Comparative Study of Radial and Median Nerve Blocks with Hematoma Block under Ultrasound Guide in Distal Radius Fracture Reduction: A Randomized Clinical Trial.

Background: Distal radius fractures are one of the most common upper extremity fractures, and their incidence continues to increase due to an aging population and an increase in osteoporosis. Various methods of analgesia for distal radius fractures have been described-including hematoma blocks and nerve blocks. Hematoma blocks are a simple and effective method of providing analgesia; nonetheless, their efficacy may be limited in some cases. On the other hand, nerve blocks provide more targeted analgesia and may be more effective in reducing pain during fracture reduction. This study aimed to compare the analgesic effectiveness of radial and median nerve blocks with hematoma blocks under ultrasound guidance in treating distal radius fractures. Also, this study aimed to compare the analgesia of radial and median nerve blocks with hematoma blocks under ultrasound guidance to reduce distal radius fractures. Methods: In this prospective trial, patients with distal radius fractures referring to 2 academic centers were placed into 2 randomized groups, including hematoma block, and radial median block, both of which were ultrasound-guided. The patient's pain levels were measured and recorded based on the visual analog scale before the block, 5, 10, and 15 minutes after the block, at the start of reduction, during reduction, and 5, 10, and 15 minutes after reduction. Patient satisfaction and physician satisfaction rates were assessed, and side effects were also observed for 1 week. Quantitative variables were reported as mean ± standard deviation, and number and frequency percentages were reported for qualitative variables. The Student t test and the chi-square test were used on a case-by-case basis. The significance level was set at P ˂ 0.05. Results: In this study, 120 patients were included. The groups had no significant differences in pain reduction during the procedure. Analgesic medication was needed during the procedure for 17 patients; nerve blocks were applied for 6 patients, and hematoma blocks for 11 patients, which was statistically significant (P = 0.041). Satisfaction rates for patients and physicians performing the procedure were significantly higher in the nerve block group than in the hematoma block group ( P = 0.001; P ˂ 0.001, respectively). Conclusion: The results of this study suggest that ultrasound-guided radial and median nerve blocks can be used as alternative methods of analgesia with other techniques in the reduction of distal radius fractures in emergency departments.

Can low-dose of ketamine reduce the need for morphine in renal colic? A double-blind randomized clinical trial.

BACKGROUND: The combination of morphine with low doses of ketamine (MK) has been utilized in the Emergency Department (ED) compared with morphine and placebo (MP) for the treatment of acute pain in few studies. The purpose of this study was to compare the effect of MP with MK for the treatment of severe pain with renal colic of patients who had been referred to the ED. METHODS: This study is a double blind randomized clinical trial on patients with severe renal colic pain who were referred to the ED. Patients were enrolled with pain severity of at least 6 of the 10 visual analogue scales (VAS). Patients were divided into two groups: Morphine 0.1mg/kg and placebo (MP group) and morphine 0.1mg/kg and ketamine 0.15mg/kg (MK group). Pain of patients was studied in 10, 30, 60, 90, and 120min after injection. RESULTS: Totally, 106 patients were enrolled in study groups. Assessment of the average pain during 120min at 10 and 30min after the start in the drug, MK group was significantly lower than the MP group (p=0.019 and p=0.003 respectively). CONCLUSION: Given that combinations of morphine with low doses of ketamine in patients with renal colic pain causes more pain and morphine consumption reduction then this combination is suggested as an alternative treatment that could be utilized in patients with renal colic.

Can intravenous acetaminophen reduce the needs to more opioids to control pain in intubated patients?

AIMS: To evaluate the effect of intravenous (IV) acetaminophen on reducing the need for morphine sulfate in intubated patients admitted to the Intensive Care Unit (ICU). SETTINGS AND DESIGN: Current study was done as a clinical trial on the patients supported by mechanical ventilator. SUBJECTS AND METHODS: Behavioral pain scale (BPS) scoring system was used to measure pain in the patients. All of the patients received 1 g, IV acetaminophen, every 6 h during the 1(st) and 3(rd) days of admission and placebo during the 2(nd) and 4(th) days. Total dose of morphine sulfate needed, its complications, and the BPS scores at the end of every 6 h interval were compared. RESULTS: Totally forty patients were enrolled. The mean pain scores were significantly lower in the 2(nd) and 4(th) days (4.33 and 3.66, respectively; mean: 4.0) in which the patients had received just morphine sulfate compared to the 1(st) and 3(rd) days (7.36 and 3.93, respectively; mean: 5.65) in which the patients had received acetaminophen in addition to morphine sulfate too (P < 0.001). Cumulative dose of morphine sulfate used, was significantly higher in the 1(st) and 3(rd) days (8.92 and 3.15 mg, respectively; 12.07 mg in total) compared to the 2(nd) and 4(th) days (6.47 mg and 3.22 mg, respectively; 9.7 mg in total) (P = 0.035). CONCLUSION: In our study, IV acetaminophen had no effect on decreasing the BPSs and need of morphine sulfate in intubated patients admitted to ICU.

Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial.

OBJECTIVE: We compared the efficacy and safety of ultrasound-guided haematoma block with that of procedural sedation and analgesia in patients with acute distal radial fracture reduction pain control. METHODS: This was a randomised clinical trial on adult patients conducted in two teaching hospitals. Patients received intravenous midazolam plus fentanyl in the procedural sedation and analgesia group, and fracture site injection of lidocaine 10% in the ultrasound guided haematoma block group. We measured pain scores before reduction, during reduction and 5, 10 and 15 min after reduction by a numeric rating scale, and patient and physician satisfaction by a four-level Likert scale. Time to discharge, early adverse effects and late complications were also compared. RESULTS: We enrolled 160 patients with distal radial fracture and randomised 143 patients into two groups (after excluding 17 patients). Pain was effectively controlled in both groups. Pain scores had no statistically significant difference before and during reduction and 5 and 15 min after reduction in the procedural sedation and analgesia and ultrasound guided haematoma block groups. Patient and physician overall satisfaction were similar in the two groups. Time to discharge was significantly lower in the ultrasound guided haematoma block group. Four patients (5.5%) in the procedural sedation and analgesia group showed early adverse effects. No patient in either group showed any late complications. CONCLUSIONS: Ultrasound guided haematoma block may be a safe and effective alternative to procedural sedation and analgesia. TRIAL REGISTRATION NUMBER: 201112308104N5.

Oral oxycodone plus intravenous acetaminophen versus intravenous morphine sulfate in acute bone fracture pain control: a double-blind placebo-controlled randomized clinical trial.

OBJECTIVES: Bone fracture is a common cause of acute pain in emergency and orthopedics departments. Targeting the multifaceted mechanisms of pain with combinations of multiple analgesics (multimodal analgesia) can increase the pain control efforts efficacy and decrease the adverse effects of each medication. METHODS: One hundred and fifty-three patients with acute bone fracture were randomly allocated to two groups receiving intravenous morphine sulfate (74 patients) or oral oxycodone plus intravenous acetaminophen (79 patients). Pain scores and drugs' adverse effects were assessed 10, 30 and 60 min after treatment. RESULTS: Pain scores were similar between groups before, 30 and 60 min after medication but patients in morphine sulfate group experienced less pain 10 min after medication. Eight (10.8%) patients in morphine sulfate group and 26 (32.9%) patients in acetaminophen/oxycodone group experienced nausea that was statistically significant higher (P value = 0.001). Itching was seen in 12 (15.1%) patients of acetaminophen/oxycodone group and three (4.0%) patients of patients in morphine sulfate group (P value = 0.02). CONCLUSION: Intravenous acetaminophen plus oral oxycodone is as effective as intravenous morphine sulfate in acute pain control in emergency department but with a less desirable safety profile.

Role of plasma ammonia level in detecting intra-abdominal hemorrhage following blunt abdominal trauma.

BACKGROUND: Blunt abdominal injury is a leading cause of death in trauma patients. A reliable test predicting intra-abdominal hemorrhage would be a novel method. The study objective was to assess the diagnostic accuracy of plasma ammonia in detection of intra-abdominal bleeding in patients with blunt abdominal trauma (BAT). MATERIALS AND METHODS: In this observational study, all patients suffering from BAT, referred to our university teaching hospital included. The levels of ammonia were measured at the time of emergency department admission and 1 h after initial treatment. Demographic data, vital signs, and venous blood gas reports were recorded. Findings of contrast-enhanced abdominopelvic computed tomography scan and laparotomy were assumed as a gold standard for abdominal injuries. RESULTS: A total of 104 patients was enrolled in the study. 15 patients (14.4%) had intra-abdominal hemorrhage and the mean plasma ammonia level in this group was significantly higher than the other patients on admission time (101.73 ± 5.41 µg/dL vs. 47.36 ± 26.31 µg/dL, P < 0.001). On receiver-operator characteristic curve analysis, in cutoff point of 89 µg/dL, the sensitivity, specificity, positive and negative likelihood ratios were 100% (95% confidence interval [CI], 79.6-100), 93.26% (95% CI, 86-96.8), 14.83 (95% CI, 6.84-32.12), and 0, respectively. CONCLUSION: The study findings suggest the measurement of ammonia level at the time of admission in the patients with BAT would be a useful test predicting intra-abdominal hemorrhage. Furthermore, decrease in the ammonia level could be a useful marker for monitoring response to treatment in these patients.

Diagnostic accuracy of ultrasonographic examination in the management of shoulder dislocation in the emergency department.

STUDY OBJECTIVE: Emergency physicians frequently encounter shoulder dislocation in their practice. The objective of this study is to assess the diagnostic accuracy of ultrasonography in detecting shoulder dislocation and confirming proper reduction in patients presenting to the emergency department (ED) with possible shoulder dislocation. We hypothesize that ultrasonography could be a reliable alternative for pre- and postradiographic evaluation of shoulder dislocation. METHODS: This was a prospective observational study. A convenience sample of patients suspected of having shoulder dislocation was enrolled in the study. Ultrasonography was performed before and after reduction procedure with a 7.5- to 10-MHz linear transducer. Shoulder dislocation was confirmed by taking radiographs in 3 routine views as a criterion standard. The operating characteristics of ultrasonography to detect dislocation in patients with possible shoulder dislocation and to confirm reduction in patients with definitive dislocation were calculated as the primary endpoints. RESULTS: Seventy-three patients were enrolled. The ultrasonography did not miss any dislocation. The results of ultrasonography and radiography were identical and the sensitivity of ultrasonography in detection of shoulder dislocation was 100% (95% confidence interval 93.4% to 100%). The sensitivity of ultrasonography for assessment of complete reduction of the shoulder joint reached 100% (95% confidence interval 93.2% to 100%) in our study as well. CONCLUSION: We suggest that ultrasonography be performed in all patients who present to the ED with a clinical impression of shoulder dislocation on admission time. The results of this study provide promising preliminary support for the ability of ultrasonography to detect shoulder dislocation. However, further investigation is necessary to validate the results and assess the ability of ultrasonography in detecting fractures associated with dislocation.

Effects of brain contusion on mild traumatic brain-injured patients.

Traumatic brain injury (TBI) is an important health issue with high prevalence. The most common type of TBI is mild TBI (MTBI). MTBI is known as a condition with self-limited symptoms; however, it could cause some structural abnormalities of brain and become complicated. Visible structural brain damage could have an important effect on recovery after MTBI, but the outcome is not fully understood. This study investigated the clinical course of MTBI patients with the existence of contusion in computed tomography (CT) imaging. Fifty patients with MTBI and simultaneous brain contusion in CT scan were enrolled according to specific exclusion criteria in 14 month. Patients were followed up for two weeks after their first arrival for neurosurgical interventions, decreased level of consciousness, and other neurological complications. Presence of neurological symptoms increased duration of hospital stay and number of CT scans. Forty-two percent of MTBI patients with contusion did not have any objective neurological signs. Fifty percent returned to the hospital with neurologic symptoms and signs. Leading causes were headache followed by seizure and dizziness. Rehospitalization was increased in the patients with altered level of consciousness. The size of brain contusion increased in two patients without further need for neurosurgical intervention. Contusion alone did not worsen the prognosis of patients in short-term follow-up and did not cause neurosurgical interventions.

Comparison of diagnostic value of conventional ultrasonography by emergency physicians with Doppler ultrasonography by radiology physicians for diagnosis of deep vein thrombosis.

OBJECTIVES: To determine sensitivity, specificity and other operating characteristics of bedside three-point compression ultrasonography performed in emergency department by emergency physicians in comparison with duplex ultrasonography. METHODS: The cross-sectional study at Rasoul-e-Akram Hospital in Tehran, Iran, prospectively evaluated 81 suspected patients of lower extremity deep vein thrombosis between March 2006 and March 2007. A trained second-year resident and one attending physician of emergency medicine evaluated the veins of all the patients with through compression ultrasonography. Then, a second-year resident of radiology assessed the patients with duplex ultrasonography. Finally, data were compared and quantitative and categorical variables were worked out along with other statistical analysis through SPSS version 16. RESULTS: The mean age of the patients was 47.2 +/- 18.6 years. When cases who lost the compressibility of at least one of their femoral or popliteal veins were considered to be positive, there were 80.2% diagnosed by compression ultrasonography and 79% by the duplex variety. Sensitivity, specificity and accuracy of the former in comparison with the latter were 85.9%, 41.2% and 84.6% respectively. CONCLUSION: Compression ultrasonography has relatively an acceptable sensitivity and accuracy level, but has low specificity in the diagnosis of deep vein thrombosis in the hands of Iranian emergency physicians. It is better to implement duplex ultrasonography whenever accessible. Otherwise, compression ultrasonography results should be compared with the results of duplex ultrasonography as soon as possible.

Prevalence of occupational exposure to blood and body secretions and its related effective factors among health care workers of three Emergency Departments in Tehran.

BACKGROUND: Accidental exposure to blood and body secretions is frequent among health care workers (HCWs). They are at risk of acquiring blood-borne diseases. In this study, we have investigated the prevalence and risk factors of occupational exposure among the HCWs of the Emergency Departments (ED) at three teaching hospitals in Tehran. MATERIALS AND METHODS: We conducted this observational, descriptive, cross-sectional study using a self-reporting 25-question survey, related to occupational exposures, in February 2010. It was carried out among 200 HCWs (specialist physicians, residents, medical interns, nurses, laboratory personnel, housekeepers, cleaners, and others), who were working in the EDs of the three teaching hospitals of the Tehran University of Medical Sciences. The age, sex, and job category of the HCWs suffering from the injury were determined, as also the risk factors responsible for the exposure of the HCWs. RESULTS: One hundred and fifteen (57.5%) of the 200 HCWs had had at least one episode of blood or body fluid exposure in their professional life. Hollow-bore needles accounted for the highest amount of injuries, with 41.5%, followed by suture needles (18.5%). The most prevalent procedures associated with injuries were suturing (17.5%) and recapping used syringes (16.5%), respectively. All the specialist doctors in this study reported at least one exposure. The percentage of exposure in the other participants of our study was 74.3% for ED residents, 61.1% for laboratory technicians, 51.9% for nurses, and 51% for medical interns. Binary logistic regression analysis revealed that male gender, recapping needles, and job profession were independently associated with exposure to blood or body fluids. CONCLUSION: High prevalence of occupational exposure in this study emphasized the importance of promoting awareness, training, and education for the HCWs, for preventive strategies, and also reporting of occupational exposure to blood and body secretions.

An unusual case of bilateral anterior shoulder and mandible dislocations.

Unilateral anterior shoulder dislocation is the most common major joint dislocation seen by emergency physicians. Bilateral glenohumeral dislocations are rarely seen and almost always posterior after seizure or electrical shock. We present an unusual case of bilateral anterior dislocation of shoulder that had anterior dislocation of temporomandibular joint simultaneously. These problems occurred after a course of generalized tonic-clonic seizure. The coincidence of these dislocations is the first case published in the literature.

Intravenous Acetaminophen vs. Ketorolac in Terms of Pain Management in Prehospital Emergency Services: A Randomized Clinical Trial.

INTRODUCTION: Although pain management in EDs has been fully addressed in clinical trials, prehospital settings have rarely been investigated. OBJECTIVE: The present study was conducted to compare the effectiveness of intravenous acetaminophen with that of ketorolac in pre-hospital pain control. METHOD: This randomized clinical trial (RCT) was performed at a prehospital setting during EMS missions in Tehran, Iran. The eligible candidates comprised all patients over the age of 7 years with a complaint of moderate to severe pain. The patients were randomly assigned to two groups, one receiving 30 mg of intravenous (IV) ketorolac and the other 1 g of IV acetaminophen. The pain intensity was measured using a visual analog scale (VAS) before administering the analgesic and upon admission to the ED. RESULTS: The present study was conducted on 150 patients aged 8-81 years with a mean age of 40.4 ± 17.7, including 84 (56%) males. The mean reduction in the pain score was 14.9±8.6 in the acetaminophen group and 16.0±8.8 in the ketorolac group. Univariate analyses suggested no statistically significant differences between the two groups in terms of delta pain score (pain reduction) (P=0.429). CONCLUSION: Based on the obtained findings, both ketorolac and acetaminophen could be administered for pain management in prehospital settings in both traumatic and non-traumatic patients in case their contraindications are considered.

Validity, reliability and acceptability of Professionalism Mini-Evaluation Exercise (P-MEX) for emergency medicine residency training.

Professionalism is a core competency in the medical profession. In this paper, we aimed to confirm the validity, reliability and acceptability of the Professionalism Mini-Evaluation Exercise (P-MEX) instrument for the emergency medicine (EM) residency program. Twenty-two EM attending physicians completed 383 P-MEX forms (the Persian version) for 90 EM residents. Construct validity was assessed via structural equation modeling (SEM). The reliability coefficient was estimated by the generalizability theory, and acceptability was assessed using two researcher-made questionnaires to evaluate the perspectives of residents and assessors. There was a consensus among the participants regarding the content of P-MEX. According to the results of SEM, the first implementation of the original model was associated with a moderate fit and high item loadings. The model modified with correlated error variances for two pairs of items showed an appropriate fit. The reliability of P-MEX was 0.81 for 14 occasions. The perception survey indicated high acceptability for P-MEX from the viewpoint of the residents and increasing satisfaction with P-MEX among the assessors over time. According to the results of the research, P-MEX is a reliable, valid, and acceptable instrument for assessing professionalism in EM residents.

Daylight saving time and incidence ratio of acute myocardial infarction among Iranian people.

Iran is among the countries which change official time, every year according to their constitutions. Studies have shown an increase of incidence ratio (IR) of acute myocardial infarction by these time transitions. Despite annual time changes in Iran, there is no published data to prove this among the Iranian. This retrospective study examined the IR of patients with AMI, who were admitted to the Emergency Department (ED) of 5 teaching hospitals during the week just after the time transitions (observed period), with two weeks before and after the time transitions (expected period), both in spring and fall. In total, 11051 patients were admitted during the ten weeks (observed and expected), in both spring and fall time transitions. The IR of AMI during both observed and expected period did not show any significant difference (p > 0.05); however, the incidence of AMI was increased during the first week after the transition in spring (p > 0.05). Although the results of the present study did not prove the relation between time transitions and incidence of AMI, a slight increase existed for IR of AMI during three days after spring shift. This increase in IR of AMI can be due to Nowrooz, the national holidays which lasts four days after turning clocks forward in Iran.

Propofol-Ketamine vs. Propofol-Fentanyl Combinations in Patients Undergoing Closed Reduction: A Randomized, Double-blind, Clinical Trial.

INTRODUCTION: Painful surgical procedures require adequate sedation and analgesia. A vast array of medications can be used for Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs). OBJECTIVE: The present study was conducted to compare Propofol-Ketamine (PK) and Propofol-Fentanyl (PF) compounds in patients undergoing closed reduction in EDs. METHODS: This randomized, double-blind, clinical trial was conducted on 110 consecutive patients who required sedation for closed reduction. The patients were randomly divided into two groups of equal sizes. The PK group received an intravenous bolus of 1 mg/kg of propofol plus 0.5 mg/kg of ketamine, and the PF group received an intravenous bolus of 1 mg/kg of propofol plus 1 µg/kg of fentanyl. The analgesic effect and success rate were the primary outcomes under study. RESULTS: The PK group achieved more effective analgesia at the end of the experiment. The success rate was almost the same in both groups Shivering (p=0.005) and a drop in oxygen saturation to below 92% (p=0.048) were two side effects that were more prevalent in the FK group. The mean recovery time was significantly shorter in the PK group (p<0.001). The patients in the PK group were more satisfied. CONCLUSION: In comparison with the PF compound, the use of KP leads to better pain relief and greater patient satisfaction and shorter sedation time in PSA.

Screening performance of Ultrasonographic B-lines in Detection of Lung Contusion following Blunt Trauma; a Diagnostic Accuracy Study.

INTRODUCTION: Chest ultrasonography is routinely used in evaluation of chest trauma for diagnosis of pulmonary injury. This study aimed to evaluate the accuracy of B-Lines for diagnosing lung contusion in patients with blunt trauma of the chest. METHODS: Trauma patients who met the inclusion criteria were enrolled in the study and underwent ultrasonography by trained emergency medicine residents. Ultrasound results were recorded in terms of number of B-lines and the existence of peripheral parenchymal lesion (PPL). After ultrasound, the patient underwent chest x-ray and chest CT scan (as reference test) and screening performance of B-lines and PPL were evaluated. RESULTS: 147 patients underwent chest ultrasound. The mean age of the patients was 40.74 ± 18.6 (78.9% male). B-lines˃3 had 94.0% (95% CI: 83.45-98.75) sensitivity and 57.7% (95% CI: 47.3-67.7) specificity, B-lines˃6 had 90.0% (95% CI: 78.2-96.7) sensitivity and 93.81% (95% CI: 87.0-97.7) specificity, and PPL had 34.0% (95% CI: 21.2-48.8) sensitivity and 100% (95% CI: 96.3-100.0) specificity. Composite findings of B-lines˃6 + PPL had 92.0% (95% CI: 80.8-97. 8) sensitivity and 93.8% (95% CI: 87.0-97.7) specificity in the diagnosis of lung contusion. CONCLUSION: PPL and B-Lines˃6 had the highest accuracy in detecting lung contusion. B-Line˃6 had high sensitivity and specificity and was easy to perform; thus, it seems that B-Line˃6 could be considered as an alternative screening tool in detection of lung contusion.

Effects of Pre-Injury Anti-Platelet Agents on Short-Term Outcome of Patients with Mild Traumatic Brain Injury: A Cohort Study.

OBJECTIVE: To determine the effects of pre-injury consumption of anti-platelet agents on the 30-day outcomes of patients with mild traumatic brain injury (TBI). METHODS: This prospective cohort study was conducted at three general hospitals in Tehran, Iran between July 2013 and July 2014. The study population included all patients with mild TBI aged over 18 years that medicated with aspirin or clopidogrel before occurring trauma. Within hospitalization, all patients were assessed with respect to in-hospital conditions especially complications and adverse events. After discharge, the individuals were followed for 30 days by telephone to assess mortality and disability using the Glasgow outcome scale (GOS). RESULTS: Of 1140 patients with mild TBI, only 135 had previously received aspirin and/or clopidogrel. The mean age was dramatically higher in those who were taking aspirin or clopidogrel (p<0.001). The patients with previously use of anti-platelets were more transferred by ambulance when compared to another group (p=0.006). The patients on anti-platelets had significantly lower GCS on admission when compared to others (p<0.001). Length of hospitalization was significantly longer in those receiving anti-platelets (p=0.003). In follow-up, 30-day mortality and disability was revealed in 2.8% of patients that received only aspirin and 7.5% in aspirin with clopidogrel and in 1.6 % of those who did not receive drugs without any significant difference between aspirin and control group (p=0.208) and significant difference in aspirin with clopidogrel group (p<0.001). CONCLUSION: The premedication by anti-platelets (aspirin and/or clopidogrel) in patients with mild TBI leads to prolonged hospital stay, and increase rate of disability. Age and on admission GCS are the independent risk factors for predicting the outcome in patients with mild TBI receiving anti-platelet agents.

Jolt accentuation and its value as a sign in diagnosis of meningitis in patients with fever and headache.

OBJECTIVES: Meningitis is an important disease among the patients being visited in Emergency Departments (EDs). There are many signs to diagnose it with different sensitivity and specificity reported in previously done studies. Current study tries to evaluate diagnostic accuracy of "Jolt accentuation" in the diagnosis (Dx.) of meningitis in patients with fever and headache. MATERIALS AND METHODS: 48 adult patients, who were referred to two teaching EDs for fever and headache and were diagnosed as suspected meningitis, were included in this prospective observational study. Demographic characteristics of patients were recorded in data sheets, as well as the results of exams including nuchal rigidity, Kernig and Brudzinski signs, and Jolt accentuation. Then, lumbar puncture (LP) was done and cerebrospinal fluid (CSF) was analyzed for each patient; pleocytosis (more than five white blood cells in high power field) were considered as meningitis. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (LR+ and LR-) of the above mentioned signs were compared to each other. RESULTS: Meningitis was proved in 33 patients (68.8% of them), according to CSF analysis. Jolt accentuation had sensitivity, specificity, PPV, NPV, LR+, and LR- of 69.6%, 33.3%, 69.6%, 33.3%, 1.02, and 0.91, respectively. Jolt accentuation had the highest sensitivity rate all of the signs mentioned above; although, it was not significant. CONCLUSION: Jolt accentuation alone cannot rule in or out the Dx. of meningitis in patients with fever and headache; LP is still recommended for these patients.