Evolution of Fagan's Nomogram; a Commentary

Abdelrahman Ibrahim Abushouk

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 114-115

I read with interest your paper entitled "Pre and post-test probabilities and Fagan’s nomogram. I would like to add a note concerning an update on Fagan’s Nomogram. In 2011, a group of researchers published a modern version of the nomogram that they named "Bayes’ theorem nomogram".

Review Article

Application of Ultrasonography and Radiography in Detection of Hemothorax: a Systematic Review and Meta-Analysis

Vafa Rahimi-Movaghar, Mahmoud Yousefifard, Parisa Ghelichkhani, Masoud Baikpour, Abbas Tafakhori, Hadi Asady, Gholamreza Faridaalaee, Mostafa Hosseini, Saeed Safari

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 116-126

Introduction: Hemothorax is one of the most prevalent injuries caused by thoracic traumas. Early detection and treatment of this injury is of utmost importance in prognosis of the patient, but there are still controversial debates on the diagnostic value of imaging techniques in detection of hemothorax. Therefore, the present study aimed to evaluate the diagnostic value of chest ultrasonography and radiography in detection of hemothorax through a systematic review and meta-analysis. Methods: Two independent reviewers performed an extended systematic search in databases of Medline, EMBASE, ISI Web of Knowledge, Scopus, Cochrane Library, and ProQuest. Data were extract and quality of the relevant studies were assessed. The number of true positive, false positive, true negative and false negative cases were extracted and screening performance characteristics of two imaging techniques were calculated using a mixed-effects binary regression model. Results: Data from 12 studies were extracted and included in the meta-analysis (7361 patients, 77.1% male). Pooled sensitivity and specificity of ultrasonography in detection of hemothorax were 0.67 (95% CI: 0.41-0.86; I2= 68.38, p<0.001) and 0.99 (95% CI: 0.95-1.0; I2= 88.16, p<0.001), respectively. These measures for radiography were 0.54 (95% CI: 0.33-0.75; I2= 92.85, p<0.001) and 0.99 (95% CI: 0.94-1.0; I2= 99.22, p<0.001), respectively. Subgroup analysis found operator of the ultrasonography device, frequency of the transducer and sample size to be important sources of heterogeneity of included studies. Conclusion: The results of this study showed that although the sensitivity of ultrasonography in detection of hemothorax is relatively higher than radiography, but it is still at a moderate level (0.67%). The specificity of both imaging modalities were found to be at an excellent level in this regard. The screening characteristics of ultrasonography was found to be influenced of the operator and frequency of transducer.

Original/Research Article

Diagnostic Value of Clinical Findings in Evaluation of Thoracolumbar Blunt Traumas

Ali Shahrami, Majid Shojaee, Seyed Mohammadreza Tabatabaee, Elaheh Mianehsaz

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 127-131

Introduction: Necessity of imaging for symptom-free conscious patients presented to emergency department (ED) following traumatic thoracolumbar spine injuries has been a matter of debate. The present study was aimed to evaluate the diagnostic value of clinical findings in prediction of traumatic thoracolumbar injuries compared tocomputed tomography (CT) scan. Methods: The present diagnostic value study was carried out using non-random convenience sampling during the time between October 2013 and March 2014. All trauma patients > 15 years old underwent thoracolumbar CT scan were included. Correlation between clinical and CT findings was measured using SPSS 21.0 and screening performance characteristics of clinical findings in prediction of thoracolumbar fracture were calculated. Results: 169 patients with mean age of 37.8 ± 17.3 years (rage: 15-86) were evaluated (69.8% male). All fracture patients had at least 1 positive finding in history and physical examination. The fracture was confirmed in only 24.6% of the patients with positive findings in history or physical examination. In 37.5% of patients the location of fracture, matched the area of positive physical examinations. Sensitivity, specificity, PPV, NPV, PLR, and NLR of clinical findings in comparison to thoracolumbar CT scan were 100 (95% CI: 89 - 100), 1.5 (95% CI: 0.2-6), 24.5 (95% CI: 18.3-31.9), 100 (95% CI: 19.7-100), 32.5 (95% CI: 24.6-43.03), and infinite, respectively. Conclusion: The results of the present study, show the excellent screening performance characteristics of clinical findings in prediction of traumatic thoracolumbar fracture (100% sensitivity). It could be concluded that in conscious patients with stable hemodynamic, who have no distracting pain and are not intoxicated, probability of thoracolumbar fracture is very low and near to zero in case of no positive clinical finding.

Ultrasound-Guided Reduction of Distal Radius Fractures

Anita Sabzghabaei, Majid Shojaee, Ali Arhami Dolatabadi, Mohammad Manouchehrifar, Mahdi Asadi

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 132-135

Introduction: Distal radius fractures are a common traumatic injury, particularly in the elderly population. In the present study we examined the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to emergency department (ED). Methods: In this prospective case control study, eligible patients were adults older than 18 years who presented to the ED with distal radius fractures. 130 consecutive patient consisted of two group of Sixty-Five patients were prospectively enrolled for around 1 years. The first group underwent ultrasound-guided reduction and the second (control group) underwent blind reduction. All procedures were performed by two trained emergency residents under supervision of senior emergency physicians. Results: Baseline characteristics between two groups were similar. The rate of repeat reduction was reduced in the ultrasound group (9.2% vs 24.6%; P = .019). The post reduction radiographic indices were similar between the two groups, although the ultrasound group had improved volar tilt (mean, 7.6° vs 3.7°; P = .000). The operative rate was reduced in the ultrasound groups (10.8% vs 27.7%; P = .014). Conclusion: Ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures.

Outcome of Blunt Abdominal Traumas with Stable Hemodynamic and Positive FAST Findings

Firooz Behboodi, Zahra Mohtasham-Amiri, Navid Masjedi, Reza Shojaie, Peyma Sadri

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 136-139

Introduction: Focused assessment with sonography for trauma (FAST) is a highly effective first screening tool for initial classification of abdominal trauma patients. The present study was designed to evaluate the outcome of patients with blunt abdominal trauma and positive FAST findings. Methods: The present prospective cross-sectional study was done on patients over 7 years old with normal abdominal examination, positive FAST findings, and available abdominopelvic computed tomography (CT) scan findings. The frequency of need for laparotomy as well as its probable risk factors were calculated. Results: 180 patients were enrolled (mean age: 28.0 ± 11.5 years; 76.7% male). FAST findings were confirmed by abdominopelvic CT scan in only 124 (68.9%) cases. Finally, 12 (6.6%) patients needed laparotomy. Mean age of those in need of laparotomy was significantly higher than others (36.75 ± 11.37 versus 27.34 ± 11.37, p = 0.006). Higher grading of spleen (p = 0.001) and hepatic (p = 0.038) ruptures increased the probability of need for laparotomy. Conclusion: 68.9% of the positive FAST findings in patients with blunt abdominal trauma and stable hemodynamics was confirmed by abdominopelvic CT scan and only 6.6% needed laparotomy. Simultaneous presence of free fluid and air in the abdominal area, old age, and higher grading o solid organ injuries were factors that had a significant correlation with need for laparotomy.

Bedside Ultrasonography versus Brain Natriuretic Peptide in Detecting Cardiogenic Causes of Acute Dyspnea

Keihan Golshani, Mehrdad Esmailian, Aniseh Valikhany, Majid Zamani

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 140-144

Acute dyspnea is a common cause of hospitalization in emergency departments (ED).Distinguishing the cardiac causes of acute dyspnea from pulmonary ones is a major challenge for responsible physicians in EDs. This study compares the characteristics of bedside ultrasonography with serum level of blood natriuretic peptide (BNP) in this regard. Methods: This diagnostic accuracy study compares bedside ultrasonography with serum BNP levels in differentiating cardiogenic causes of acute respiratory distress. Echocardiography was considered as the reference test. A checklist including demographic data (age and sex), vital signs, medical history, underlying diseases, serum level of BNP, as well as findings of chest radiography, chest ultrasonography, and echocardiography was filled for all patients with acute onset of dyspnea. Screening characteristics of the two studied methods were calculated and compared using SPSS software, version 20. Results: 48 patients with acute respiratory distress were evaluated (50% female). The mean age of participants was 66.94 ± 16.33 (28-94) years. Based on the results of echocardiography and final diagnosis, the cause of dyspnea was cardiogenic in 20 (41.6%) cases. Bedside ultrasonography revealed the cardiogenic cause of acute dyspnea in 18 cases (0 false positive) and BNP in 44 cases (24 false positives). The area under the ROC curve for bedside ultrasonography and BNP for differentiating the cardiogenic cause of dyspnea were 86.4 (95% CI: 74.6-98.3) and 66.3 (95% CI: 49.8-89.2), respectively (p = 0.0021). Conclusion: It seems that bedside ultrasonography could be considered as a helpful and accurate method in differentiating cardiogenic causes of acute dyspnea in emergency settings. Nevertheless, more study is needed to make a runaway algorithm to evaluate patients with respiratory distress using bedside ultrasonography, which leads to rapid therapeutic decisions in a short time.

Epidemiology and Death-Related Factors of Oncology Patients in Emergency Department

Bahram Mofid, Kambiz Novin, Elham Sadat Roointan, Mohammad Mehdi Forouzanfar

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 145-150

Introduction: Accurate diagnosis and proper treatment of oncology patients presented to emergency department
(ED) can dramatically enhance their quality of life and decrease their mortality rate. Therefore, the present
study aimed to evaluate these patients from an epidemiologic point of view as well as identifying death-related
factors. Methods: In this retrospective cross-sectional study, all the oncology patients presented to ED during
one year were evaluated using census sampling. A checklist that consisted of clinical and demographic data as
well as patients outcome was filled for each patient. Using SPSS 21, multivariate stepwise logistic regression
analysis was done to identify independent death-related factors. Results: 568 patients with the mean age of
53.64§18.99 years were studied (56.5% male). The most common locations of tumor were brain (32.7%) and
gastrointestinal tract (27.1%). Pain (32.5%) was the most frequent chief complaint on ED arrival. The overall
mortality rate of studied patients was 154 (27.1%), 25 (16.2%) of them in ED. Among the evaluated factors,
marital status, visiting on a weekday, arrival to ED via ambulance, type of cancer, stage of cancer, presence of
metastasis, being under treatment with chemo-radiotherapy, chief complaint on arrival, tumor location, and
admission to intensive care unit (ICU) correlated significantly with in-hospital mortality. Conclusion: The most
common type of cancer in the studied patients was solid, located in the brain or gastrointestinal tract, in stage III
and IV, metastatic, and under chemo-radiotherapy. Independent death-related factors included ICU admission,
presentation with loss of consciousness or bleeding, arrival via ambulance, cancer stage > II, neuroendocrine
and genitourinary location of cancer, and being under chemo-radiotherapy.

Brief Report

Frequency of Electrocardiographic Abnormalities in Tramadol Poisoned Patients; a Brief Report

Anahita Alizadeh Ghamsari, Bita Dadpour, Fares Najari

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 151-154

Introduction: Previous studies have raised the probably of cardiac manifestation in tramadol poisoning. However, conclusive information on electrocardiographic (ECG) abnormalities of tramadol overdose remains to be explained. Therefore, the present study aimed to evaluate the epidemiology of ECG abnormalities in tramadol poisoned patients. Methods: In a prospective cross-sectional study, all patients with tramadol poisoning, who were admitted to the emergency department of Loghman Hospital during 2012 – 2013, were evaluated. Patients’ baseline characteristics and ECG findings including axis, rate, rhythm, PR interval, QRS duration, QTc interval, evidence of Brugada pattern, and evidence of blocks were recorded. Obtained Data were descriptively analyzed using SPSS 21.0 statistical software. Results: 1402 patients with the mean age of 24 ± 6 years were studied (71.1% male). Sinus tachycardia was detected in 463 (33%) patients, sinus bradycardia in one patient (0.07%), right axis deviation in 340 (24.2), QRS widening in 91 (6.5%), long QTc interval in 259 (18.4%), dominant S wave in either I or aVL lead in 395 (28.1%), and right bundle branch block in 73 (5.2%). Increased PR interval was not detected in any cases. The evidence of Brugada pattern was observed in 2 (0.14%) patients (100% male), both symptomatized with seizure. All abnormalities had same sex distribution. Conclusion: Based on the results of the present study, the most common types of ECG changes were sinus tachycardia, a deep S wave in leads I and aVL, right axis deviation, and long QTc interval, respectively. Brugada pattern and sinus bradycardia were rarely presented.

Proper Angle of Sono-guided Central Venous Line Insertion; a Brief Report

Hassan Barzegari, Arash Forouzan, Mohammad Ali Fahimi, Behzad Zohrevandi, Mandana Ghanavati

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 155-158

Introduction: Determining the proper angle for inserting central venous catheter (CV line) is of great importance for decreasing the complications and increasing success rate. The present study was designed to determine the proper angle of needle insertion for internal jugular vein catheterization. Methods: In the present case series study, candidate patients for catheterization of the right internal jugular vein under guidance of ultrasonography were studied. At the time of proper placing of the catheter, photograph was taken and Auto Cad 2014 software was used to measure the angles of the needle in the sagittal and axial planes, as well as patient’s head rotation. Result: 114 patients with the mean age of 56.96 ± 14.71 years were evaluated (68.4% male). The most common indications of catheterization were hemodialysis (55.3%) and shock state (24.6%). The mean angles of needle insertion were 102.15 ± 6.80 for axial plane, 36.21 ± 3.12 for sagittal plane and the mean head rotation angle was 40.49 ± 5.09. Conclusion: Based on the results of the present study it seems that CV line insertion under the angles 102.15 ± 6.80 degrees in the axial plane, 36.21 ± 3.12 in the sagittal plane and 40.49 ± 5.09 head rotation yield satisfactory results. 

Case Report

Focal Myopericarditis as a Rare but Important Differential Diagnosis of Myocardial Infarction; a Case Series

Younes Nozari, Masih Tajdini, Mehdi Mehrani, Roza Ghaderpanah

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 159-162

Distinguishing ST-elevation myocardial infarction (STEMI) differential diagnoses is more challenging. Myopericarditis is one of these differentials that results from viral involvement of myocardium and pericardium of the heart. Myopericarditis in focal form can mimic acute STEMI in its electrocardiogram (ECG) features and elevated cardiac enzymes.

Myocarditis patients may face thrombolytic related complications such as intracranial bleeding, myocardial rupture, and hemorrhagic cardiac tamponade. Furthermore, re-administration of streptokinase (a common thrombolytic agent in our country) is banned for at least six months of previous administration; however, it can save patients’ lives in emergency conditions such as massive pulmonary embolism. It seems that, when dealing with a young patient presenting to emergency department with acute chest pain and ST segment elevation on ECG, we should consider focal myocarditis as an important but rare differential diagnosis of STEMI. In this report, we describe three cases of focal myocarditis, primarily misdiagnosed as STEMI.

Erythema Multiforme as a Result of Orf Disease; a Case Report

Tahmine Biazar, Mehran Shokri, Hajar Hosseinnia, Masomeh Bayani

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 163-165

Orf is a mucocutaneous disease that occurs when non-intact skin comes into contact with contaminated sheep saliva. The lesions may complicate to lymphangitis or secondary bacterial infection, but systemic complications such as erythema multiforme, maculopapular rash, and generalized lymphadenopathy are rare. In this paper, we present two cases of erythema multiforme following Orf disease.

Photo Quiz

A 33-year-old Man with Abdominal Pain

Kuo-Chih Chen, Aming Chor-Ming Lin, Chin-Chu Wu, Tzong-Luen Wang, Chai-Hock Chua

EMERGENCY , Vol. 4 No. 3 (2016), 11 April 2016, Page pp. 166-168

A 33-year-old man presented to the emergency department ED) with complaint of 2-day history of abdominal pain. His pain developed with gradual onset prominently in epigastric area after eating dried mushrooms. The pain was diffuse, persistent, radiating to the back and aggravated by meal. He had been tolerating only liquids and had complaints of nausea and vomiting. He had no history of diabetes mellitus, hypertension, alcohol consumption, malignancy, or prior surgery. On arrival his blood pressure was 128/72 mmHg, with a heart rate of 101 beats/minute and a respiratory rate of 20 breaths/minute. He was afebrile. Physical examination revealed diffuse abdominal distention, hyper-pitched bowel sounds, and tenderness more marked over the umbilicus with no guarding or rebound tenderness. A complete blood cell count showed the following: leukocyte count 12600 /mm3; segmented neutrophils 90%; hemoglobin level of 14 mg/dl; hematocrit 30%; and platelet 420000/µL. Other laboratory studies included: glucose 101 mg/dL; serum urea nitrogen 45 mg/dL; serum creatinine 2.0 mg/dL; sodium 148 mEq/L; potassium 3.1 mEq/L; serum glutamic oxaloacetic transaminase (SGOT) 38 U/L and lipase 30 U/L. Figure 1 shows patient’s plain upright abdominal X-ray as well as coronal and axial cuts of abdominal CT scan.