Original/Research Article

The Value of Serum NR2 Antibody in Prediction of Post-Cardiopulmonary Resuscitation Survival

Ali Bidari, Samira Vaziri, Ehsan Moazen Zadeh, Sahar Farahmand, Elham Talachian

EMERGENCY , Vol. 3 No. 3 (2015), 5 July 2015, Page pp. 89-94

Introduction: N-methyl-D-aspartate receptor subunits antibody (NR2-ab) is a sensitive marker of ischemic brain damage in clinical circumstances, such as cerebrovascular accidents. We aimed to assess the value of serum NR2-ab in predicting the post-cardiopulmonary resuscitation (CPR) survival. Methods: In this cohort study, we examined serum NR2-ab levels 1 hour after the return of spontaneous circulation (ROSC) in 49 successfully resuscitated patients. Patients with traumatic or asphyxic arrests, prior neurological insults, or major medical illnesses were excluded. Participants were followed until death or hospital discharge. Demographic data, coronary artery disease risk factors, time before initiation of CPR, and CPR duration were documented.  In addition, Glasgow coma scale (GCS), blood pressure, and survival status of patients were recorded at 1, 6, 24, and 72 hour(s) after ROSC. Descriptive analyses were performed, and the Cox proportional hazard model was applied to assess if NR2-ab level is an independent predictive factor of survival. Results: 49 successfully resuscitated patients were evaluated; 27 (55%) survived to hospital discharge, 4 (8.1%) were in vegetative state, 10 (20.4%) were physically disabled, and 13 (26.5%) were physically functional. Within 72 hours of ROSC all of the 12 NR2-ab positive patients died. In contrast, 31 (84%) of the NR2-ab negative patients survived. Sensitivity, specificity, positive and negative likelihood ratios of NR2-ab in prediction of survival were 54.5% (95%CI=32.7%-74.9%), 100% (95%CI=84.5%-100%), infinite, and 45.5% (95%CI=28.8%-71.8%), respectively. Subsequent analysis showed that both NR2-ab status and GCS were independent risk factors of death. Conclusions: A positive NR2-ab serum test 1 hour after ROSC correlated with lower 72-hour survival. Further studies are required to validate this finding and demonstrate the value of a quantitative NR2-ab assay and its optimal time of measurement.

Diagnostic Accuracy of Cincinnati Pre-Hospital Stroke Scale

Behzad Zohrevandi, Vahid Monsef Kasmaie, Payman Asadi, Hosna TajiK, Nastaran Azizzade Roodpishi

EMERGENCY , Vol. 3 No. 3 (2015), 5 July 2015, Page pp. 95-98

Introduction: Stroke is recognized as the third cause of mortality after cardiovascular and cancer diseases, so that lead to death of about 5 million people, annually. There are several scales to early prediction of at risk patients and decreasing the rate of mortality by transferring them to the stroke center. In the present study, the accuracy of Cincinnati pre-hospital stroke scale was assessed. Methods: This was a retrospective cross-sectional study done to assess accuracy of Cincinnati scale in prediction of stroke probability in patients referred to the emergency department of Poursina Hospital, Rasht, Iran, 2013 with neurologic symptoms. Three criteria of Cincinnati scale including facial droop, dysarthria, and upper extremity weakness as well as the final diagnosis of patients were gathered. Sensitivity, specificity, predictive values, and likelihood ratios of Cincinnati scale were calculated using SPSS version 20. Results: 448 patients were assessed. The agreement rate of Cincinnati scale and final diagnosis was 0.483 ± 0.055 (p<0.0001). The sensitivity of 93.19% (95% Cl: 90.11-95.54), specificity of 51.85% (95% Cl: 40.47-63.10), positive predictive value of 89.76% (95% Cl: 86.27-92.62), negative predictive value of 62.69% (95% Cl: 55.52-72.45), positive likelihood ratio of 1.94% (95% Cl: 1.54-2.43), and negative likelihood ratio of 0.13% (95% Cl: 0.09-0.20) were calculated. Conclusion: It seems that pre-hospital Cincinnati scale can be an appropriate screening tool in prediction of stroke in patients with acute neurologic syndromes.

Introduction: Rib fracture is one of the common causes of trauma disabilities in many events and the outcome of these patients are very extensive from temporary pain management to long-term significant disability. Control and management of the pain in such patients is one of the most important challenges in emergency departments. Thus, the aim of the present study was assessing the efficacy of IV acetaminophen in pain control of patients with rib fracture. Methods: In this double-blind study, 54 patients over 18 years of age, referred to two educational hospitals with rib fracture, were entered. Patients were randomly categorized in two groups of morphine sulfate (0.1 milligram per kilogram of body weight) and IV acetaminophen (1gram), as single-dose infused in 100 cc normal saline. The pain severity was measured by Numeric Rating Scale on arrival and 30 minutes after drug administration. At least three scores reduction was reported as therapeutic success. Results: The mean and standard deviation of patients’ age was 41.2 ± 14.1 years. There is no difference in gender (p=0.24) and age frequency (p=0.77) between groups. 30 minutes after drug administration the mean of pain severity were 5.5 ± 2.3 and 4.9 ± 1.7 in morphine and acetaminophen groups, respectively (p=0.23). Success rate in morphine and acetaminophen groups were 58.6% (95% Cl: 39.6-77.7) and 80% (95% Cl: 63.2-96.7), respectively, (p=0.09). Only 3 (5.6%) patients had dizziness (p=0.44) and other effects were not seen in any of patients. Conclusion: The findings of the present study shows that intravenous acetaminophen and morphine have the same therapeutic value in relieving the pain of rib fracture. The success rate after 30 minutes drug administration were 80% and 58.6% in acetaminophen and morphine groups, respectively. Presentation of side effects was similar in both groups.

Introduction: Methodologically correct assessment of patient satisfaction (PS) plays a crucial role for quality-improvement purposes. Evaluation of Iranian literature on emergency department’s PS resulted in an emerging need for developing a new instrument with satisfactory psychometric properties. The present study, aimed to develop and initially validate a scale to measure PS in emergency departments. Methods: A sample of 301 patients was selected in 2014 from two hospitals in Tehran. A pool of 24 items was prepared for administering. An item analysis was conducted to evaluate the quality of each item. Validity and reliability of the scale were evaluated. The data were analyzed using SPSS. Results: Item analysis and exploratory factor analysis yielded in a 20-item scale in five domains named emergency department staff, emergency department environment, physician care satisfaction, general patient satisfaction, and patient’s family’s satisfaction. Validity and factor structure of the scale were reported satisfactory. Reliability coefficients of the domains ranged between 0.75 and 0.88. Conclusion: The findings of the present study provided evidence for psychometric properties of a newly developed scale for PS assessment in emergency departments. Five underlying components of PS were found in the item pool. In sum, this scale may be used in research and emergency departments to measure PS.

Comparison of Oral Midazolam and Promethazine with Oral Midazolam alone for Sedating Children during Computed Tomography

Hassan Barzegari, Behzad Zohrevandi, Kambiz Masoumi, Arash Forouzan, Ali Asgari Darian, Shaqayeq Khosravi

EMERGENCY , Vol. 3 No. 3 (2015), 5 July 2015, Page pp. 109-113

Introduction: Both midazolam and promethazine are recommended to be used as sedatives in many studies but each have some side effects that limits their use. Combination therapy as an alternative method, may decreases these limitations. Therefore, this study aimed to compare midazolam with midazolam-promethazine regarding induction, maintenance, and recovery characteristics following pediatric procedural sedation and analgesia. Methods: Children under 7 years old who needed sedation for being CT scanned were included in this double-blind randomized clinical trial. The patients were randomly divided into 2 groups: one only received midazolam (0.5 mg/kg), while the other group received a combination of midazolam (0.5 mg/kg) and promethazine (1.25 mg/kg). University of Michigan Sedation Scale (UMSS) was used to assess sedation induction. In addition to demographic data, the child’s vital signs were evaluated before prescribing the drugs and after inducing sedation (reaching UMSS level 2). The primary outcomes in the present study were onset of action after administration and duration of the drugs’ effect. Results: 107 patients were included in the study. Mean onset of action was 55.4±20.3 minutes for midazolam and 32.5±11.1 minutes for midazolam-promethazine combination (p<0.001). But duration of effect was not different between the 2 groups (p=0.36). 8 (7.5%) patients were unresponsive to the medication, all 8 of which were in the midazolam treated group (p=0.006). Also in 18 (16.8%) cases a rescue dose was prescribed, 14 (25.9%) were in the midazolam group and 4 (7.5%) were in the midazolam-promethazine group (p=0.02). Comparing systolic (p=0.20) and diastolic (p=0.34) blood pressure, heart rate (p=0.16), respiratory rate (p=0.17) and arterial oxygen saturation level (p=0.91) showed no significant difference between the 2 groups after intervention. Conclusion: Based on the findings of this study, it seems that using a combination of midazolam and promethazine not only speeds up the sedation induction, but also decreases unresponsiveness to the treatment and the need for a rescue dose.

Brief Report

Introduction: Chest x-ray (CXR) is the simplest diagnostic tool of Community Acquired Pneumonia (CAP), but it has some limitation. Therefore, the aim of this study is comparing the diagnostic accuracy of CXR and chest ultrasonography (CUS) in detection of CAP. Methods: In the present study, a consecutive sample of suspected patients with CAP was underwent CUS, CXR, and chest computed tomography (CT) scan. Diagnostic accuracy of CUS and CXR was assessed by calculating the sensitivity, specificity, predictive values, and likelihood ratios using SPSS 20 statistical software. Results: 30 patients with CAP were enrolled (93.3% male with mean age of 63.8 ± 18.3 years). Sensitivity of CUS and CXR in detection of CAP were 100.0% (95% Cl: 85.4-100.0) and 93.1% (95% Cl: 75.8-98.8), respectively. Specificity of CXR was 0.0 (95% Cl: 0.0-94.5), while the CUS specificity was not calculable. Conclusion: Findings of the present study demonstrated on the higher diagnostic accuracy of CUS versus CXR in detection of pneumonia.

Case Report

Foreign body aspiration is unusual in adults, except those who are debilitated or have neuropsychiatric disorders. It can be a life-threatening situation and it often requires a high index of suspicion, because the diagnosis can be obscure. Prompt diagnosis and intervention through foreign body retrieval are critical to prevent significant morbidity and mortality. We present a case of denture aspiration by a debilitated 90 years old man. He had aspirated his complete upper denture to pharynx causing incomplete obstruction with pleasure whistling respiratory sound, dyspnea, dysphagia and dysphonia. He underwent successful retrieval of the dental plate manually by fingers with complete resolution of symptoms. 

Periumbilical Pain with Radiation to Both Legs Following Tarantula Bite; a Case Report

Mahboob Pouraghaei, Samad Shams Vahdati, Ibrahim Mashhadi, Taranoom Mahmoudieh

EMERGENCY , Vol. 3 No. 3 (2015), 5 July 2015, Page pp. 120-121

Tarantulas have recently become as pets in most parts of the world that increased the probability of encountering emergency physicians with patients hurt with these spiders. Their attacks usually do not cause general manifestation, however there are some case reports in this regard. Here, a 40-year-old man was reported who was referred to the emergency department with severe periumbilical pain that radiated to both legs and diagnosed as a victim of tarantula bite. Such symptoms usually are belonging to other spiders like Black Widow spider, but it seems that tarantula can mimic them in some cases, too.

Odontogenic Pain as the Principal Presentation of Vertebral Artery Pseudoaneurysm; a Case Report

Marco Zenteno, Hernando Raphael Alvis-Miranda, Angel Lee, Luis Rafael Moscote-Salazar

EMERGENCY , Vol. 3 No. 3 (2015), 5 July 2015, Page pp. 122-124

Dissection of the vertebral artery is an important but rare cause of cerebrovascular accidents. Here we report a 48-year-old man with toothache since 4 days before who presented to the emergency department with neck pain and final diagnosis of dissecting right vertebral artery pseudoaneurysm. To our knowledge, this maybe the first report of odontogenic pain as the first manifestation of vertebral artery pseudoaneurysm in the literatures.

Photo Quiz

An 88-Year-Old Man with Sudden Onset Abdominal Pain

Mohammad Manouchehrifar, Soheil Soltani, Sona Ziaei

EMERGENCY , Vol. 3 No. 3 (2015), 5 July 2015, Page pp. 125-126

An 88-year-old man presented to the emergency department with sudden onset of abdominal pain since 6 hours before. He was a known case of chronic renal failure that underwent hemodialysis three times a week. He also suffered from hypertension and benign prostatic hyperplasia. The patients’ on-arrival vital signs were as follows: systolic blood pressure: 100/60 mmHg, pulse rate: 88/minute, respiratory rate: 25/minute, oral temperature: 36C, oxygen saturation 93% in room air.  He had severely ill appearance on admission. Distended abdomen was considerable but had normal bowel sound and clearly, pain was disproportionate to physical examination. His electrocardiogram showed sinus rhythm and venous blood gas analysis revealed the following: pH=6.96, PaCO2=49 mmHg, HCO3=11 mEq/L, Base excess= -20.  The bedside ultrasonography showed echogenic particles in hepatic parenchyma and same findings that were passing through the portal vein. Chest and abdominal X-rays were reported as normal. The patient underwent abdominal and pelvic computed tomography (CT) scan with oral contrast.

What is your diagnosis?


Medical Journalism and Emergency Medicine

Saeed Safari, Alireza Baratloo, Mahmoud Yousefifard

EMERGENCY , Vol. 3 No. 3 (2015), 5 July 2015, Page pp. 83-86

Nowadays, many researches in the field of medicine are conducting all around the world and medical journalism is a way to share the results. In fact, dissemination of the related manuscripts can prevent the repetitive research or may even lead to conducting a better survey. Therefore high quality medical journals are considered as up-to-date resources for further investigations. Medical journals are propagating their papers in various media including television programs, newspapers, internet websites and different social media. So they can influence the government policy makers, health-care professionals and even public. Moreover, most researchers hear about medical discoveries for the first time through medical journals and their related social media. So as well a high quality journal can help to improve medical science, a journal of poor quality can be damaging and distorting. Indeed, popular journals have the power of inventing a “communication storm” to draw attention to a certain topic. Thus they have to respect the accepted international principles to prevent spreading inaccurate and misleading data. This paper aims to review the previous and current situation of medical journalism by focus on field of emergency medicine.

Evidence-Based Emergency Medicine