Archives of Academic Emergency Medicine

Introduction: Erythrocyte sedimentation rate (ESR) remains as one of the most reliable tests in clinical practices. Yet its use is time consuming and requires a large blood sample. The aim of this study was assessing a faster and reliable method of ESR estimation. Methods: An ESR estimation method was described and performed on 108 patients using capillary tube (micro ESR) and capillary peripheral blood. Micro ESR results at different intervals were measured and compared with Westergren ESR (conventional ESR) estimation by Pearson and Spearman’s coefficients. A regression equation was derived to predict conventional ESR values based on micro ESR results. The agreement of two measurements was demonstrated using the Bland-Altman plot. Results: Micro ESR results at 20 minutes showed the earliest close correlation with conventional ESR results at one hour (0.99). The presented regression equation was able to closely predict ESR values (r^2 = 0.974) and the Bland-Altman plot showed an acceptable agreement between converted and conventional ESR measurements. Conclusion: Using capillary tube and capillary blood sample (micro ESR) appears to be a faster, cheaper, more reliable, and precise tool for ESR measurement in the ED. The results have acceptable correlation with conventional ESR, especially at 20 minutes of measurement.

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

Introduction: Ketamine is an agent used broadly for pediatric procedural sedation and analgesia in emergency departments. It has been found to be safe and with a low risk of complications. As choosing between intravenous (IV) and intramuscular (IM) injections is a matter of concern, we did comparison between two methods in terms of their efficacy and the rate of complications. Methods: This single-blind clinical trial study recruited 240 children (age: three months to 15 years, weight > 5 kg), who underwent short and painful procedures at the emergency departments. They were randomly allocated in to two groups of 120 patients to receive either IV or IM ketamine with doses of 1.5 and 4 mg/kg, respectively. Indications for use, dose, side effects, and efficacy of the medications as well as duration of the procedure and time to recovery were compared between two groups. Results: The mean age of the IV and IM groups were 6.5 ± 3.6 and 3.05 ± 2.6 years, respectively (p < 0.001). The onset of action of ketamine was 1.7 ± 1.1 minutes in the IV group and 8.6 ± 3.1 in the IM ones (p < 0.001). Patients of the IV and IM groups remained in optimal sedation for 20.6±12.0 and 37.2±11.8 minutes, respectively (P < 0.001). Time until emergency department discharge was 65.3 ± 36.9 minutes in the IV group and 72.2 ± 14.5 in the IM group (P = 0.40). Ketamine had excellent and moderate efficacy in 66.7% and 32.5% of the IV group and 70.0% and 25.0%  in the IM group, respectively (p = 0.02). Totally, 60.0% of IV group patients and 40.0% of IM group experienced drug side effects (p = 0.21). Need to rescue dose was significantly higher in IV group (26.7% vs. 10.0%; p < 0.001). Finally, recovery was tranquil and comfortable in 88 patients (73.3%) of the IV group and 108 patients (90.0%) of the IM group (p = 0.06). Conclusion: We found that although the sedative and analgesic effects of IM and IV ketamine are not significantly different, duration of effect and onset of action are more desirable in the IV group for suturing, fracture reduction, and foreign body removal. Meanwhile, the IM method can lead to lesser need of rescue doses.

Introduction: Motion artifacts are a common problem in pediatric radiographic studies and are a common indication for pediatric procedural sedation. This study aimed to compare the combination of oral midazolam and ketamine (OMK) with oral midazolam alone (OM) as procedural sedatives among children undergoing computed tomography (CT) imaging. Methods: The study population was comprised of six-month to six-year old patients with medium-risk minor head trauma, who were scheduled to undergo brain CT imaging. Patients were randomly allocated to two groups: one group received 0.5 mg/kg midazolam (OM group; n = 33) orally and the other one received 0.2 mg/kg midazolam and 5 mg/kg ketamine orally (OMK group; n=33). The vital signs were monitored and recorded at regular intervals. The primary outcome measure was the success rate of each drug in achieving adequate sedation. Secondary outcome measures were the time to achieve adequate sedation, time to discharge from radiology department, and the incidence of adverse events. Results: Adequate sedation was achieved in five patients (15.2%) in OM group and 15 patients (45.5%) in OMK group, which showed a statistically significant difference between the groups (P = 0.015). No significant difference was noted between OM and OMK groups with respect to the time of achieving adequate sedation (33.80 ± 7.56 and 32.87 ± 10.18 minutes, respectively; P = 0.854) and the time of discharging from radiology department (89.60 ± 30.22 and 105.27 ± 21.98 minutes, respectively; P=0.223). The complications were minor and similar among patients of both groups. Conclusion: This study demonstrated that in comparison with OM, OMK was more effective in producing a satisfactory level of sedation in children undergoing CT examinations without additional complications; however, none of these two regimens fulfilled clinical needs for procedural sedation.

Introduction: Headache is the most common neurologic symptom among referees to the emergency department (ED), while the best treatment has not yet been found. Therefore, in the present study pain relief effects of metoclopramide and acetaminophen were compared in patients suffered acute primary headache. Methods: This study was a double-blind randomized clinical trial performed in Imam Khomeini Hospital, Urmia, Iran, through July to October 2014.  All adult patients, with acute primary (migraine, tension type and cluster) headache referred to the ED were included in this study. Pain Severity was measured with 10 centimeters numeric rating scales. The patients were randomized in to two groups of intravenous (IV) metoclopramide (10 milligrams) and acetaminophen (1 gram). Pain score, success rate, and complication of drugs were compared within administration time and 15, 30, 60, as well as 120 minutes after medication. Results: 100 patients were equally categorized in to two groups (mean age of 32 ± 13.2 years; 51.2% male). Initial pain score in metoclopramide and acetaminophen groups were 9.1 and 9.4, respectively (p=0.46). IV metoclopramide did not have any analgesic effect at 15 minutes, but had good effect at 30 minutes. While, the analgesic effect of acetaminophen initiated after 15 minutes. After 2 hours, both drugs had good treatment effect on primary headaches (p<0.001). Conclusion: The present study demonstrated that efficacy of metoclopramide for pain relief in primary headaches is lower than acetaminophen.  In this regard, success rate of acetaminophen was 42.0% versus 0% for metoclopramide within 15 minutes. The efficacy of acetaminophen continued until 60 minutes.

Brachial artery aneurysms are rare but potentially limb threatening condition. The presented case here is a 52-year old male referred to the emergency department complaining a sudden onset and progressive pain with coldness of his right upper extremity during brushing. The right upper extremity was pulseless and three-dimensional computed tomography showed an aneurysm of the proximal right brachial artery associated with arterial occlusion in its distal branch. Embolectomy was done, the aneurysm resected, and the artery successfully re-vascularised by interposing a saphenous vein graft.

Endoscopic Retrograde Cholangiopancreatography (ERCP) is widely used for the diagnosis and treatment of biliary and pancreatic tract disease. Perforation is a rare complication of it, but it is associated with high rate of mortality, an overall mortality rate of 1.0-1.5%. Here, a case of massive subcutaneous emphysema following ERCP was reported without an obvious retroperitoneal or peritoneal perforation.

One of the important and usual missed causes of pediatric traumas is child abuse. This ominous phenomenon, which can be presented physically, psychologically, sexually, and emotionally has grown significantly in recent years. Many children are not diagnosed in the early stages of evaluation. Battered Child Syndrome is used to describe the clinical condition of the child serious physical abuse by parents or caregivers. Medical staff should always keep the syndrome in their mind for those brought to the emergency department with trauma. In this report, we described a patient complained of dysphagia following a falling from a height and multiple epidural hematomas and final diagnosis of battered child syndrome.

Emergency physicians, like other specialists, are faced with different patients and various situations each day. They have to use ancillary diagnostic tools like laboratory tests and imaging studies to be able to manage them. In most cases, numerous tests are available. Tests with the least error and the most accuracy are more desirable. The power of a test to separate patients from healthy ones determines its accuracy and diagnostic value. Therefore, a test with 100% accuracy should be the first choice. This does not happen in reality as the accuracy of a test varies for different diseases and in different situations. For example, the value of D-dimer for diagnosing pulmonary embolism varies based on pre-test probability. It shows high accuracy in low risk patient and low accuracy in high risk ones. The characteristics of a test that reflects the aforementioned abilities are accuracy, sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios. In this educational review, we will simply define and calculate the accuracy, sensitivity, and specificity of a hypothetical test.