Single intravenous dose ondansetron induces QT prolongation in adult emergency department patients: a prospective observational study.

BACKGROUND: Ondansetron is one of the most commonly used drugs in the emergency department (ED) for treating nausea and vomiting, particularly in intravenous (IV) form. Nevertheless, it has been shown to prolong QT interval and increase the risk of ventricular dysrhythmias. This study evaluated the associations between single IV ondansetron dosage and subsequent QTc prolongation in the ED. METHODS: In this prospective observational study, a total number of 106 patients presenting to the ED in a 3-month period with nausea and vomiting treated with IV ondansetron were enrolled. QT and QTc intervals were measured at baseline (QT0 and QTc0), and 60 min (QT60 and QTc60) following a single-dose administration of ondansetron at 4 or 8 mg doses. To evaluate the predictive ability of these variables, we employed receiver operating characteristic (ROC) curve analyses. RESULTS: The predictive models for QTc prolongation 1-hour post-ondansetron administration showed the following: at baseline, the area under curve of 0.70 for QT, 0.71 for QTc, and 0.64 for dosage. Conversely, a QTc0 = 375 msec indicated a QTc60 > 480 msec with a specificity of 97%. Additionally, a QTc0 of 400 msec had a sensitivity of 100% in predicting a QTc60 < 480 msec, while a QTc0 > 460 msec predicted a QTc60 > 480 msec with a specificity of 98%. Moreover, 8 mg doses were associated with higher rates of QTc60 prolongation, while 4 mg doses favored maintaining QTc60 within normal limits. CONCLUSIONS: Our study demonstrates the predictive capacity of QT0, QTc0, and ondansetron dosage in forecasting QTc60 prolongation (> 480 msec) post-ondansetron administration. These findings advocate for their incorporation into clinical protocols to enhance safety monitoring in adult ED patients.

Ultrasound-guided femoral nerve block versus fascia iliaca compartment block for femoral fractures in emergency department: A randomized controlled trial.

Aim: Femoral fractures are one of the most debilitating injuries presenting to the emergency departments (EDs). The pain caused by these fractures is typically managed with opioids and adjunctive regional analgesia. These approaches are often associated with adverse side effects. Thus, appropriate alternative methods should be thoroughly investigated. To evaluate ultrasound-guided femoral nerve block (FNB) with ultrasound-guided fascia iliaca compartment block (FICB) in femoral fractures, to determine which provides better analgesia and less opioid requirement. Methods: This study was a randomized clinical trial performed on adult patients presenting to the ED within 3 h of isolated femoral fracture with initial numerical pain rating scale (NRS-0) score of more than 5. The patients were randomized to receive FNB or FICB. The outcomes were block success rates, pain at 20 (NRS-20) and 60 (NRS-60) min after the end of the procedures, as well as the number and total dose of fentanyl administration during ED stay. Results: Eighty-seven patients were recruited (40 FNB and 47 FICB). Success rates were 82.5% in FNB and 83.0% in FICB group, with no significant difference between the groups. NRS-20, NRS-60, the number of patients who received supplemental fentanyl, and the total dose of administered fentanyl were significantly lower following FNB. However, the length of the procedure was significantly lower in the FICB group. Conclusion: Both FNB and FICB are effective in pain reduction for fractures of femur, but FNB provides more pain relief and less need for supplemental fentanyl.

Effect of oral clonidine on pain reduction in patients with opioid use disorder in the emergency department: A randomized clinical trial.

AIMS: Pain can create physical and psychosocial discomfort. Pain management of patients with opioid misuse history can be challenging, in part due to their tolerance to opioids. Clonidine is an alpha-2 agonist that has been used for the reduction of anxiety and pain. The aim of this study was to investigate the effect of oral clonidine on pain outcomes in patients with a history of opioid use disorder presenting with orthopaedic fractures in the emergency room. METHODS: In this blinded clinical trial in the emergency department, 70 opioid-dependent patients with orthopaedic fractures were divided into a control group of 35 and an intervention group of 35 subjects. Initially, 0.2 mg of oral clonidine was given to the intervention group and the control group received placebo tablets. Pain levels were recorded based on the Numerical Rating Scale rating before intervention, at 30 min, 1 h after intervention and at disposition from the emergency room (3-6 h after intervention). The total morphine requirement was also recorded. RESULTS: The pain score of the clonidine group was significantly lower than that of the control group at 1 h and at disposition time. The amount of morphine required was significantly reduced in the clonidine group (P < 0.05). Oral clonidine had no significant effect on pulse rate. Oral clonidine was more effective for pain reduction in lower limb injuries. CONCLUSION: Oral clonidine significantly reduced pain and the need for morphine in opioid-dependent patients with orthopaedic fractures.

Emergency Severity Index Triage in Iran: A Comparison Between Age Groups in a Trauma Center.

There are concerns about the accuracy of Emergency Severity Index (ESI) triage system in the geriatric population. This study was performed to compare the correlation of ESI triage with injury severity score (ISS) between adults with trauma younger than 60 years and those 60 years of age and older and to determine the ability of ESI to predict an ISS of greater than 15 in these two age groups. This was an observational study performed in an academic trauma center in Kerman, Iran. A convenience sample of trauma patients older than 16 years was included. Five-level ESI triage was performed by nurses with 2-10 years of exclusive experience in triage. The ISS scores were calculated by the researchers. Both numerical and categorical (ISS >15) forms of the score were considered as outcomes. Ultimately, a total of 556 patients were enrolled in the study. No difference in undertriage was seen between the age groups (p = 0. 51). Spearman's correlation coefficient between ESI level and ISS was -0.69 and -0.77 in patients younger than 60 years and those aged 60 years or older, respectively (z = 1.20). The areas under the curves (AUCs) for prediction of ISS of greater than 15 were also similar between the two age groups (0.89 in less than 60 and 0.85 in 60 or more). In conclusion, the performance of ESI was similar between the two age groups. Therefore, the application of the ESI triage system for initial categorization of trauma patients seems to be a reliable and easy-to-learn method for the triage of elderly as well as younger age groups.

COMPARISON OF ULTRASOUND-GUIDED ERECTOR SPINAE PLANE BLOCK WITH INTERCOSTAL NERVE BLOCK FOR TRAUMA-ASSOCIATED CHEST WALL PAIN.

BACKGROUND: Pain associated with chest wall trauma is a major issue in the emergency department (ED). However, it may be challenging to select among the various analgesic procedures. OBJECTIVE: Our aim was to compare single-shot erector spinae plane block (ESPB) with intercostal nerve block (ICNB) under ultrasound guidance for pain management in thoracic trauma. METHODS: This study was a randomized nonblinded clinical trial performed in a level I urban trauma center. A convenience sample of patients with isolated chest wall trauma and initial Numeric Rating Scale pain scores (NRS 0) > 5 were included. Exclusion criteria were large pain area, surgical interventions, discharged from the ED, and presence of contraindications to lidocaine. Pain scores at 20 min and 60 min (NRS 20 and 60) and at disposition (disp) were recorded. RESULTS: Twenty-seven patients in the ESPB and 23 in the ICNB groups were enrolled. Mean values of NRS 0, 20, 60, and disp for the ESPB vs. ICNB groups were 8.0 vs. 7.4, 5.2 vs. 6.1, 4.1 vs. 5.4, and 4.3 vs. 5.8, respectively (p = 0.07, p = 0.04, p = 0.001, and p < 0.001, respectively). Four patients in the ESPB and 8 patients in the ICNB groups required administration of adjunctive doses of fentanyl for satisfactory pain control (p = 0.09). CONCLUSIONS: Ultrasound-guided ESPB was superior to ICNB regarding pain control during the ED stay period of patients with painful chest wall trauma. We recommend ESPB in the ED for pain control in blunt or penetrating thoracic trauma.

The effect of preoperative oral magnesium oxide on the severity of postoperative pain among women undergoing hysterectomy.

BACKGROUND: Magnesium sulfate has been reported to be effective in perioperative pain treatment and in blunting somatic, autonomic, and endocrine reflexes provoked by noxious stimuli. The pre-emptive analgesic effects of magnesium in reducing postoperative pain could be beneficial in abdominal and gynecologic surgeries. OBJECTIVE: The aim of study was to compare the pre-emptive analgesic effects of oral magnesium oxide and naproxen for hysterectomy surgery. METHODS: This study evaluated all patients who were candidates for hysterectomy in 2 months. The 64 patients were randomly divided into two groups using a random allocation sequence. The patients in the intervention and control groups received either magnesium oxide tablet (500 mg) or naproxen tablet (500 mg) orally half an hour before surgery, respectively. The severity of postoperative pain is assumed as a primary outcome which is evaluated using the visual analogue scale (VAS). RESULTS: In this study, 64 patients were assessed. The results showed age, weight, systolic and diastolic blood pressure, and pulse rate of the patients in the two groups were not significantly different (p > 0.05). The mean score of pain intensity for these patients was significantly lower than the patients receiving naproxen (p-value: 0.03). Besides, more than one-quarter of patients in the magnesium oxide group (n = 9, 28.12%) received this analgesia with lower dose than the patients in the naproxen group (p-value: 0.03). CONCLUSION: The results of this study showed that preoperative oral magnesium oxide had a significant effect on the severity of postoperative pain and consumption of postoperative analgesia.

Persistence of post-concussion symptoms in patients with mild traumatic brain injury and no psychiatric history in the emergency department.

PURPOSE: To elucidate the predictive factors for persistent post-concussion symptoms at 1 and 3 months following minor traumatic brain injuries (mTBIs) in patients with no psychiatric history. METHODS: This was an observational study in an academic trauma centre including adult patients with a history of mTBI and no psychiatric history. Exclusion criteria were missing the follow-up phone calls, radiologic abnormalities, simultaneous injuries and refusal to participate. Outcomes were post-concussion syndrome according to the international classification of diseases (ICD)-10 (ICD-PCS) and persistence of more than one mTBI related symptoms at 1 and 3 months post-injury. RESULTS: From 364 enrolled patients, 16 (4.4%) developed ICD-PCS, whereas 28 (7.6%) and 8(2.1%) reported more than one symptom at one and three months, respectively. Multivariable analysis showed associations between ICD-PCS with more than one initial symptom in the emergency department (ED) and the non-motor vehicle collision (non-MVC) impact mechanism with area under curve of 0.77. The former variable was associated with the persistence of more than one post-concussion symptom at one and three months. CONCLUSION: More than one symptom in the ED and the mechanism of injury not related to MVCs (sports, violence or fall injuries) may predict symptom persistence. Early treatment and follow-up strategies may be beneficial for vulnerable patients.

Consensus statements on the approach to patients in a methanol poisoning outbreak.

Background: Methanol poisoning is an important cause of mortality and morbidity worldwide. Although it often occurs as smaller sporadic events, epidemic outbreaks are not uncommon due to the illicit manufacture and sale of alcoholic beverages.Objective: We aimed to define methanol poisoning outbreak (MPO), outline an approach to triaging an MPO, and define criteria for prioritizing antidotes, extracorporeal elimination treatments (i.e., dialysis), and indications for transferring patients in the context of an MPO.Methods: We convened a group of experts from across the world to explore geographical, socio-cultural and clinical considerations in the management of an MPO. The experts answered specific open-ended questions based on themes aligned to the goals of this project. This project used a modified Delphi process. The discussion continued until there was condensation of themes.Results: We defined MPO as a sudden increase in the number of cases of methanol poisoning during a short period of time above what is normally expected in the population in that specific geographic area. Prompt initiation of an antidote is necessary in MPOs. Scarce hemodialysis resources require triage to identify patients most likely to benefit from this treatment. The sickest patients should not be transferred unless the time for transfer is very short. Transporting extracorporeal treatment equipment and antidotes may be more efficient.Conclusion: We have developed consensus statements on the response to a methanol poisoning outbreak. These can be used in any country and will be most effective when they are discussed by health authorities and clinicians prior to an outbreak.

Measuring serum albumin levels at 0 and 24h: Effect on the accuracy of clinical evaluations in the prediction of burn-related mortality.

OBJECTIVES: To evaluate whether measuring serum albumin levels in clinical assessments affects the accuracy of mortality predictions in large burns and to compare patients' serum albumin levels at hour 0(Alb0h) and hour 24(Alb24h) following their admission. METHODS: This prospective observational study was performed at an academic burn unit. Aged between 16 and 65, patients who presented with burns on more than 20% of total body surface area (%TBSA) were included. Patients with severe comorbidities, concomitant trauma or referred from other centres were excluded from the study. The main variables in the study were Alb0h, Alb24h and Abbreviated Burn Severity Index (ABSI) scores. The primary outcome was in-hospital mortality. RESULTS: In a population of 105 patients, %TBSA, being female, inhalational injury, Alb0h, Alb24h and ABSI score (p<0.001) and the presence of a full thickness injury (p=0.008) were associated with mortality. In the multivariable analysis, ABSI scores and Alb24h remained in the model (OR, 2.32 and 0.06, respectively). The area under curves (AUCs) were 0.94, 0.97 and 0.97 for ABSI, ABSI+Alb0h and ABSI+Alb24h, respectively. No significant difference among the AUCs was seen, but adding Alb0h and Alb24h improved the mortality predictions of ABSI by 5 (4.7%) and 4 (3.8%) patients, respectively. Alb0h (at 3.5g/dL) and Alb24h (at 2.4g/dL) showed 84-85% and 88-85% sensitivity-specificity for mortality, respectively. CONCLUSION: Measuring serum albumin levels in clinical assessments slightly increases the accuracy of mortality predictions; however, different cut-off points for Alb0h and Alb24h needs to be considered to avoid interpretation errors.

Ultrasound-guided interscalene nerve block vs procedural sedation by propofol and fentanyl for anterior shoulder dislocations.

BACKGROUND: Few studies were performed to compare ultrasound guided brachial plexus block with procedural sedation for reduction of shoulder dislocations in the Emergency Department (ED). This study was done to provide further evidence regarding this comparison. METHODS: This was a randomized clinical trial performed on patients presenting with anterior shoulder dislocations to the emergency department of an academic level 2 trauma center. Exclusion criteria were any contraindications to the drugs used, any patient which may not be potentially assigned into both groups because of an underlying medical condition, presence of neurovascular compromise related to the dislocation, presence of concomitant fractures, and patient refusal to participate in the study. Patients were randomly assigned into the Procedural Sedation and Analgesia (PSA) group with propofol and fentanyl or ultrasound guided Inter-Scalene Brachial Plexus Block (ISBPB) with lidocaine and epinephrine. RESULTS: A total of 60 patients (30 in each group) were included in the study. The emergency room length of stay was significantly lower in the ISBPB group, with mean (SD) values of 108.6 (42.1) vs. 80.2 (25.2) minutes (p=0.005). However, pain scores in the PSA group during reduction showed advantage over ISBPB [0.38 vs. 3.43 (p<0.001)]. Moreover, patient satisfaction was higher with PSA (p<0.001). CONCLUSION: Using ISBPB for reduction of anterior shoulder dislocations takes less time to discharge and may make it more feasible in conditions mandating faster discharge of the patient. However, since pain scores may be lower using PSA, this method may be preferred by many physicians in some other situations.

Eleven years of children methadone poisoning in a referral center: A review of 453 cases.

OBJECTIVES: Methadone can be fatal due to respiratory failure even in little doses. This study aimed to evaluate the possible risk factors of death and/or intubation in methadone-poisoned children of 12 years or younger. DESIGN: Retrospective routine database study. SETTING: The only tertiary hospital for children poisoning in Tehran. PATIENTS: Four hundred fifty-three methadone-poisoned patients aged 12 or younger were studied between 2001 and 2012. MAIN OUTCOME MEASURES: In-hospital mortality and intubation/mechanical ventilation. RESULTS: Of a total of 475 children included, 22 were excluded due to coingestion of other drugs. Three (0.66 percent) expired and 12 (2.65 percent) were intubated during the course of hospital stay. Intubation (p < 0.001), fever (T axillary ≥ 37.5°C, p = 0.01), being unresponsive at presentation (p = 0.02), tachycardia (p = 0.01), acidosis (p = 0.03), leukocytosis (p = 0.02), and longer hospital stay (p = 0.01) associated with death. Mortality (p < 0.001), fever (p = 0.004), aspartate aminotransferase (AST; p = 0.006), alanine transaminase (p = 0.04), creatinine (p = 0.005), corrected QT (QTc) interval in triage electrocardiogram (p = 0.02), and longer hospital stay (p = 0.005) associated with intubation in univariate analysis. However, after running regression analysis, only fever, QTc ≥ 480 ms, tachycardia, and AST independently associated with intubation and death. Axillary T ≥ 37.45 °C with an accuracy of 91.9 (95% confidence interval [CI] 88.8-94.2) and odds ratio of 9.3 (95% CI 2.5-34.9) predicted intubation, and T ≥ 37.75 with an accuracy of 96.0 (95% CI 93.5-97.5) and odds ratio of 47.4 (95% CI 4.1-550.1) predicted death. CONCLUSION: A methadone-poisoned child presenting with tachycardia, fever, abnormal AST, or an initial prolonged QTc interval should be managed with great caution.

Shock index, modified shock index, and age shock index for prediction of mortality in Emergency Severity Index level 3.

OBJECTIVES: To elucidate the predictive capability of shock index (SI), modified SI (MSI), and age SI for mortality in patients assigned to Emergency Severity Index (ESI) level 3 patients. METHODS: This was a retrospective medical record review performed in an academic internal medicine emergency department in Kerman, Iran. All patients older than 14 years triaged to ESI level 3 were enrolled in the study. Triage time vital signs were used to calculate SI, MSI, and age SI. The primary outcome was in-hospital mortality. RESULTS: A total number of 3375 patients were enrolled in the study, in which 84 (2.5%) died during hospital stay. In the adjusted multivariate analysis, age SI, systolic blood pressure (SBP), and sex were independently associated with mortality, with P values (odds ratio [95% confidence interval]) of <.001 (1.03 [1.01-1.04]), .003 (0.97 [0.96-0.99]), and .04 (1.61 [1.01-2.59]), respectively. Receiver operating characteristic curve showed an area under curve of 0.717 for the 3-variable final model and an area under curve of 0.678 for age SI in mortality prediction. CONCLUSIONS: In ESI level 3 patients, age SI and SBP showed to be better than SI or MSI in predicting mortality. However, because their predictive capability was modest, age SI or SBP should be considered adjuncts to sort actions in favor of patients with higher risk for mortality.

Association of triage time Shock Index, Modified Shock Index, and Age Shock Index with mortality in Emergency Severity Index level 2 patients.

BACKGROUND: Shock Index (SI) is considered to be a predictor of mortality in many medical and trauma settings. Many studies have shown its superiority to conventional vital sign measurements in mortality prediction. OBJECTIVES: The objectives were to compare mortality and intensive care unit admission prediction of triage time SI, Modified SI (MSI), and Age SI with each other and with triage time blood pressure in Emergency Severity Index (ESI) level 2 patients. METHODS: A retrospective medical record review was performed in the internal medicine emergency department of a general hospital in Kerman, Iran. Triage time vital signs were used to calculate the indices. Multivarible regression analysis was used to create the final model. RESULTS: A total of 1285 patients triaged to ESI level 2 were enrolled in the study. In the multivariate analysis, SI, MSI, and Age SI were found to be the only variables independently associated with mortality, whereas none of them were associated with intensive care unit admission. Sensitivity, specificity, and area under curve in the receiver operating characteristic curve for the model including SI, MSI, and Age SI were 60.8%, 65.4%, and 0.675, respectively. Sensitivity, specificity, and area under curve did not change significantly by excluding SI, MSI, or Age SI from the final model. CONCLUSION: In nontrauma adult patients, triage time SI, MSI, and Age SI are superior to blood pressure for mortality prediction in ESI level 2. They can be used alone or in combination with similar results, but their low sensitivity and specificity make them usable only as an adjunct for this purpose.

Risk Factors for Mortality and Endotracheal Intubation after Methadone Intoxication.

This was a retrospective chart review to evaluate various risk factors associated with in-hospital mortality and intubation risk in acute methadone overdose. All patients admitted to an academic hospital in Tehran, Iran, during a 10-year period (2000-2009) constituted the study sample. Exclusion criteria were significant comorbidities and age under 18 years. Outcome variables were in-hospital mortality and being intubated during admission. A total of 802 patients were enrolled in the study. There were 15 (1.8%) deaths due to methadone overdose or its complications. The number of yearly admissions was 15 patients in 2000, 16 in 2001, 16 in 2002, 18 in 2003, 23 in 2004, 38 in 2005, 59 in 2006, 110 in 2007, 206 in 2008 and 301 in 2009. Based on logistic regression analysis, the most important independent variable predicting mortality was length of admission in toxicology ward [OR (95% CI): 1.6 (1.1-2.3)]. For the prediction of intubation, independent variables were Glasgow Coma Scale (GCS) score of 5-9 [OR (95% CI): 356.5 (9.8-12907.4)] in the emergency department (ED), miosis in the ED [356.9 (1.4-87872.5)] and respiratory rate in the ED [1.5 (1.1-2.1)]. Linear regression model for length of hospitalization showed patient age as the most important variable for prediction of this outcome. Despite a relatively low mortality rate, the increasing number of methadone-poisoned patients requires special attention to this common intoxication. Careful disposition of patients from ED to ordinary wards or intensive care units and also from higher to lower levels of care should be considered in methadone overdose.

Methanol mass poisoning in Iran: role of case finding in outbreak management.

BACKGROUND: There are no guidelines addressing the public health aspects of methanol poisoning during larger outbreaks. The current study was done to discuss the role of active case finding and a national guideline that organizes all available resources according to a triage strategy in the successful management of a methanol mass poisoning in Rafsanjan, Iran, in May 2013. METHODS: A retrospective cross-sectional study was performed reviewing the outbreak Emergency Operation Center files. The objectives were to describe the characteristics, management and outcome of a methanol outbreak using Active Case Finding to trace the victims. RESULTS: A total of 694 patients presented to emergency departments in Rafsanjan after public announcement of the outbreak between 29th May and 3rd June 2013. The announcement was mainly performed via short message service (SMS) and local radio broadcasting. A total of 361 cases were observed and managed in Rafsanjan and 333 were transferred to other cities. Seventy-five and 100 patients underwent hemodialysis (HD), retrospectively. The main indication for HD was refractory metabolic acidosis. Eight patients expired due to the intoxication. Except for the deceased cases, no serum methanol level was available. CONCLUSION: In developing countries, where diagnostic resources are limited, use of active case finding and developing national guidelines can help in the management of large outbreaks of methanol poisonings.

The correlation between prolonged corrected QT interval with the frequency of respiratory arrest, endotracheal intubation, and mortality in acute methadone overdose.

Corrected QT interval (QTc) prolongation is long considered as a predisposing factor for the occurrence of torsade de pointes (TdP) and sudden cardiac arrest in methadone maintenance treatment. We aimed to elucidate the correlation between QTc prolongation and in-hospital death, respiratory arrest, and endotracheal intubation in acute methadone-intoxicated patients presenting to the emergency department and to assess the value of QTc in predicting these outcomes. A prospective cross-sectional study with a convenience sample of patients with acute methadone overdose was done. Participants were 152 patients aged 15-65 with negative urinary dipstick test for cyclic antidepressants, no history of other QTc-prolonging conditions and co-ingestions, no severe comorbidities affecting the outcomes, and positive urinary dipstick results for methadone. QTc intervals were measured and calculated in triage-time electrocardiogram (ECG). Death was correlated with QTc (P = 0.014) and length of ICU admission (P < 0.001). In multivariable analysis, death was independently associated only with length of ICU admission [odds ratio (OR) 95 % confidence intervals (95 % CI) 1.36 (1.14-1.61)]. Intubation and respiratory arrest were independently associated with QTc interval [OR (95 % CI) 1.03 (1.02-1.04) and 1.02 (1.01-1.03), respectively]. The receiver operating characteristics curves drawn to show the ability of QTc to predict death, intubation, and respiratory arrest showed thresholds of 470, 447.5, and 450 ms with sensitivity (95 % CI) and specificity (95 % CI) of 87.5 (47.3-99.7), 86.8 (74.7-94.5), and 77.3 (62.2-88.5), respectively. Our study showed that QTc is a potential predictor for adverse outcomes related to acute methadone intoxication. The correlations shown in this study between triage-time QTc and in-hospital respiratory arrest or intubation in methadone overdose may be of clinical value, whether these outcomes are hypothesized to be a reflection of background TdP or intoxication severity.