Central Venous Pressure Monitoring; Introduction of a New Device

Mahmood Ghafoori Yazdi, Arya Shoghli, Sina Faghihi, Alireza Baratloo

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 52-54

Hemodynamic monitoring is needed in up to 58% of patients presented to the emergency department. Central venous pressure (CVP) monitoring is generally useful to assess general volume status. There are several methods of CVP measurement, which can be categorized as invasive and non-invasive. CVP manometer and electronic transducer are among the invasive methods and direct observation, ultrasonography and plethysmography are examples of non-invasive ones. All the mentioned methods have some negative points and shortcomings. Here we introduce a new device that can facilitate CVP measurement and provide physicians with further data that can be helpful regarding decision making and patient management.

Review Article

Comparison of Ultrasonography and Radiography in Detection of Thoracic Bone Fractures; a Systematic Review and Meta-Analysis

Mahmoud Yousefifard, Masoud Baikpour, Parisa Ghelichkhani, Hadi Asady, Abolfazl Darafarin, Mohammad Reza Amini Esfahani, Mostafa Hosseini, Mehdi Yaseri, Saeed Safari

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 55-64

Introduction: The potential benefit of ultrasonography for detection of thoracic bone fractures has been proven in various surveys but no comprehensive conclusion has been drawn yet; therefore, the present study aimed to conduct a thorough meta-analytic systematic review on this subject. Methods: Two reviewers independently carried out a comprehensive systematic search in Medline, EMBASE, ISI Web of Knowledge, Scopus, Cochrane Library, and ProQuest databases. Data were summarized as true positive, false positive, true negative and false negative and were analyzed via STATA 11.0 software using a mixed-effects binary regression model. Sources of heterogeneity were further assessed through subgroup analysis. Results: Data on 1667 patients (807 subjects with and 860 cases without thoracic fractures), whose age ranged from 0 to 92 years, were extracted from 17 surveys. Pooled sensitivity and specificity of ultrasonography in detection of thoracic bone fractures were 0.97 (95% CI: 0.90-0.99; I2= 88.88, p<0.001) and 0.94 (95% CI: 0.86-0.97; I2= 71.97, p<0.001), respectively. The same measures for chest radiography were found to be 0.77 (95% CI: 0.56-0.90; I2= 97.76, p<0.001) and 1.0 (95% CI: 0.91-1.00; I2= 97.24, p<0.001), respectively. The sensitivity of ultrasonography was higher in detection of rib fractures, compared to fractures of sternum or clavicle (97% vs. 91%). Moreover, the sensitivity was found to be higher when the procedure was carried out by a radiologist in comparison to an emergency medicine specialist (96% vs. 90%). Conclusion: Base on the findings of the present meta-analysis, screening performance characteristic of ultrasonography in detection of thoracic bone fractures was found to be higher than radiography. However, these characteristics were more prominent in detection of rib fractures and in cases where was performed by a radiologist.

Ventilator Weaning and Spontaneous Breathing Trials; an Educational Review

Hossam Zein, Alireza Baratloo, Ahmed Negida, Saeed Safari

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 65-71

The term "weaning" is used to describe the gradual process of decreasing ventilator support. It is estimated that 40% of the duration of mechanical ventilation is dedicated to the process of weaning. Spontaneous breathing trial (SBT) assesses the patient's ability to breathe while receiving minimal or no ventilator support. The collective task force in 2001 stated that the process of SBT and weaning should start by assessing whether the underlying cause of respiratory failure has been resolved or not. Weaning predictors are parameters that are intended to help clinicians predict whether weaning attempts will be successful or not. Although the international consensus conference in 2005 did not recommend their routine use for clinical decision making, researchers did not stop working in this area. In the present article, we review some of the recent studies about weaning predictors, criteria, procedure, as well as assessment for extubation a mechanically ventilated patient.

Original/Research Article

Unintentional Home Injury Prevention in Preschool Children; a Study of Contributing Factors

Somaye Younesian, Soad Mahfoozpour, Ensiye Ghaffari Shad, Hamid Kariman, Hamid Reza Hatamabadi

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 72-77

Introduction: Different factors such as parents’ knowledge and attitudes regarding preventive measures (PM) have a great role in reducing children unintentional home injuries. The present study aims to evaluate the contributing factors of unintentional home injury prevention in preschool victims presented to the emergency department. Methods: The subjects consisted of all the mothers of preschool children who were presented to the emergency department of Imam Hossein and Shohadaie-Hafte-Tir Hospitals, with unintentional home injuries, from March 2011 to February 2012. The participants were divided into two groups according to implementation of preventive measures status. The significant confounding factors of PM application was determined by chi-squared test and entered into the backward multivariate logistic regression model. Results: 230 mothers with the mean age of 29.4 ± 5.2 years were evaluated. 225 (97.83%) of them were still married, 74 (32.17%) had high school education or higher, 122 (53.04%) were homemakers, and 31 (13.49%) worked outside the home for at least 8 hours daily. High level of knowledge (OR = 0.05; 95% CI: 0.002‒0.32; P = 0.002), appropriate attitude (OR = 0.12; 95% CI: 0.03‒0.51; P = 0.01), having at least three children (OR = 7.2; 95% CI: 1.1‒32.9; P = 0.04), daily absence of mother for at least 8 hours (OR = 9.2; 95% CI: 2.2‒35.46; P = 0.002), and a history of home injury during the previous 3 weeks (OR = 8.3; 95% CI: 2.1‒41.3; P = 0.001) were independent factors which influenced application of preventive measures. Conclusion: Increasing mothers’ knowledge level and improving their attitudes were facilitating factors and mothers’ absence from the house for more than 8 hours a day and having at least 3 children were obstacles to application of preventive measures. In addition, a history of same injury during the previous 3 weeks increased the risk of repeated event.

Effective Factors in Severity of Traffic Accident-Related Traumas; an Epidemiologic Study Based on the Haddon Matrix

Kambiz Masoumi, Arash Forouzan, Hassan Barzegari, Ali Asgari Darian, Fakher Rahim, Behzad Zohrevandi, Somayeh Nabi

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 78-82

Introduction: Traffic accidents are the 8th cause of mortality in different countries and are expected to rise to the 3rd rank by 2020. Based on the Haddon matrix numerous factors such as environment, host, and agent can affect the severity of traffic-related traumas. Therefore, the present study aimed to evaluate the effective factors in severity of these traumas based on Haddon matrix. Methods: In the present 1-month cross-sectional study, all the patients injured in traffic accidents, who were referred to the ED of Imam Khomeini and Golestan Hospitals, Ahvaz, Iran, during March 2013 were evaluated. Based on the Haddon matrix, effective factors in accident occurrence were defined in 3 groups of host, agent, and environment. Demographic data of the patients and data regarding Haddon risk factors were extracted and analyzed using SPSS version 20. Results: 700 injured people with the mean age of 29.66 ± 12.64 years (3-82) were evaluated (92.4% male). Trauma mechanism was car-pedestrian in 308 (44%) of the cases and car-motorcycle in 175 (25%). 610 (87.1%) cases were traffic accidents and 371 (53%) occurred in the time between 2 pm and 8 pm. Violation of speed limit was the most common violation with 570 (81.4%) cases, followed by violation of right-of-way in 57 (8.1%) patients. 59.9% of the severe and critical injuries had occurred on road accidents, while 61.3% of the injuries caused by traffic accidents were mild to moderate (p < 0.001). The most common mechanisms of trauma for critical injuries were rollover (72.5%), motorcycle-pedestrian (23.8%), and car-motorcycle (13.14%) accidents (p < 0.001). Conclusion: Based on the results of the present study, the most important effective factors in severity of traffic accident-related traumas were age over 50, not using safety tools, and undertaking among host-related factors; insufficient environment safety, road accidents and time between 2 pm and 8 pm among environmental factors; and finally, rollover, car-pedestrian, and motorcycle-pedestrian accidents among the agent factors.

Introduction: The correlation of central venous pressure (CVP) with inferior vena cava (IVC) sonographic diameter has been reported in several studies. However, few studies have attempted to find the best anatomic location of measurement. Therefore, the purpose of this study was determining the best anatomic location to find precise correlation between CVP and IVC diameter using transesophageal echocardiography (TEE). Methods: In the present diagnostic accuracy study, patients in need of central venous catheterization and TEE were enrolled. Maximum diameter of IVC were measured during expiratory phase of respiratory cycle at the level of diaphragm, 2cm above the diaphragm and at the point of entry into the right atrium using SonoSite TEE device. CVP was measured using an electronic transducer connected to the central venous line. The best location for sonography was determined via calculating and comparing area under the receiver operating characteristics (ROC) curve (AUC). Results: 39 patients were enrolled (53.8% female). Mean CVP was 6.8 ± 1.4 mmHg and 25 (64.1%) patients had normal CVP, while 14 (35.9%) showed elevated CVP (> 6 mmHg). Evaluating AUC showed that IVC diameter (p = 0.01), aorta diameter (p = 0.01) and IVC / aorta ratio (p = 0.004) had acceptable correlation with CVP. Point of entry of IVC into the right atrium with AUC of 0.98 (95% CI: 0.95 – 1.00) was the location of highest correlation with CVP. Conclusion: Based on the present findings, the IVC sonographic diameter and IVC / aorta ratio had acceptable correlation with CVP at the level of IVC entry into the right atrium.

Acute Physiology and Chronic Health Evaluation (APACHE) III Score Compared to Trauma-Injury Severity Score (TRISS) in Predicting Mortality of Trauma Patients

Parvin Darbandsar Mazandarani, Kamran Heydari, Hamidreza Hatamabadi, Parvin Kashani, Yasin Jamali Danesh

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 88-91

Introduction: More than 50 scoring systems have been published for classification of trauma patients in the field, emergency room, and intensive care settings, so far. The present study aimed to compare the ability of trauma injury severity score (TRISS) and acute physiology and chronic health evaluation (APACHE) III in predicting mortality of intensive care unit (ICU) admitted trauma patients. Methods: This prospective cross-sectional study included ICU admitted multiple trauma patients of Imam Hossein and Hafte-Tir Hospitals, Tehran, Iran, during 2011 and 2012. Demographic data, vital signs, mechanism of injury and required variables for calculating APACHE III score and TRISS were recorded. The accuracy of the two models in predicting mortality of trauma patients was compared using area under the ROC curve. Results: 152 multiple trauma patients with mean age of 37.09 ± 14.60 years were studied (78.94% male). 48 (31.57%) cases died. For both APACHE III and TRISS, predicted death rates significantly correlated with observed death rates (p < 0.0001). The mean age of dead patients was 37.21 ± 14.07 years compared to 37.03±14.96 years for those who survived (p = 0.4). The area under ROC curve was 0.806 (95% CI: 0.663-0.908) for TRISS and 0.797 (95% CI: 0.652-0.901) for APACHE III (p = 0.2). Conclusion: Based on the results of this study, both TRISS and APACHE models have the same accuracy in predicting mortality of ICU admitted trauma patients. Therefore, it seems that TRISS model would be more applicable in this regard because of its easier calculation, consideration of trauma characteristics, and independency of patient care quality.

Introduction: Performance of painful diagnostic and therapeutic procedures is common in emergency department
(ED), and procedural sedation and analgesia (PSA) is a fundamental skill for every emergency physician.
This studywas aim to compare the efficacy of remifentanil with fentanyl/midazolam in painless reduction of anterior
shoulder dislocation. Methods: In this randomized, double blind, clinical trial the procedural characteristics,
patients satisfaction as well as adverse events were compared between fentanyl/midazolamand remifentanil
for PSA of 18–64 years old patients, which were presented to ED following anterior shoulder dislocation.
Results: 96 cases were randomly allocated to two groups (86.5% male). There were no significant difference between
groups regarding baseline characteristics. Remifentanil group had lower duration of procedure (2.5§1.6
versus 4.6§1.8 minutes, p Ç 0.001), higher pain reduction (53.7§13.3 versus 33.5§19.6, p Ç 0.001), lower failure
rate (1 (2.1%) versus 15 (31.3%), p Ç 0.001), higher satisfaction (p Æ 0.005). Adverse events were seen in 12 (25%)
patients in midazolam/fentanyl and 8 (16.7%) cases in remifentanil group (p Æ 0.122). Conclusion: It seems
that use of remifentanil resulted in lower procedural time, lower failure rate, and lower pain during procedure
as well as higher patient satisfaction in comparison with midazolam/fentanyl combination in anterior shoulder

Brief Report

Sudden Death Following Exercise; a Case Series Study

Fares Najari, Alimohammad Alimohammadi, Parisa Ghodrati

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 97-100

Introduction: Natural and unexpected death that happens within less than one hour of first symptom occurrence is called sudden death. Cardiovascular diseases are the main known reason of sudden death and more than 75% of sudden deaths in athletes are assigned to it. Here we reported the autopsy results of all cases with sudden death following exercise that were referred to forensic center of Tehran, Iran, from 2009 to 2014. Methods: In this cross sectional study all subjects who were registered to forensic medicine center of Tehran, Iran, from 2009 to 2014, as a case of sudden death following exercise were evaluated. Demographic data and medical history as well as autopsy and toxicology findings were retrospectively gathered using profiles of the deceased. Results were reported using descriptive analysis. Results: 14 cases were registered as sudden death following exercise in forensic medicine profiles during the study period. Exploring the files of the mentioned deceased, revealed five non-compatible cases in this regard. Finally, 9 eligible cases were enrolled (88.9% male). The mean age of the deceased was 28.66 ± 10.86 years (range: 7 – 40). Toxicological tests were available for 7 cases, one of which was positive for tramadol. Sudden death following football was reported most frequently (44.4%). Only 3 (33.3%) cases had herald signs such as chest pain, syncope, or loss of consciousness. 1 case (11.11%) had a positive history of sudden death in relatives. Conclusion: Although most sudden death victims are asymptomatic until the event, all those who suffer from symptoms such as chest pain, shortness of breath, dizziness, fatigue and irregular heart rate during physical activities, should be screened regarding common probable causes of sudden death.

Ultrasound and Perforated Viscus; Dirty Fluid, Dirty Shadows, and Peritoneal Enhancement

Hamid Shokoohi, Keith S. Boniface, Bruce M. Abell, Ali Pourmand, Mohammad Salimian

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 101-105

Early detection of free air in the peritoneal cavity is vital in diagnosis of life-threatening emergencies, and can play a significant role in expediting treatment. We present a series of cases in which bedside ultrasound (US) in the emergency department accurately identified evidence of free intra-peritoneal air and echogenic (dirty) free fluid consistent with a surgical final diagnosis of a perforated hollow viscus. In all patients with suspected perforated viscus, clinicians were able to accurately identify the signs of pneumoperitoneum including enhanced peritoneal stripe sign (EPSS), peritoneal stripe reverberations, and focal air collections associated with dirty shadowing or distal multiple reflections as ring down artifacts. In all cases, hollow viscus perforation was confirmed surgically. It seems that, performing US in patients with suspected perforated viscus can accurately identify presence of intra-peritoneal echogenic or “dirty” free fluid as well as evidence of free air, and may expedite patient management.

Case Report

Peganum Harmala (Aspand) Intoxication; a Case Report

Rezvan Sadr Mohammadi, Reza Bidaki, Fazlollah Mirdrikvand, Nader Mostafavi, Pouria Yazdian Anari

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 106-107

There are several reports in the literature indicating a great variety of pharmacological effects for peganum harmala or aspand such as sedative anti-bacterial, anti-fungal, antiviral and antiprotozoal. Some people believe that can be used for treatment of some organic or psychiatric disorders. We introduce a woman with history of long time constipation that was disappointed in novel medical treatment and decided to use comminuted Aspand to relieve her problem. Two hours after use, the intoxication symptoms manifested as blurred vision, phonophobia, floating feeling, and tinnitus ringing. Here we report the treatment process and outcome of this case.

Eosinophilic Gastroenteritis as a Rare Cause of Recurrent Epigastric Pain

Mohammad Taghi Safari, Shabnam Shahrokh, Mohammad Bagher Miri, Mohammad Javad Ehsani Ardakani

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 108-110

Eosinophilic gastroenteritis (EGE) is a rare inflammatory disorder of gastrointestinal tract characterized by eosinophilic infiltration of the bowel wall. It can mimic many gastrointestinal disorders due to its wide spectrum of presentations. Diagnose is mostly based on excluding other disorders and a high suspicion. Here we report a case of 26 year old man with a history of sever epigastric pain followed by nausea, vomiting since a few days before admission with final diagnosis of EGE.

Evidence-Based Emergency Medicine

Part 5: Receiver Operating Characteristic Curve and Area under the Curve

Saeed Safari, Alireza Baratloo, Mohamed Elfil, Ahmed Negida

EMERGENCY , Vol. 4 No. 2 (2016), 11 April 2016, Page pp. 111-113

Multiple diagnostic tools are used by emergency physicians,
every day. In addition, new tools are evaluated to obtain
more accurate methods and reduce time or cost of conventional
ones. In the previous parts of this educational
series, we described diagnostic performance characteristics
of diagnostic tests including sensitivity, specificity, positive
and negative predictive values, and likelihood ratios. The
receiver operating characteristics (ROC) curve is a graphical
presentation of screening characteristics. ROC curve is used
to determine the best cutoff point and compare two or more
tests or observers by measuring the area under the curve
(AUC). In this part of our educational series, we explain ROC
curve and two methods to determine the best cutoff value.