortality; a Prognostic Accuracy Study.

Introduction : It is critical to quickly and easily identify severe coronavirus disease 2019 (COVID-19) patients and predict their mortality. This study aimed to determine the accuracy of the physiologic scoring systems in predicting the mortality of COVID-19 patients. Methods: This prospective cross-sectional study was performed on COVID-19 patients admitted to the emergency department (ED). The clinical characteristics of the participants were collected by the emergency physicians and the accuracy of the Quick Sequential Failure Assessment (qSOFA), Coronavirus Clinical Characterization Consortium (4C) Mortality, National Early Warning Score-2 (NEWS2), and Pandemic Respiratory Infection Emergency System Triage (PRIEST) scores for mortality prediction was evaluated. Results: Nine hundred and twenty-one subjects were included. Of whom, 745 (80.9%) patients survived after 30 days of admission. The mean age of patients was 59.13 ± 17.52 years, and 550 (61.6%) subjects were male. Non-Survived patients were significantly older (66.02 ± 17.80 vs. 57.45 ± 17.07, P< 0.001) and had more comorbidities (diabetes mellitus, respiratory, cardiovascular, and cerebrovascular disease) in comparison with survived patients. For COVID-19 mortality prediction, the AUROCs of PRIEST, qSOFA, NEWS2, and 4C Mortality score were 0.846 (95% CI [0.821-0.868]), 0.788 (95% CI [0.760-0.814]), 0.843 (95% CI [0.818-0.866]), and 0.804 (95% CI [0.776-0.829]), respectively. All scores were good predictors of COVID-19 mortality. Conclusion: All studied physiologic scores were good predictors of COVID-19 mortality and could be a useful screening tool for identifying high-risk patients. The NEWS2 and PRIEST scores predicted mortality in COVID-19 patients significantly better than qSOFA.

The Role of Cardiac Arrest Sonographic Exam (CASE) in Predicting the Outcome of Cardiopulmonary Resuscitation; a Cross-sectional Study.

INTRODUCTION: Ultrasonography (US) has been suggested as an integral part of resuscitation to identify potentially reversible causes of cardiac arrest (CA). This study aimed to evaluate the association between cardiac activity on ultrasonography during resuscitation and outcome of patients with non-shockable rhythms. METHODS: We conducted a prospective, observational study on adult patients presenting with CA or experiencing CA in the emergency department (ED), and initial non-shockable rhythm. US examination of the sub-xiphoid region was performed during the 10-second interval of rhythm and pulse check and the association of US findings and patients' outcomes was evaluated. RESULTS: 151 patients with the mean age of 65.32 ± 11.68 years were evaluated (76.2% male). 43 patients (28.5%) demonstrated cardiac activity on the initial US. The rate of asystole in initial rhythm was 58.9% (n=89). Return of spontaneous circulation (ROSC) was achieved in 36 (23.8%) patients, twenty (13.2%) survived to hospital admission and seven (4.6%) survived to hospital discharge. When the cardiac standstill duration increased to six minutes, no patient survived hospital discharge. Potentially reversible causes were detected in 15 cases (9.9%), and four of them survived to hospital discharge. Cardiac activity on first scan was associated with ROSC (OR: 6.86, 95%CI: 2.92-16.09; p < 0.001), survival to hospital admission (OR: 17.80, 95%CI: 3.95-80.17; p < 0.001), and survival to hospital discharge (OR: 17.35, 95%CI: 2.02-148.92; p = 0.001). CONCLUSION:  In non-traumatic cardiac arrest patients with non-shockable rhythms, bedside US is of great importance in predicting ROSC. The presence of pulseless electrical activity (PEA) rhythm and cardiac activity on initial US were associated with ROSC, survival to hospital admission, and hospital discharge. When the cardiac standstill duration increased to six minutes, no patient survived hospital discharge.

Topical Lidocaine plus Diclofenac as a Local Anesthetic Agent in Central Venous Catheterization; a Randomized Controlled Clinical Trial.

INTRODUCTION: Various methods of analgesia can be used to reduce or prevent procedural pain in emergency department (ED). This study aimed to evaluate the effectiveness of topical lidocaine-diclofenac combination compared to lidocaine-prilocaine combination (Xyla-P) in reduction of the pain during central venous catheter (CVC) insertion. METHODS: In this randomized clinical trial, 100 adult patients requiring CVC insertion in the ED were enrolled. These patients were randomly divided into two groups. The site of CVC insertion was covered with 2 g of topical Xyla-P cream in the first group, and 2 g of topical lidocaine-diclofenac cream in the second group. The primary outcome was the pain during CVC implantation. The secondary outcomes were physician satisfaction and the incidence of side effects. RESULTS:  On the visual analog scale (VAS), the pain score during CVC insertion was significantly lower in the second group (p = 0.027). However, there was no difference in pain scores during lidocaine injection between the two groups (p = 0.386). Also, there was no significant difference in the rate of side effects between the two groups (p = 1.0). The physician's satisfaction with the first group was significantly lower than the second group (p = 0.042). CONCLUSION: Although the CVC insertion pain was significantly lower in patients who received the topical combination of Lidocaine plus Diclofenac, there was no clinically important difference between the two groups and both topical anesthetics were effective and safe in reducing pain intensity. Also, lidocaine-diclofenac combination cream was more cost-effective than Xyla-P cream.

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.

Physiologic Scoring Systems versus Glasgow Coma Scale in Predicting In-Hospital Mortality of Trauma Patients; a Diagnostic Accuracy Study.

INTRODUCTION: In recent years, several scoring systems have been developed to assess the severity of trauma and predict the outcome of trauma patients. This study aimed to compare Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) in predicting the in-hospital mortality of trauma patients. METHODS: This diagnostic accuracy study was done on adult patients admitted to the emergency department (ED) between June 21, 2019, and September 21, 2020, following multiple trauma. Patients were followed as long as they were hospitalized. The REMS, MEWS, GCS, and ISS were calculated after data gathering and comprehensive assessment of injuries. Receiver operating characteristics (ROC) analysis was performed to examine the prognostic performance of the four different tools. RESULTS: Of the 754 patients, 32 patients (4.2%) died and 722 (95.8%) survived after 24 hours of admission. The mean age of the patients was 38.54 ± 18.58 years (78.9% male). The area under the ROC curves (AUC) of REMS, MEWS, ISS, and GCS score for predicting in-hospital mortality were 0.942 (95% CI [0.923-0.958]), 0.886 (95% CI [0.861-0.908]), 0.866 (95% CI [0.839-0.889]), and 0.851 (95% CI [0.823-0.876]), respectively. The AUC of REMS was significantly higher than GCS (p=0.035). The sensitivities of GCS ≤ 11, ISS ≥ 13, REMS ≥ 4, and MEWS ≥ 3 scores for in-hospital mortality were 0.56, 0.97, 0.81, and 0.94, respectively. Also, the specificities of GCS, ISS, REMS, and MEWS scores for in-hospital mortality were 0.93, 0.82, 0.81, and 0.85, respectively. CONCLUSION: It seems that REMS is more accurate than GCS, ISS, and MEWS in predicting in-hospital mortality ≥ 24 hours of multiple trauma patients.