Archives of Academic Emergency Medicine

Introduction: Nausea and vomiting are the most common complications after minor head trauma that increases the risk of intracranial pressure rising. Therefore, the present study was aimed to compare the antiemetic effects of metoclopramide and ondansetron in the treatment of post-traumatic nausea and vomiting. Methods: The study was a controlled, randomized, double blind clinical trial, which was conducted in the first 6 months of 2014 in emergency department Al-Zahra and Kashani Hospitals in Isfahan, Iran. The patients with minor head trauma associated with nausea and vomiting were randomly divided into 2 groups: treatment with metoclopramide (10mg/2ml, slow injection) and treatment with ondansetron (4mg/2ml, slow injection). The comparison between the 2 groups was done regarding antiemetic efficacy and side effects using SPSS 21 statistical software. Results: 120 patients with minor head trauma were distributed and studied into two groups of 60 patients (mean age 35.6±14.1 years; 50.0% male). Administration of both ondansetron and metoclopramide significantly reduced the severity of nausea (P<0.001). Changes in the severity of nausea in both groups before and after the treatment revealed that nausea had been decreased significantly in both groups (P < 0.001). The incidence of fatigue (p=0.44), headache (p=0.58) and dystonia (p=0.06) had no significant difference in the two groups but the incidence of drowsiness and anxiety in the metoclopramide group was significantly higher (P < 0.001). Conclusion: The present study indicated that the treatment effectiveness of ondansetron and metoclopramide are similar. However, incidence of drowsiness and anxiety in the metoclopramide was considerably higher. Since these complications can have adverse effects on the treatment of patients with brain injury, it is suggested that it may be better to use ondansetron in these patients.

Introduction: Traumatic brain injuries (TBI) are one of the most important causes of death in patients under the age of 25 years and is responsible for one third of total deaths caused by trauma. Therefore, knowing its epidemiologic pattern in different populations seems vital. Therefore, this study aims to examine the epidemiologic pattern of TBI in emergency department. Methods: In this cross-sectional study, the profiles of 1000 patients affected by TBI were selected using simple random sampling. The examined variables in this study included demographic, season, mechanism of injury, accompanying injuries, level of consciousness, hospitalization duration, computed tomography (CT) scan results, needing surgery, admission to intensive care unit, and outcome of the patient. In the end, independent risk factors for the death of patients were determined. Results: 1000 patients suffering from were studied (81.8% male; mean age 38.5±21.7 years). The frequency of their referral to hospital in spring (31.4%) was more (p<0.01). 45.9% of the patients had a level of consciousness less than 9 based on the Glasgow Coma Scale (GCS). Subdural (45.9%) and epidural bleeding (23.7%) were the most common findings in CT scans in this study (p<0.001). Finally, 233 (23.3%) of the patients were dead. Over 60 years of age, falling and motorcycle accidents, intracranial hemorrhage accompanied by brain contusion, subdural bleeding, a GCS of less than 9, and the need to be admitted to intensive care unit were independent risk factors of death in TBI. Conclusion: Age Over 60 years, falling and motorcycle accidents, intracranial hemorrhage accompanied by brain contusion, subdural bleeding, a GCS of less than 9, and need to be admitted to intensive care unit were independent risk factors for the death in TBI patients.

Introduction: Creating a calm and stress-free environment affects education significantly. The effects of the emergency department overcrowding (EDO) on the training of emergency medicine residents (EMR) is a highly debated subject. Therefore, this study aimed to evaluate the effect of EDO on efficiency of EMR’s education. Methods: In this cross-sectional study, the effects of overcrowding on EMR’s education in the resuscitation room and acute care unit. Data collection was done using a questionnaire, which was filled out by the second year EMRs.  The crowding level was calculated based on the national emergency department overcrowding scale (NEDOCS). The relationship between the two studied variables was evaluated using independent sample t-test and SPSS 21 statistical software. Results: 130 questionnaires were filled out during 61 shifts. 47 (77.05%) shifts were overcrowded. The attend’s ability to teach was not affected by overcrowding in the resuscitation room (p=0.008). The similar results were seen regarding the attend’s training ability in the acute care unit. Conclusion: It seems that the emergency department overcrowding has no effect on the quality of education to the EMRs.

Introduction: The effect of severe soft tissue injury on the severity of hemorrhagic shock is still unknown. Therefore, the present study was aimed to determine hemodynamic and metabolic changes in traumatic/hemorrhagic shock in an animal model. Methods: Forty male rats were randomly divided into 4 equal groups including sham, hemorrhagic shock, soft tissue injury, and hemorrhagic shock + soft tissue injury groups. The changes in blood pressure, central venous pressure (CVP) level, acidity (pH), and base excess were dynamically monitored and comparedsented. Results: Mean arterial blood pressure decreased significantly in hemorrhagic shock (df: 12; F=10.9; p<0.001) and severe soft tissue injury + hemorrhagic shock (df: 12; F=11.7; p<0.001) groups 15 minutes and 5 minutes after injury, respectively. A similar trend was observed in CVP in severe soft tissue injury + hemorrhagic shock group (df: 12; F=8.9; p<0.001). After 40 minutes, pH was significantly lower in hemorrhagic shock (df: 12; F=6.8; p=0.009) and severe soft tissue injury + hemorrhagic shock (df: 12; F=7.9; p=0.003) groups. Base excess changes during follow ups have a similar trend. (df: 12; F=11.3; p<0.001). Conclusion: The results of this study have shown that the effect of hemorrhage on the decrease of mean arterial blood pressure, CVP, pH, and base excess is the same in the presence or absence of soft tissue injury.

Introduction: Hanging is one of the most commonly used way to commit suicide in many countries. This method used in suicide is considered a problem in Iran too, but no clear data exists regarding hanging in different regions or the country as a whole. Because of the epidemiologic differences in non-judicial hanging in different regions, this study aimed to assess it in Gilan province, Iran between 2011 and 2013. Methods: In this cross-sectional study, profiles of hanging cases registered in Poorsina hospital in Gilan, Iran between 2011 and 2013 were evaluated. Age, sex, marital status, place of residency, level of education, occupation, history of suicide, history of clinical illness, season of suicide and hanging outcome were evaluated. Results: 59 cases of hanging (mean age 31.4 ± 13.1 years and 83.0% male) were evaluated. 12 (20.34%) suffered from psychological disorders, and 9 (15.2%) confessed to substance abuse. 7 (11.9%) had a history of suicide attempts by hanging. Hanging was significantly higher in men (p<0.001), people with an education level of less than high school diploma (p=0.02) and the unemployed (p<0.05) patients. In the end, 20 (33.9%) of these attempts resulted in death. Conclusion: The results of this study showed that in 2 years, 59 cases committed suicide by hanging themselves, 33.9% of which finally died. Committing suicide by hanging was significantly more prevalent in men, people with an education level of less than high school diploma and the unemployed.

Introduction: Ultrasonography is currently being used as one of the diagnostic modalities in various medical emergencies for screening of trauma patients. The diagnostic value of this modality in detection of traumatic chest injuries has been evaluated by several studies but its diagnostic accuracy in diagnosis of pulmonary contusion is a matter of discussion. Therefore, the present study aimed to determine the diagnostic accuracy of ultrasonography and radiography in detection of pulmonary contusion through a systematic review and meta-analysis. Methods: An extended systematic search was performed by two reviewers in databases of Medline, EMBASE, ISI Web of Knowledge, Scopus, Cochrane Library, and ProQuest. They extracted the data and assessed the quality of the studies. After summarization of data into true positive, false positive, true negative, and false negative meta-analysis was carried out via a mixed-effects binary regression model. Further subgroup analysis was performed due to a significant heterogeneity between the studies. Results: 12 studies were included in this meta-analysis (1681 chest trauma patients, 76% male). Pooled sensitivity of ultrasonography in detection of pulmonary contusion was 0.92 (95% CI: 0.81-0.96; I2= 95.81, p<0.001) and its pooled specificity was calculated to be 0.89 (95% CI: 0.85-0.93; I2 = 67.29, p<0.001) while these figures for chest radiography were 0.44 (95% CI: 0.32-0.58; I2= 87.52, p<0.001) and 0.98 (95% CI: 0.88-1.0; I2= 95.22, p<0.001), respectively. Subgroup analysis showed that the sources of heterogeneity between the studies were sampling method, operator, frequency of the transducer, and sample size. Conclusion: Ultrasonography was found to be a better screening tool in detection of pulmonary contusion. Moreover, an ultrasonography performed by a radiologist / intensivist with 1-5MHz probe has a higher diagnostic value in identifying pulmonary contusions.

Introduction: Previous studies have shown that there is a probability of seizure even with therapeutic doses of tramadol. Yet, no accurate data exist regarding this problem in Iran. Therefore, the present study aimed to evaluate the prevalence of tramadol consumption in patients with first seizure referred to the emergency department (ED). Methods: In the present retrospective one-year cross-sectional study, all patients who were referred to the ED of Poursina Hospital, Rasht, Iran, with the complaint of first seizure were evaluated. Demographic data and data regarding history of tramadol consumption, duration, total dose, last dose, and time passed from the last dose of consumption were recorded and analyzed regarding the study questions using SPSS 20. Results: 383 (68.9%) out of the 556 patients referred to the ED, were experiencing their first seizure (mean age 26.43 ± 6.48 years; 70.5% male). 84 (21.9%) patients had recently used tramadol. History of seizure in the family of tramadol consumers was significantly lower (3.6% compared to 11%; p = 0.036). Mean total tramadol consumption dose in the last 24 hours was 140.17 ± 73.53 mg (range: 50-300 mg). Duration of tramadol consumption was less than 10 days in 84.5% (df: 2; χ²Â = 96.1; p < 0.001). In addition, 62 (73.8%) patients had seizure within 6 hours of consumption (df: 3; χ²Â = 29.5; p < 0.001). Conclusion: Results of the present study showed that 21.9% of the patients with first seizure had a history of tramadol consumption. Seizure following tramadol consumption is more prevalent in the initial 10 days and within 6 hours of consumption. In addition, it seems that lower doses of tramadol may also induce seizure.

Colloid cysts are mucous-filled masses with an outer fibrous layer. These cysts are rare developmental malformation and not a true neoplasm. They usually found incidentally and are asymptomatic; but in some cases may associate with rapid neurologic deterioration, herniation, and sudden death. Recognition of this rare but important diagnosis may result in decreasing mortality. In this report, we presented a 13-year-old boy with complaint of two times drop attack and final diagnosis of colloid cyst in the third brain ventricle.

Although death is a gradual process, sometimes sudden death occurs in a fraction of a minute or seconds. Here we report a 49-year-old man without any underlying disease, which has instantly died in an accident scene due to compression of neck critical elements by a three-point seat belt. The examination of the body and the results of the autopsy, toxicology and pathology tests are described from the viewpoint of forensic medicine.

A 78-year-old woman with a history of colon cancer with metastasis to the liver was presented to our emergency department because of bilateral groin pain and difficulty in walking, which had gradually increased during the previous 5 days. The pain was of sudden onset, radiating to the back, without aggravating or relieving factors. It was associated with constipation, dysuria and vaginal discharge. She reported passing fecal matter from the vagina one month ago. On physical examination, she appeared malnourished. Her blood pressure was 98/65 mmHg, with a 108 beats/min heart rate and 28 breaths/min respiratory rate. She was afebrile. Physical examinations were unremarkable, except for pale conjunctiva, abdominal distention, and diffuse tenderness especially over the umbilicus with guarding tenderness. Bowel sounds were decreased. Pelvic examination showed a yellowish odorous vaginal discharge from the external orifice of uterus. A complete blood cell count showed the following: leukocyte count, 34,200/mm3; segmented neutrophils, 87.5%; hemoglobin level of 7.4 mg/dl; hematocrit, 18.8%; and platelet, 180000/uL. Other laboratory studies included: glucose, 86 mg/dL; serum urea nitrogen, 28 mg/dL; serum creatinine, 0.87 mg/dL; sodium, 142 mEq/L; potassium, 4.8 mEq/L; albumin, 2.5g/dL; a carbohydrate antigen 19-9 level of 3,244 U/ml, and a carcinoembryonic antigen (CEA) level of 64.6 ng/ml. Coronal and axial cuts of patient’s abdominopelvic computed Tomography (CT) are shown in figures 1 and 2.

In the previous two parts of educational manuscript series in Emergency, we explained some screening characteristics of diagnostic tests including accuracy, sensitivity, specificity, and positive and negative predictive values. In the 3rd  part we aimed to explain positive and negative likelihood ratio (LR) as one of the most reliable performance measures of a diagnostic test. To better understand this characteristic of a test, it is first necessary to fully understand the concept of sensitivity and specificity. So we strongly advise you to review the 1st part of this series again. In short, the likelihood ratios are about the percentage of people with and without a disease but having the same test result. The prevalence of a disease can directly influence screening characteristics of a diagnostic test, especially its sensitivity and specificity. Trying to eliminate this effect, LR was developed. Pre-test probability of a disease multiplied by positive or negative LR can estimate post-test probability. Therefore, LR is the most important characteristic of a test to rule out or rule in a diagnosis. A positive likelihood ratio > 1 means higher probability of the disease to be present in a patient with a positive test. The further from 1, either higher or lower, the stronger the evidence to rule in or rule out the disease, respectively. It is obvious that tests with LR close to one are less practical. On the other hand, LR further from one will have more value for application in medicine. Usually tests with 0.1 < LR > 10 are considered suitable for implication in routine practice.