Cover Page/Table of Content

Review Article

The Risk of Venous Thromboembolism with Different Generation of Oral Contraceptives; a Systematic Review and Meta-Analysis

Alireza Baratloo, Saeed Safari, Alaleh Rouhipour, Behrooz Hashemi, Farhad Rahmati, Maryam Motamedi, Mohammadmehdi Forouzanfar, Pauline Haroutunian

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 1-11

Introduction: Oral contraceptives (OCs) are considered as one of the most common risk factor of venous thromboembolism (VTE) in child bearing age. Some of the recent researches indicate that the odds of VTE may be even higher with newer generations of OCs. The present meta-analysis was designed to evaluate the effect of different generation of OCs on the occurrence of VTE. Methods: Two researchers independently ran a thorough search in Pubmed, ISI Web of Science, EMBASE, CINAHL and Scopus databases regarding study keywords including thromboembolic event, thromboembolism, embolism, thromboembolic, thrombotic and thrombosis, combined with oral contraceptive. The outcomes were the incidence of diagnosed thromboembolism, such as deep vein thrombosis, pulmonary embolism and cerebral venous thrombosis. Based on the heterogeneity of the studies, random effect model was used and pooled odds ratio was reported. Results: Three cohort and 17 case-control studies with 13,265,228 subjects were entered into meta-analysis. Analysis showed that the odds of VTE in women taking OCs are more than three-fold (OR=3.13; 95% CI: 2.61-3.65). The risk of VTE in women taking first-, second- and third-generation OCs are 3.5 fold (OR=3.48; 95% CI: 2.01-4.94), 3 fold (OR=3.08; 95% CI: 2.43-3.74) and 4.3 fold (OR=4.35; CI: 3.69‒5.01), respectively. Conclusion: It seems that the risk of VTE is not same between different generations of OCs, so that third-generation has highest risk. Taking second and third-generation OCs increases the risk of VTE up to 3 and 4.3 fold, respectively. The researchers of the present study suggest that more clinical trials be designed in relation to the effect of newer generations of OCs in different communities.


Original/Research Article

Causes of Sudden Cardiac Death on Autopsy Findings; a Four-Year Report

Dinesh Rao, Divya Sood, P Pathak, Sudhir. D Dongre

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 12-17

Introduction: Incidence of sudden cardiac death (SCD) has been steadily increasing all over the world. While knowing the cause of SCD is one of the favorites of the physicians involved with these cases, it is very difficult and challenging task for the forensic physician. The present report is a prospective study regarding cause of SCDs on autopsy examination in four-year period, Bangalore, India. Methods: The present prospective study is based on autopsy observations, carried out for four-year period from 2008 to 2011, and analyzed for cause of SCDs. The cases were chosen as per the definition of sudden death and autopsied. The material was divided into natural and unnatural groups. Finally, on histopathology, gross examination, hospital details, circumstantial, and police reports the cause of death was inferred. Results: A total of 2449 autopsy was conducted of which 204 cases were due to SCD. The highest SCDs were reported in 50-60 years age group (62.24%; n-127), followed closely by the age group 60-69 (28.43%; n-58). Male to female ratio was around 10:1. The maximum number of deaths (n=78) was within few hours (6 hours) after the onset of signs and symptoms. In 24 (11.8%) cases major narrowing was noted in both the main coronaries, in 87 (42.6%) cases in the left anterior descending coronary artery (LAD), and in 18 (51.5%) cases in the right coronary artery (RCA). The major cardiac pathology resulting in sudden death was coronary artery disease (n-116; 56.86%) and myocardial infarction (n-104; 50.9%). most of the SCDs occurred in the place of residence (n-80; 39.2%) followed closely by death in hospital (n-49; 24.01%). Conclusion: Coronary occlusion was the major contributory cause of sudden death with cardiac origin and the highest number of deaths were reported in the age 50-59 years with male to female ratio of 10:1.


Short-Term Outcome of Discharged Low-Risk Chest Pain without Provoke Ischemia Study

Anita Sabzghabaei, Setareh Asgarzadeh, Reza Miri, Majid Shojaee, Hossein Alimohammadi, Kamran Heidari

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 18-21

Introduction: Chest pain is a common problem in patients referring to emergency units. The present study was undertaken to evaluate the short-term outcome of patients presenting with a low risk chest pain and discharging without provoke ischemia study during emergency department admission. Methods: In the present prospective cohort study, patients with low-risk chest pain, referring to the emergency department of Imam Hossein Hospital, Tehran, during the first half of 2012, were evaluated. All the patients underwent electrocardiogram (ECG) and cardiac enzyme tests, including cardiac isoenzymes creatine kinase MB and troponin I. One week after referring to the emergency department, the patients underwent an exercise test and were followed for a month. Data were analyzed with chi-squared test at a significant level of P<0.05. Results: A total of 252 patients were included. The mean and standard deviation of patient ages was 56±7.7 years (47.5% male). The results of exercise tests for 47 (26.3%) subjects were positive [32 (28.8%) patients in the 41-60 year age group and 15 (22.7%) over 60 years of age].The angiography examination results of 5 patients (2.8%) were abnormal. There were no significant relationships between the age and gender and the results of exercise test and angiography (P>0.05). During the one-month follow-up no cases of mortality, cardiac problems, or referring again to the hospital were recorded. Conclusion: Based on the results of the present study, prevalence of cardiac etiology in patients with low risk chest pain was 2.8% and one-month follow-up did not reveal any complications or serious problems in such cases.

QT Interval in Pregnant and Non-pregnant Women

Majid Zamani, Mehrdad Esmailian, Zahra Yoosefian

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 22-25

Introduction: Prolongation of QT interval might result in dangerous cardiac arrhythmias, including Torsades de Pointes (TdP), consequently leading to syncope or death. A limited number of studies carried out in this respect to date have shown that QT interval might increase during pregnancy. On the other hand, it has been shown that each pregnancy might result in an increase in the risk of cardiac accidents in patients with long QT interval. Therefore, the present study was undertaken to compare QT intervals in pregnant and non-pregnant women. Methods: Pregnant women group consisted of 40 women in the second and third trimesters of pregnancy and the non-pregnant control group consisted of healthy women 18-35 years of age. All the patients underwent standard 12-lead electrocardiogram (ECG). The QT interval was measured for each patient at lead II. The mean corrected QT interval (QTc) and QT dispersions (QTd) were compared between the two groups. Results: Mean heart rates in the pregnant and non-pregnant groups were 98.55±14.09 and 72.53±13.17 beats/minutes (P<0.001). QTd and QTc means were in the normal range in both groups; however, these variables were 49.50±12.80 and 43.03±18.47 milliseconds in the pregnant group and 39.5±9.59 and 40.38±17.20 milliseconds in the control group, respectively (P<0.001). Conclusion: The QT interval was longer in pregnant women compared to non-pregnant women; however, it was in the normal range in both groups. Therefore, it is important to monitor and manage risk factors involved in prolongation of QT interval and prevent concurrence of these factors with pregnancy.

Introduction: Although the synergistic effects of opioids and other analgesic drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) have been established in relieving acute pain due to renal calculi, no studies today have evaluated the concomitant administration of opiates and other drugs with analgesic effects, such as serotonin re-uptake inhibitors. Considering the high prevalence of renal colic, the present study was carried out to compare the effect of concomitant prescription of morphine and a placebo with that of morphine and citalopram on the management of acute pain due to renal calculi. Methods: The present double-blind randomized clinical trial was carried out from October 2012 to March 2013 in the Al-Zahra educational Hospital in Isfahan, Iran. A total of 90 patients with acute renal colic pain were randomly divided into two groups of 45 subjects. The subjects in one group received morphine/ placebo and another one morphine/citalopram. The patients’ pain severity was determined by visual analogue scale (VAS) before and 20 minutes after administration of medications. In case of persistent pain the second or even third dose was administered and the pain severity was once again determined. Data were analyzed with STATA 11.0 using chi-squared, two-way ANOVA, Bonferroni post hoc test, and log rank test. Results: The decrease in pain severity in the morphine/citalopram group was significantly compared to the morphine/placebo group and the time before administration of the medications (p<0.001). In contrast, administration of morphine/placebo did not have a significant effect on pain severity at this interval (p=0.32). Kaplan-Meier curve showed that the first injection was successful in relieving pain in 15 (33.3%) and 26 (57.8%) subjects in the morphine/placebo and morphine/citalopram groups, respectively. The second injection of these medications resulted in therapeutic success in 35 (87.8%) and 42 (95.6%) subjects in the above groups, respectively. Log rank test showed a significant difference in the treatment success between the two groups (p=0.001). Conclusion: It seems that the combination of citalopram and morphine sulfate causes increased efficacy and higher success rate in pain control of patients presented to the emergency department with a complaint of renal colic.

Cause of Emergency Department Mortality; a Case-control Study

Hossein Alimohammadi, Farahnaz Bidarizerehpoosh, Farzaneh Mirmohammadi, Ali Shahrami, Kamran Heidari, Anita Sabzghabaie, Shahram Keikha

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 30-35

Introduction: Based on previous studies, cardiovascular diseases, traffic accidents, traumas and cancers are the most important etiology of mortalities in emergency departments (ED). However, contradictory findings have been reported in relation to mortality in emergency departments. Therefore, the present study was undertaken to evaluate the role of clinical factors in mortality among patients referring to an emergency department in a third-level hospital in Tehran, Iran. Methods: In the present case-control study, all the patients over 18 years of age were evaluated, referring to the ED of Imam Hossein Hospital, Tehran, Iran, from the beginning of 2009 to the end of 2010. The patients died in the ED were placed in the case group and those discharged or hospitalized in other hospital wards in the control group. Demographic data, background diseases, and the final diagnoses were recorded. Chi-squared test, multivariate logistic regression, and Pearson’s correlation coefficient were used to evaluate the relationship between the variables mentioned above and patient mortality. Results: A total of 2907 patients (969 (59.9% male) in the case and 1938 (62.2% male) in the control groups) were evaluated. Cardiovascular diseases (39.2%), severe traumas (18.5%), and cerebrovascular accidents (17.7%) were the most frequent etiology of patient mortality in ED. Multivariate regression analysis showed that presentation with cardiovascular complaints (OR=7.3; 95% CI: 3.5-16.1; p<0.001), a history of hypertension (OR=5.4; 95% CI: 1.2-12.3; p<0.001), severe trauma (OR=4.6; 95% CI: 2.0-13.2; p<0.001), age over 60 (OR=3.8; 95% CI: 1.8-7.8; p<0.01) and a final diagnosis of renal disease (OR=3.4; 95% CI: 2.1-6.4; p<0.001) were factors that increased the odds of mortality in patients referring to the ED. Multivariate regression analysis in patients over 60 years showed that sepsis was an independent factor increasing the risk of death (OR=2.9; 95% CI: 1.3-5.9; p=0.009). A patient’s risk of death increases with an increase in the number of risk factors in that patient (r2=0.96; p=0.02). Conclusion: It appears the odds of mortality in patients referring to ED with cardiovascular complaints, a history of hypertensive, severe trauma, age over 60 and a final diagnosis of renal disease are higher versus other patients. In addition, the patients’ odds of death increase with an increase in the number of risk factors. Such an increase is more noticeable at age over 60.

The Effect of Intravenous Ketamine in Suicidal Ideation of Emergency Department Patients

Parvin Kashani, Shiva Yousefian, Afshin Amini, Kamran Heidari, Somaie Younesian, Hamid Reza Hatamabadi

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 36-39

Introduction: Suicidal ideation is an emergent problem in the Emergency Department (ED) that often complicates patient disposition and discharge. It has been shown that ketamine possesses fast acting antidepressant and anti-suicidal effects. This study was conducted to examine the effects of a single intravenous bolus of ketamine on patients with suicidal ideations in ED. Methods: Forty-nine subjects with suicidal ideations with or without an unsuccessful suicide attempt, received 0.2 mg/kg of ketamine. Scale for suicidal ideation (SSI) and Montgomery-Abserg depression rating scale (MADRS) were evaluated before and 40, 80 and 120 minutes after drug intervention. The results were compared using the paired t-test and patients were followed up 10 days after ED admission for remnant suicide ideation. Results: SSI (df: 3, 46; F=80.7; p<0.001) and MADRS (df: 3, 46; F=87.2; p<0.001) scores significantly dropped after ketamine injection; the SSI score before and after 20, 40, and 80 minutes of ketamine injection were 23.0±6.7, 16.2±5.2, 14.3±4.3, and 13.6±4.0 respectively. The MADRS scores were 38.2±9.3, 25.6±7.1, 22.7±6.3, and 22.1±5.95 at the same time intervals. 25.5% of patients were hospitalized, 63.3% received medications and 12.2% discharged. 6.2% of patients had suicidal ideations ten days after ED disposition.  Conclusion: It seems that Ketamine couldn't be a good choice for fast reduction of suicidal ideations in ED patients. Further studies are needed to determine the optimal dose of ketamine for different patients.

Brief Report

Treatment Costs of Traffic Accident Casualties in a Third-level Hospital in Iran; a Preliminary Study

Mohammad Manouchehrifar, Hamid Reza Hatamabadi, Niloufar Derakhshandeh

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 40-42

Introduction: The costs of traffic accidents in low- and middle-income countries are estimated to add up to $65 billion annually, which is a little higher than the amount they receive as a final aid for development. The present retrospective study aims to evaluate the treatment costs of the hospitalized injured individuals in traffic accidents. Methods: The present study was carried out in Imam Hossein Hospital, Tehran, Iran. The study population consisted of all the individuals injured in traffic accidents, admitted to the hospital wards. Data were collected by a trained emergency physician. Demographic data, injury mechanism, the type of vehicle, the admission ward of the patient, and treatment costs were collected. Results: A total of 200 patient files were evaluated (males: 89%). The results showed that 54% of the patients were in the 18‒40-year age group and collisions between cars and motorcycles were the most frequent accidents (47%). The mean hospitalization cost for each patient was estimated to be $1622.1. Statistical analyses showed that treatment costs in the neurosurgery ward was significantly higher than those in orthopedic and general surgery wards (df: 3; F=9.5, P=0.008). Conclusion: The results of the present study showed that the mean cost of each traffic accident victim in Tehran is approximately $1622.1 and these patients sustain significantly higher costs in neurosurgery ward.

Case Report

A Young Man with Myocardial Infarction due to Trenbolone Acetate; a Case Report

Kavous Shahsavari Nia, Farzad Rahmani, Hanieh Ebrahimi Bakhtavr, Yashar Hashemi aghdam, Moloud Balafar

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 43-45

Over the four decades, a significant decrease has been observed in age-related mortality caused by cardiovascular disease. People in developing countries suffer from CAD at a relatively younger age and about half of MI occurs under the age of fifty years. Abuse of anabolic steroids is one of the less common causes of atherosclerosis. In this report, a 23-year-old body builder male referred to emergency department (ED) with myocardial infarction (MI) following chronic Trenbolone acetate consumption. It seems that a comprehensive history of steroid consumption in young patients referred to ED with the chief complaint of chest pain or its equivalents is necessary in adjunct to other cardiac risk factors.

Atypical Presentation of Massive Pulmonary Embolism, a Case Report

Alireza Majidi, Sadrollah Mahmoodi, Alireza Baratloo, Sahar Mirbaha

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 46-47

The lack of pathognomonic signs and symptoms makes the diagnosis of pulmonary embolism (PE) difficult. Here, we report a case of a 42-year-old man presented to the emergency department with worsening epigastric pain, hypotension, frank bradycardia, and final diagnosis of PE. Although previous studies have indicated that abdominal pain was observed in 6.7% of patients with PE, the exact reason for abdominal pain in PE still remains unknown. Tension on the sensory nerve endings, hepatic congestion, and distention of Gilson’s capsule are some of the possible mechanisms of abdominal pain in PE. We conclude that emergency physicians should pay more attention to PE, which is an important differential diagnosis of shock state. In this context, rapid ultrasound in shock (RUSH) should be considered as a vital sign that needs to be evaluated when recording the history of patients presented to the emergency department with signs and symptoms of shock.

Epidural Hematoma Following Hemodialysis in a Methanol Poisoned Pa-tient; a Case Report

Payman Moharamzadeh, Farzad Rahmani, Mahboob Pouraghaei, Hanieh Ebrahimi Bakhtavar, Ehsan Mohammadzadeh Abachi

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 48-49

Brain injury associated with methanol toxicity can be ischemic, necrotic or hemorrhagic in nature. It most commonly affects the putamenal area bilaterally, but can be seen in other locations. This report describes a 22-year-old intoxicated patient who developed an epidural hematoma following hemodialysis. Heparinization during hemodialysis may contribute to cerebral hemorrhagic complications in methanol poisoning. In addition, a history of head trauma may raise the incidence of post-hemodialysis hemorrhagic brain insults. Heparin-free dialysis or peritoneal dialysis can be a good option in these cases.

Photo Quiz

A 16-Year-Old Girl with Acute Onset Respiratory Distress

Saeed Safari, Ebrahim Karimi, Alireza Baratloo, Mostafa Alavi-Moghaddam, Mohammad Kalantarimeibodi

EMERGENCY , Vol. 2 No. 1 (2014), 1 March 2014, Page pp. 50-52

A 16-year-old girl with an intellectual disability (known case of Down syndrome) arrived in the emergency eepartment with complaints of severe breathlessness, bloody salivation (bright red blood or clots), and difficulty in speaking and swallowing of liquids and solids. The patient gradually developed progressive bloody salivation and hoarseness, never had any history of trauma to the head and neck and respiratory problems, and was symptomatic from the previous 48 h. Furthermore, the patient had a positive history of peptic ulcer, chronic consumption of non-steroidal anti-inflammatory drugs, and traveled out of town and drank water from a well in the mentioned period. On admission, the patient had a respiratory rate of 17 per min, pulse rate of 89 per min, blood pressure of 120/80 mmHg, 90% O2 saturation in room air, and 38°C axillary temperature. The only positive finding on physical examination was inspiratory stridor. The auscultation of lung and heart sounds was normal. Digital rectal examination revealed brown feces. Throat examination was not possible owing to lack of patient cooperation. After initial assessment and essential consideration, electrocardiography (ECG) and imaging was performed. The ECG showed normal sinus rhythm, and analysis of arterial blood gas revealed the following: pH = 7. 35, Pa-CO2 = 39 mmHg, HCO3 = 24 mEq/L, PaO2 = 89 mmHg, and O2 saturation = 92%. All other laboratory data, including complete blood counts (CBC), urine analysis, hepatic and renal function tests, and coagulation profile were in the normal range.  

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