Cover Page/Table of Content


Review Article

Poisonous Spiders: Bites, Symptoms, and Treatment; an Educational Review

Farzad Rahmani, Seyed Mahdi Banan Khojasteh, Hanieh Ebrahimi Bakhtavr, Farnaz Rahmani, Kavous Shahsavari Nia, Gholamreza Faridaalaee

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 54-58

More than 40,000 species of spiders have been identified in the world. Spider bites is a common problem among people, however few of them are harmful but delay in treatment can cause death. Since the spider bites are risk full to human, they should be taken seriously, especially in endemic areas. Our objective in this review was to study about poisonous spiders and find out treatments of them. Therefore we collected related articles from PubMed database and Google Scholar. Three important syndromes caused by spider bites are loxoscelism, latrodectism and funnel web spider syndrome. Many treatments are used but much more studies should have done to decrease the mortality. In this review, we describes different venomous spiders according to their appearance, symptoms after their bites and available treatments.


Development of an Easy-to-Use Tool for the Assessment of Emergency Department Physical Design

Alireza Majidi, Ali Tabatabaey, Hassan Motamed, Maryam Motamedi, Mohammad Mehdi Forouzanfar

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 59-65

Physical design of the emergency department (ED) has an important effect on its role and function. To date, no guidelines have been introduced to set the standards for the construction of EDs in Iran. In this study we aim to devise an easy-to-use tool based on the available literature and expert opinion for the quick and effective assessment of EDs in regards to their physical design. For this purpose, based on current literature on emergency design, a comprehensive checklist was developed.  Then, this checklist was analyzed by a panel consisting of heads of three major EDs and contradicting items were decided. Overall 178 crude items were derived from available literature. The Items were categorized in to three major domains of Physical space, Equipment, and Accessibility. The final checklist approved by the panel consisted of 163 items categorized into six domains. Each item was phrased as a “Yes or No” question for ease of analysis, meaning that the criterion is either met or not.


Original/Research Article

Knowledge of Emergency Medicine Residents in Relation to Prevention of Tetanus

Hojjat Derakhshanfar, Behrooz Hashemi, Mohammad Manouchehrifar, Parvin Kashani, Mohammad Mehdi Forouzanfar

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 71-76

Introduction: Knowledge of emergency medicine residents about the management of patients suspected of having tetanus favoring wounds is very important due to their responsibility for the treatment of such patients. The aim of the present study was to evaluate this knowledge and making sure of the adequacy of instructions they have received in relation to prevention of tetanus.  Methods: A reliable and reproducible questionnaire was used to evaluate knowledge of all the emergency medicine residents in Imam Hussein Hospital in Tehran, Iran, about conditions favoring tetanus (9 questions) and proper interventions in such conditions (12 questions). The questionnaires were completed and scored as poor and good. The Mann-Whitney U test was used to analyze data. Statistical significance was set at P<0.05. Results: In the present study, 73 emergency medicine residents were evaluated (45.2% male). Knowledge of 31 (42.5%) residents in relation to conditions favoring tetanus and 41 (56.2%) residents in correct therapeutic interventions was in good level. The most frequent incorrect answer was related to diabetic ulcers and wounds in patients with sepsis. There was an increase in scores of conditions favoring tetanus (P<0.001) and correct therapeutic interventions (P=0.001) with an increase in educational years. However, age (P=0.64), gender (P=0.31), job experience (P=0.38) and participation in educational courses (P=0.67) had no effect on the knowledge level of emergency medicine residents. Conclusion: According to the findings of the present study, the knowledge of emergency medicine residents about correct management of patients suspected of tetanus was low, which emphasizes the necessity of providing further instructions on prevention of tetanus in wound management.


Introduction: The selective medication for pain control in many clinical situations is morphine but its complications prevent its widespread use. Ketamine has been introduced as an alternative for morphine in some studies. However, the efficacy of its solitary use has not yet been evaluated. Therefore, the present study was undertaken to evaluate the effect of ketamine alone in relieving pain in trauma patients referring to an emergency unit. Methods: In this double-blind clinical trial, patients with long bone fractures were randomly divided into two groups of treatment with intravenous (IV) morphine at a dose of 0.1 mg/kg and treatment with IV ketamine at a dose of 0.5 mg/kg. Pain severity of the patients was recorded before and 10 minutes after injection based on numeric rating scale. The means in the two groups were compared using independent t-test. Then the Kaplan-Meier curve and log rank analysis were used to evaluate the success of treatment. Results: A total of 126 patients were included in this study. The mean ages of the patients in the morphine and ketamine groups were 33.6±14.3 and 35.1±13.5 years, respectively (P=0.54). After therapeutic intervention, the pain severity significantly decreased in ketamine (2.7±1.8; P<0.0001) and morphine (2.4±1.5; P<0.0001) groups, with a similar effect of both medications on alleviating pain (P=0.28). The success rate of the treatment at 10-minute interval in groups receiving ketamine and morphine were 59 (93.65%) and 61 (96.8%) patients, respectively (P=0.62). Conclusion: The results of the present study showed that administration of ketamine at a low dose (0.5 mg/kg) results in a significant decrease in the severity of acute pain in patients with fractures of long bones. This palliative effect is very similar to that of morphine.


Diagnostic Accuracy of Ultrasonography in the Initial Evaluation of Patients with Penetrating Chest Trauma

Farhad Heydari, Mehrdad Esmailian, Masoumeh Dehghanniri

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 81-84

Introduction: Traumatic chest injuries (TCI) are one of the most common causes of referring to the emergency departments, with high mortality and disability. This study was designed to evaluate the diagnostic accuracy of ultrasonography versus chest X ray (CXR) in detection of hemo-pneumothorax for patients suffering penetrating TCI. Methods: The present cross-sectional study was performed to evaluate the diagnostic accuracy of ultrasonography in penetrating TCI victims referred to the emergency department of Shahid Kashani and Alzahra hospitals of Isfahan, Iran, from July 2012 to June 2013. Bedside ultrasonography and plain CXR was done on arrival and three hours after admission. The results of ultrasonography and radiography were separately evaluated by an emergency medicine specialist and a radiologist, who were blind to the aims of the study. Then, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and kappa coefficient was considered to evaluate the accuracy of ultrasonography. Results: In this research 64 patients with penetrating chest trauma were assessed (98.4% male). The mean age of them was 25.6±8.5 years (rang: 13-65). The plain radiography revealed the eight (12.5 %) cases of pneumothorax and one (1.6%) hemothorax. The findings of primary ultrasonography also showed the same number of hemo-pneumothorax. Sensitivity and specificity of primary ultrasound in diagnosis of pneumothorax were 100% (95% Cl: 60.7- 100) and 100.0% (95% Cl, 92.0% to 100.0%) and in detection of hemothorax were 100% (95% Cl: 50.5-100) and 100% (95% Cl: 92.8-100), respectively. Sensitivity and specificity of ultrasound in the third hour were 100% (95% Cl: 31.3-100) and 100% (95% Cl: 91.4-100), respectively. Conclusion: Findings of the present study have shown that ultrasonography has an acceptable diagnostic accuracy in the initial assessment of patients with penetrating chest trauma. However, because of its dependency on operator proficiency and other limitations more studies are needed in this area.


Effects of Intravenous Fluid Therapy on Clinical and Biochemical Parameters of Trauma Patients

Shahram Paydar, Hamid Bazrafkan, Nasim Golestani, Jamshid Roozbeh, Abbas Akrami, Ali Mohammad Moradi

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 90-95

Introduction: The administration of crystalloid fluids is considered as the first line treatment in management of trauma patients. Infusion of intravenous fluids leads to various changes in hemodynamic, metabolic and coagulation profiles of these patients. The present study attempted to survey some of these changes in patients with mild severity trauma following normal saline infusion. Methods: This study comprised 84 trauma patients with injury of mild severity in Shahid Rajaei Hospital, Shiraz, Iran, during 2010-2011. The coagulation and metabolic values of each patient were measured before and one and six hours after infusion of one liter normal saline. Then, the values of mentioned parameters on one and six hours after infusion were compared with baseline measures using repeated measures analysis of variance. Results: Eighty four patients included in the present study (76% male). Hemoglobin (Hb) (df: 2; F=32.7; p<0.001), hematocrit (Hct) (df: 2; F=30.7; p<0.001), white blood cells (WBC) (df: 2; F=10.6; p<0.001), and platelet count (df: 2; F=4.5; p=0.01) showed the decreasing pattern following infusion of one liter of normal saline. Coagulation markers were not affected during the time of study (p>0.05). The values of blood urea nitrogen (BUN) showed statistically significant decreasing pattern (df: 2; F=5.6; p=0.007). Pressure of carbon dioxide (PCO2) (df: 2; F=6.4; p=0.002), bicarbonate (HCO3) (df: 2; F=7.0; p=0.001), and base excess (BE) (df: 2; F=3.3; p=0.04) values showed a significant deteriorating changes following hydration therapy. Conclusion: It seems that, the infusion of one liter normal saline during one hour will cause a statistically significant decrease in Hb, Hct, WBC, platelet, BUN, BE, HCO3, and PCO2 in trauma patients with mild severity of injury and stable condition. The changes in, coagulation profiles, pH, PvO2, and electrolytes were not statistically remarkable.


Report of 121 Cases of Bell's Palsy Referred to the Emergency Department

Behzad Zohrevandi, Vahid Monsef Kasmaee, Payman Asadi, Hosna Tajik

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 66-70

Introduction: According to the high incidence of Bell's palsy (IFP) and lack of clinical data regarding different aspects of disease, the present study investigated 121 Iranian patients with peripheral facial paralysis referred to the emergency department. Methods: In this retrospective study, all patients with peripheral facial paralysis, referred to the emergency department of Poursina hospital, Rasht, Iran, from August 2012 to August 2013, were enrolled. For all patients with diagnosis of Bell's palsy variables such as age, sex, occupation, clinical symptoms, comorbid disease, grade of paralysis, and the severity of the facial palsy were reviewed and analyzed using STATA version 11.0. Results: A total of 121 patients with peripheral facial paralysis were assessed with a mean age of 47.14±18.45 years (52.9% male). The majority of patients were observed in the summer (37.2%) and autumn (33.1%) and the recurrence rate was 22.3%. The most common grades of nerve damage were IV and V based on House- Brackman grading scale (47.1%). Also, the most frequent signs and symptoms were ear pain (43.8%), taste disturbance (38.8%), hyperacusis (15.7%) and increased tearing (11.6%). There were not significant correlations between the severity of palsy with age (p= 0.08), recurrence rate (p=0.18), season (p=0.9), and comorbid disease including hypertension (p=0.18), diabetes (p=0.29), and hyperlipidemia (p=0.94). The patients with any of following symptoms such as ear pain (p<0.001), taste disturbance (p<0.001), increased tearing (p=0.03), and Hyperacusis (p<0.001) have more severe palsy. Conclusion: There was equal gender and occupational distribution, higher incidence in fourth decade of life, higher incidence in summer and autumn, higher grade of nerve damage (grade V and VI), and higher incidence of ear pain and taste disturbance in patients suffered from IFP. Also, there was significant association between severity of nerve damage and presence of any simultaneous symptoms. 

Oral Chloral Hydrate Compare with Rectal Thiopental in Pediatric Procedural Sedation and Analgesia; a Randomized Clinical Trial

Reza Azizkhani, Soheila Kanani, Ali Sharifi, Keihan Golshani, Babak Masoumi, Omid Ahmadi

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 85-89

Introduction: The increasing use of diagnostic imaging in pediatric medicine has resulted in growing need for procedural sedation and analgesia (PSA) to minimize motion artifacts during procedures. The drug of choice in pediatric PSA was not introduced till now. The aim of the present study was comparison of oral chloral hydrate (OCH) and rectal sodium thiopental (RST) in pediatric PSA.

Methods: In the present randomized clinical trial, 2-6 years old pediatrics who referred for performing brain computed tomography scan was enrolled and were randomly divided in to two groups. OCH (50mg/kg) and RST (25mg/kg) were prescribed and a trained nurse recorded the time from drug prescription to receiving the conscious sedation (onset of action), the total time period which the patient has the Ramsay score≥4 (duration of action), and adverse effect of agents. Mann-Whitney U test and chi-squared test, and Non-parametric analysis of covariance (ANCOVA) were used for comparisons. Results: One hundred and forty children were entered to two groups of OCH and RST, randomly. The patients of two groups had similar age, sex, weight, and baseline vital signs except for diastolic blood pressure (p<0.001). The onset of action in OCH and RST groups were 24.5±6.1and 28.7±5.2 minutes, respectively (p<0.001). Duration of action in OCH and RST groups were 12.9±2.8 minutes and 13.7±2.6 minutes, respectively (p=0.085). Non parametric ANCOVA revealed that only diastolic blood pressure was affected by drug prescription (p=0.001). In 11(15.7%) patients in RST group, diarrhea was observed during 24 hours (p=0.001). Oxygen desaturation was observed only in two patients, both in OCH group. Conclusion: Each of the sedative has advantages and disadvantages that should be considered when selecting one for inducing short-term sedation. It seems that rectal sodium thiopental and oral chloral hydrate are equally effective in pediatric PSA and based on patient’s condition we can administrate one of these agents.


Case Report

A 55-Year Old Man with Acute Painful Flank Mass, a Case Report

Aida Alavi-Moghaddam, Reza Shirvani, Mahmoud Yousefifard, Mostafa Alavi-Moghaddam

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 96-97

Lumbar hernias (LH) accounts for less than 1.5% of total hernia incidence. It can occur in two separate triangular areas of the flank. About 300 cases have been reported in the literature. Here, we report a 55-year old man with acute painful left side flank mass and final diagnosis of LH. The mass was appeared about three hours before admission and his pain was slight at first but became more severe gradually. He had stable vital sign and the only positive finding on his physical examination was the sphere shape, firm, mobile, and mild tender mass at his left flank.

Thoracic Pneumorrhachis in Patient with Lumbar Fractures; a Case Report

Amir Ghafarzad, Ali Tagizadieh, Payman Moharamzadeh, kavous Shahsavari Nia, Golnar Majidi

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 98-100

Pneumorrhachis as a relatively rare condition may be an indication of substantial intra-spinal column injury. Here we report a 39-year-old man was admitted because of low back pain and dyspenea after locating between motor vehicle and wall three days before admission. On arrival, physical exams and vital signs were normal. Computed tomography (CT) scan showed bilateral pleural effusion, fracture of ribs number 8, 9 and 10 in lower left side of thorax, fracture of vertebra in L2-L4, and air bubbles in upper thoracic spinal canal.


Transient Unexplained Shock in 30-Year-Old Trauma Patient

Farzad Rahmani, Hanieh Ebrahimi bakhtavar, Kavous Shahsavari nia, Neda Mohammadi

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 101-103

Shock as an inadequate tissue perfusion is one of the frequent causes of death in trauma patients. In this context, there are various reasons for hemodynamic instability and shock including hypovolemic (hemorrhagic), obstructive (cardiac tamponade, tension pneumothorax), cardiogenic, neurogenic, and rarely septic. In the present report, a 30-year-old trauma patient with full clinical signs and symptoms of shock referred while had unknown origin; it was finally recognized as anaphylactic shock.


Photo Quiz

Confusing Hypoxia in a 21-Year-Old Intubated Multiple Trauma Patient

Parvin Kashani, Sahar Mirbaha

EMERGENCY , Vol. 2 No. 2 (2014), 10 March 2014, Page pp. 104-105

A 21-year-old man was brought to the emergency department due to multiple trauma (MT) caused by a motor car accident (MCA). On arrival, the patient was intubated by prehospital emergency medical services (EMS) and had a Glasgow coma scale (GCS) score of 6 on 10 (Due to intubation, verbal score was omitted). Physical examination revealed blood pressure of 150/70 mmHg, oxygen saturation (O2sat) of 60%, and pulse rate of 110/min. Examination of the tracheal tube site revealed incorrect esophageal placement. The patient was intubated again and his O2sat improved and reached approximately 96%. His pupils were reactive and of the same size. The Doll’s eye was normal, and plantar reflex was neuter in both sides. Neither expanding hematoma nor emphysema was observed in his neck. Laceration was noted on his left ear, but otorrhagia and tympanic perforation were not found. The lung sounds were normal in both sides. Extended focused abdominal sonography for trauma (e-FAST) examination revealed the absence of free fluid in the abdomen and pericardial space. No deformity of limbs was noted and the distal pulses were palpable. The patient’s O2sat decreased during his admission to the emergency department, and further examination indicated obvious decreased sound in his right lung that could not be reversed by needle thoracostomy. On reviewing his previous chest computed tomography, an obvious questionable pathology was detected in his right side Figure 1.

What is your diagnosis?