Tarantula Bite in Iran, a Letter to the Editor

Hossein Sanaei Zadeh

EMERGENCY , Vol. 4 No. 4 (2016), 15 August 2016, Page pp. 169-170

I read with great interest the case report titled “Periumbilical pain with radiation to both legs following tarantula bite; a case report” published in Emergency journal. Tarantula spiders are not medically important except for some very limited species, which do not exist in Iran. Solifugae -or rotails as they are called in Iran- are in fact another group of animals also called camel spiders (Figure 2). They are also venom-free and generally cause secondary infections in the site of their bites. Thus, it seems that the patient's signs and symptoms cannot be due to the rotail or tarantula bites.

Review Article

Gastrointestinal Headache; a Narrative Review

Majid T Noghani, Hossein Rezaeizadeh, Sayed Mohammad Baqer Fazljoo, Mahmoud Yousefifard, Mansoor Keshavarz

EMERGENCY , Vol. 4 No. 4 (2016), 15 August 2016, Page pp. 171-183

There are studies reporting primary headaches to be associated with gastrointestinal disorders, and some report resolution of headache following the treatment of the associated gastrointestinal disorder. Headache disorders are classified by The International Headache Society as primary or secondary; however, among the secondary headaches, those attributed to gastrointestinal disorders are not appreciated. Therefore, we aimed to review the literature to provide evidence for headaches, which originate from the gastrointestinal system. Gastrointestinal disorders that are reported to be associated with primary headaches include dyspepsia, gastro esophageal reflux disease (GERD), constipation, functional abdominal pain, inflammatory bowel syndrome (IBS), inflammatory bowel disorders (IBD), celiac disease, and helicobacter pylori (H. Pylori) infection. Some studies have demonstrated remission or improvement of headache following the treatment of the accompanying gastrointestinal disorders. Hypotheses explaining this association are considered to be central sensitization and parasympathetic referred pain, serotonin pathways, autonomic nervous system dysfunction, systemic vasculopathy, and food allergy. Traditional Persian physicians, namely Ebn-e-Sina (Avicenna) and Râzi (Rhazes) believed in a type of headache originating from disorders of the stomach and named it as an individual entity, the "Participatory Headache of Gastric Origin". We suggest providing a unique diagnostic entity for headaches coexisting with any gastrointestinal abnormality that are improved or cured along with the treatment of the gastrointestinal disorder.

Original/Research Article

The Accuracy of Plain Radiography in Detection of Traumatic Intrathoracic Injuries

Maryam Abedi Khorasgani, Ali Shahrami, Majid Shojaee, Hossein Alimohammadi, Afshin Amini, Hamid Reza Hatamabadi

EMERGENCY , Vol. 4 No. 4 (2016), 15 August 2016, Page pp. 184-187

Introduction: Rapid diagnosis of traumatic intrathoracic injuries leads to improvement in patient management. This study was designed to evaluate the diagnostic value of chest radiography (CXR) in comparison to chest computed tomography (CT) scan in diagnosis of traumatic intrathoracic injuries. Methods: Participants of this prospective diagnostic accuracy study included multiple trauma patients over 15 years old with stable vital admitted to emergency department (ED) during one year. The correlation of CXR and CT scan findings in diagnosis of traumatic intrathoracic injuries was evaluated using SPSS 20. Screening characteristics of CXR were calculated with 95% CI. Results: 353 patients with the mean age of 35.2 ± 15.8 were evaluated (78.8% male). Age 16-30 years with 121 (34.2%), motorcycle riders with 104 (29.5%) cases and ISS < 12 with 185 (52.4%) had the highest frequency among patients. Generally, screening performance characteristics of chest in diagnosis of chest traumatic injuries were as follows: sensitivity 50.3 (95% CI: 44.8 – 55.5), specificity 98.9 (95% CI: 99.5 – 99.8), PPV 97.8 (95% CI: 91.5 – 99.6), NPV 66.4 (95% CI: 60.2 – 72.03), PLR 44.5 (95% CI: 11.3 175.3), and NLR 0.5 (95% CI: 0.4 – 0.6). Accuracy of CXR in diagnosis of traumatic intrathoracic injuries was 74.5 (95% CI: 69.6 – 78.9) and its area under the ROC curve was 74.6 (95% CI: 69.3 – 79.8). Conclusion: The screening performance characteristics of CXR in diagnosis of traumatic intrathoracic injuries were higher than 90% in all pathologies except pneumothorax (50.3%). It seems that this matter has a great impact on the general screening characteristics of the test (74.3% accuracy and 50.3%sensitivity). It seems that, plain CXR should be used as an initial screening tool more carefully.

Screening Characteristics of Ultrasonography in Detection of Ankle Fractures

Majid Shojaee, Farhad Hakimzadeh, Parisa Mohammadi, Anita Sabzghabaei, Mohammad Manouchehrifar, Ali Arhami Dolatabadi

EMERGENCY , Vol. 4 No. 4 (2016), 15 August 2016, Page pp. 188-191

Introduction: Ankle fracture is one of the most common joint fractures. X-ray and physical examination are its
main methods of diagnosis. Recently, ultrasonography (US) is considered as a simple and non-invasive method
of fracture diagnosis. This study evaluated the diagnostic accuracy of US in detection of ankle fracture in comparison
to plain radiography. Methods: In this diagnostic accuracy study, which was done in emergency departments
of Imam Hossein and Shohadaye Tajrish hospitals, Tehran, Iran, during 2014, 141 patients with suspected
diagnosis of distal leg or ankle fracture were examined by US and radiography (gold standard), independently.
Screening performance characteristics of US in detection of distal leg fractures were calculated using SPSS version
21. Results: 141 patients with the mean age of 34§11.52 years (range: 15–50) were evaluated (75.9% male).
Radiography confirmed ankle fracture in 102 (72.3%) patients. There was a significant correlation between the
results of US and radiography [Agreement: 95%; kappa: 0.88 (95% CI: 0.80–0.97); P Ç 0.001]. The screening performance
characteristics of US in detection ankle fracture were as follows: sensitivity 98.9% (95% CI: 93.5% -
99.9%), specificity 86.4% (95% CI: 71.9%–94.3%), PPV 94.1% (95% CI: 87.1%–97.6%), NPV 97.4% (95% CI: 84.9%–
99.8%), PLR 16 (95% CI: 7.3–34.8), and NLR 0.02 (95% CI: 0.003 – 0.182). The area under the ROC curve of US
in this regard was 95.8 (95% CI: 91.9§99.7). Conclusion: According to the results of this study, we can use US
as an accurate and non-invasive method with high sensitivity and specificity in diagnosis ofmalleolus fractures.
However, the inherent limitations of US such as operator dependency should be considered in this regard.

Comparing Two Different Doses of Intravenous Midazolamin in Pediatric Sedation and Analgesia

Hassan Barzegari, Arash Forouzan, Kambiz Masoumi, Hassan Motamed, Behzad Zohrevandi, Shima Zeynadini Meymand

EMERGENCY , Vol. 4 No. 4 (2016), 15 August 2016, Page pp. 192-195

Introduction: Midazolam has turned into a common drug for pediatric procedural sedation and analgesia. However, there is not much data regarding its proper dose and potential side effects in the Iranian children population. Therefore, the present study was done to compare 2 doses of IV midazolam in this regard. Methods: The present clinical trial was performed to compare 0.1 and 0.3 mg/kg doses of IV midazolam in induction of sedation for head trauma infant patients in need of brain computed tomography (CT) scan. Conscious infants under 2 years old, with stable hemodynamics were included. Onset and duration of action as well as probable side effects were compared between the two groups using SPSS version 22. Results: 110 infants with the mean age of 14.0 §5.9 months (range: 4–24) and mean weight of 9.7±2 kg (range: 5–15) were randomly allocated to one of the 2 study groups (54.6% female). Success rate in 0.1 and 0.3 mg /kg groups were 38.2% (21 patients)and 60% (33 patients), respectively (p=0.018). Overall, 56 (50.9%) patients did not reach proper sedation and were sedated receiving ketamine (22 patients) or another dose of midazolam (34 patients, mean additional dose needed was 2.1±1.1 mg). Conclusion: The results of the present study demonstrated the higher success rate and longer duration of action for 0.3 mg /kg midazolam compared to 0.1 mg /kg. The groups were equal regarding onset of action, effect on vital signs and probable side effects.

Validation of CRASH Model in Prediction of 14-day Mortality and 6-month Unfavorable Outcome of Head Trauma Patients

Behrooz Hashemi, Mahnaz Amanat, Alireza Baratloo, Mohammad Mehdi Forouzanfar, Farhad Rahmati, Maryam Motamedi, Saeed Safari

EMERGENCY , Vol. 4 No. 4 (2016), 15 August 2016, Page pp. 196-201

Introduction: To date, many prognostic models have been proposed to predict the outcome of patients with
traumatic brain injuries. External validation of these models in different populations is of great importance
for their generalization. The present study was designed, aiming to determine the value of CRASH prognostic
model in prediction of 14-day mortality (14-DM) and 6-month unfavorable outcome (6-MUO) of patients with
traumatic brain injury. Methods: In the present prospective diagnostic test study, calibration and discrimination
of CRASH model were evaluated in head trauma patients referred to the emergency department. Variables
required for calculating CRASH expected risks (ER), and observed 14-DM and 6-MUO were gathered. Then ER
of 14-DM and 6-MUO were calculated. The patients were followed for 6 months and their 14-DM and 6-MUO
were recorded. Finally, the correlation of CRASH ER and the observed outcome of the patients was evaluated.
The data were analyzed using STATA version 11.0. Results: In this study, 323 patients with the mean age of 34.0
´s 19.4 years were evaluated (87.3% male). Calibration of the basic and CT models in prediction of 14-day and
6-month outcome were in the desirable range (P Ç 0.05). Area under the curve in the basic model for prediction
of 14-DM and 6-MUO were 0.92 (95% CI: 0.89–0.96) and 0.92 (95% CI: 0.90–0.95), respectively. In addition,
area under the curve in the CT model for prediction of 14-DM and 6-MUO were 0.93 (95% CI: 0.91–0.97) and
0.93 (95% CI: 0.91–0.96), respectively. There was no significant difference between the discriminations of the
two models in prediction of 14-DM (p Æ 0.11) and 6-MUO (p Æ 0.1). Conclusion: The results of the present
study showed that CRASH prediction model has proper discrimination and calibration in predicting 14-DMand
6-MUO of head trauma patients. Since there was no difference between the values of the basic and CT models,
using the basic model is recommended to simplify the risk calculations.

Intravenous Morphine vs Intravenous Ketofol for Treating Renal Colic; a Randomized Controlled Trial

Gholamreza Faridaalaee, Neda Mohammadi, Seyedeh Zahra Merghati, Fatemeh Keyghobadi Khajeh, Bahman Naghipour, Mahboob Pouraghaei, Sajjad Ahmadi

EMERGENCY , Vol. 4 No. 4 (2016), 15 August 2016, Page pp. 202-206

Introduction: The main purpose of emergency department (ED) management for renal colic  is prompt pain relief. The present study aimed to compare the analgesic effects of intravenus (IV) ketofol with morphine in management of ketorolac persistent renal colic. Methods: This study is a single blind randomized, clinical trial, on patients who were presented to ED with renal colic, whose pain was resistant to 30 mg IV ketorolac. The patients were randomly assigned to either IV morphine (0.1 mg/kg) or IV ketofol (0.75 mg/kg propofol and 0.75 mg/kg) and the measures of treatment efficacy were compared between the groups after 5 and 10 minutes. Results: 90 patients with mean age of 38.01 ± 9.78 years were randomly divided into 2 groups of 45 (66.7% male). Treatment failure rate was significantly lower in ketofol group after 5 (20% vs 62.2%, p < 0.001) and 10 minutes (11.1% vs 44.4%, p < 0.001). ARR and NNT for ketofol after 5 miutes were 42.22% (95% CI: 23.86 – 60.59) and 3 (95% CI: 1.7 - 4.2), respectively. After 10 minutes, these measures reached 33.33 (95% CI:16.16 – 50.51) and 4 (95% CI: 2.0 - 6.2), respectively. NNH and ARI for hallucination or agitation were 12 (95%CI: 5.8 - 174.2) and 8.89% (0.57 - 17.20), respectively. Conclusion: The results of the present study, showed the significant superiority of ketofol (NNT at 5 minute = 3 and NNT at 10 minute = 4)  in ketorolac resistant renal colic pain management. However, its NNH of 12, could limit its routine application in ED for this purpose.

Brief Report

The Reasons of Renal Transplant Recipients’ Admission to the Emergency Department; a Case Series Study

Erdal Uysal, Mehmet Dokur, Hasan Bakir, Mehmet Ali Ikidag, Turkay Kirdak, Hatem Kazimoglu

EMERGENCY , Vol. 4 No. 4 (2016), 15 August 2016, Page pp. 207-210

Introduction:  Renal transplantation are admitted to emergency department (ED) more than normal population. The present brief report aimed to determine the reasons of renal transplant patients’ ED visits.

Methods: This retrospective case series study analyzed the reasons of renal transplant recipients’ admission to one ED between 2011 and 2014. The patient data were collected via a checklist and presented using descriptive statistics tools.

Results: 41 patients with the mean age of 40.63 ± 10.95 years were studied (60.9% male). The most common ED presenting complaints were fever (36.6%) and abdominal pain (26.8%). Infections were the most common final diagnosis (68.3%). Among non-infectious causes, the most common was acute renal failure (9.7 %). 73.2% of the patients were hospitalized and no cases of graft loss and mortality were seen.

Conclusion: The most common reason for ED admission was fever, and infections were the most common diagnosis. Acute gastroenteritis being the most frequent infection and among non-infectious problems, acute renal failure was the most frequent one. 

Photo Quiz

A 48-year-old Man with Epigastric Pain and Melena

Narvir Singh Chauhan

EMERGENCY , Vol. 4 No. 4 (2016), 15 August 2016, Page pp. 211-213

A 48-year-old male patient presented to the emergency department with the complaints of epigastric pain and melena for the past 3 days. The pain was started suddenly and has progressed and after a while, he passed melena stool. He also mentioned some episodes of vomiting that was not bloody. The pain score was about 8/10 (based on verbal quantitative scale) and slightly radiated to back. He loosed his appetite and the pain aggravated by meal. He did not use any drug regularly and had no positive medical history for specific disease or prior hospital admission. The patient was slightly pale and sweaty. His pulse rate was 80/minute and blood pressure was elevated as 180/100 mm Hg. Routine blood tests such as liver enzyme and serum amylase levels were normal. Complete blood cell count showed mild anemia (Haemoglobin =10 g/dl) and leucocytosis (16600/mm3). On physical examination, there were not any positive findings except mild epigastric tenderness without rebound or guarding. Electrocardiography revealed normal sinus rhythm without any pathologic findings. The patient was admitted in surgical ward and plain abdominal computed tomography (CT) scan and abdominal CT angiogram was done. The findings of CT are shown in figures 1A-D.