Original/Research Article

Intravenous Morphine vs. Acetaminophen for Pain Management in Suspected Acute Cholecystitis Cases; a Clinical Trial

Iraj Golikhatir, Reza Jamali, Hamed Aminiahidashti, Farzad Bozorgi, Mohammad Hosseininejad, Heossein Montazar, Fatemeh Jahanian

Iranian Journal of Emergency Medicine, Vol. 3 No. 3 (2016), 21 September 2016, Page 91-86

Introduction: Acute cholecystitis is one of the most common surgical emergencies and a major cause of acute abdomen all over the world. One of the most important measures taken for these patients in emergency department (ED) is pain management. Therefore, the present study aimed to compare the effectiveness of intravenous acetaminophen and morphine for managing abdominal pain caused by acute cholecystitis. Methods: The present study is a single blind randomized clinical trial that evaluates and compares the effectiveness of morphine sulfate and intravenous acetaminophen in pain management of patients with suspected acute cholecystitis aged above 18 years with stable vital signs, who were admitted to ED. To gather data a pre-designed checklist, consisting of demographic data, pain severity on arrival and 30, 60, and 90 minutes after injection, vital signs on arrival, presence or absence of side effects, and clinical findings, was used. Finally, the 2 groups were compared regarding pain relief and side effects using SPSS 18. Results: 70 patients with the mean age of 55.2 ± 16.3 years were randomly allocated to 2 groups of 35 (61.4% female). 38 (54.3%) patients had only one ultrasonogrphic indication for acute cholecystitis, while 32 (45.7%) had 2 or more. Mean pain severity was significantly different between the 2 groups 30, 60, and 90 minutes after drug injection (p < 0.05). However, nausea (p = 0.617) and vomiting (p = 0.150) rates after injection were not significantly different between the groups. Fever was significantly lower in acetaminophen group (p < 0.001). Conclusion: Based on the results of the present study, morphine is more efficient than acetaminophen in pain relief during the initial 30 minutes after injection. However, although the difference in pain relief was statistically significant between the groups, 60 and 90 minutes after injection, it was not clinically important (less than 3 score). On the other hand, intravenous acetaminophen was simultaneously effective in controlling fever among the patients. 

Comparing the Effectiveness of Intravenous Diazepam and Methyl Prednisolone in Treatment of Acute Peripheral Vertigo; a Clinical Trial

Hasan Barzegari, Javad Mozafari, Mohammad Ali Yousefian, Behzad Zohrevandi

Iranian Journal of Emergency Medicine, Vol. 3 No. 3 (2016), 21 September 2016, Page 97-92

Introduction: Although vertigo alone is not counted as a disease, it is one of the most common complaints of patients presenting to emergency departments (ED). Considering that in facing peripheral vertigo a single treatment has not been agreed upon, we decided to evaluate the effectiveness and side effects of intravenous (IV) methyl prednisolone and diazepam in treating acute peripheral vertigo in a clinical trial. Methods:This double blind clinical trial was done to compare the effectiveness of IV methyl prednisolone and diazepam in controlling acute peripheral vertigo in patients visiting ED. Patients were allocated to one of the 2 groups using simple randomization, and vertigo severity (based on VAS score), hemodynamic changes, level of consciousness, changes in blood sugar and the side effects were compared between the 2 groups 30, 60, and 120 minutes after injection. Results: The study was done on 113 patients with the mean age of 41.8 ± 10.4 years (20-60) (58.4 male). Patients were divided into 2 groups of IV diazepam (51 patients) and IV methyl prednisolone (62 patients). A significant difference was not found between the 2 groups regarding age (p = 0.83), sex (p = 0.339), vertigo severity (p = 0.337) and vital signs (p = 0.986) on arrival. Vertigo severity only showed significant difference between the groups after 120 minutes of drug administration (p = 0.003). No case of low blood pressure, loss of consciousness, or hemodynamic instability was seen in either group during 120 minutes. Dry mouth was significantly higher in the group receiving IV diazepam (p =0.007). Mean blood sugar for diazepam and methyl prednisolone groups after 60 and 120 minutes were 120.6 ± 36.2 and 143.1 ± 51.2 (p = 0.009) and 119.5 ± 35.1 and 162.9 ± 50.9 (p < 0.001). Conclusion: In conclusion, considering the higher effectiveness and non-significant side effects of IV diazepam, it seems to be better than IV methyl prednisolone for symptom control in patients presenting with acute peripheral vertigo. 

Deep Vein Thrombosis despite Receiving Anticoagulant Prophylaxis; a Cross-sectional Study

Behrooz Hashemi, Saeed Khalaji

Iranian Journal of Emergency Medicine, Vol. 3 No. 3 (2016), 21 September 2016, Page 102-98

Introduction: Contradicting statistics exist regarding the prevalence of deep vein thrombosis (DVT) following lower limb trauma despite administration of anti-thrombotic agents. The present study aimed to evaluate the prevalence of DVT in patients with lower limb trauma despite receiving anticoagulant prophylaxis. Methods: The present cross-sectional study was carried out to evaluate the prevalence of traumatic lower limbs DVT despite anti-thrombotic therapy, in patients presenting to emergency department. Patients over 18 years old with traumas in the areas lower than knees in need for fixation with cast or splint for > 2 weeks were enrolled. Data were analyzed using SPSS version 21 and descriptive statistics. Results: 130 patients with the mean age of 40.05 ± 18.5 (15-92) were studied (61.5% male). 18 (13.8%) cases had history of drug abuse, 1 (0.8%) had diabetes mellitus, 8 (6.2%) had hypertension, 1 (0.8%) had asthma, and 1 (0.8%) had history of cranial vascular thrombosis. Mechanism of trauma was falling down in 44 (33.8%) cases, road traffic collisions in 50 (38.5%), and direct trauma in 36 (27.7%). 3 (2.3%) patients developed DVT despite receiving prophylactic anti-thrombotic agents. The mean time interval between discharge and development of DVT was 6 ± 3.6 days. Conclusion: Based on the results of the present study, the prevalence of DVT, despite receiving anti-thrombotic agents, in patients with lower limb trauma in need for fixation for > 2 weeks was 2.3%. All three cases of DVT in this study were developed in the first 2 weeks of fixation. 

Recipients Satisfaction of Emergency Medical Service Centers of Yazd and Birjand; a Cross-sectional Study

Roohollah Askari, Milad Shafiei, Leila Azadi, Elham Tayefi

Iranian Journal of Emergency Medicine, Vol. 3 No. 3 (2016), 21 September 2016, Page 108-103

Introduction: The satisfaction rate of patients is a valuable tool for evaluating the quality of providing health care and gives important data regarding the expectations of patients and the degree to which they are being met. Considering the importance emergency medical service (EMS) centers in providing proper care, this study was carried out aiming to evaluate the satisfaction rate of those receiving services from EMS centers of Yazd and Birjand. Methods: The present cross-sectional study was carried out on 150 of EMS recipients registered on the list of EMS centers of Yazd and Birjand in 2012. Systematic sampling was used and required data were gathered using the standard questionnaire of satisfaction for EMS center recipients that consisted of 2 parts; demographic data and 16 questions regarding satisfaction of recipients. Data were analyzed using SPSS 18 and descriptive tests. Results: 150 participants were studied (56.7% male). The most common reason for calling was trauma due to motor vehicle accidents (32%) in Yazd and weakness and nervous system diseases (18%) in Birjand. 10% of the participants in Yazd province had low satisfaction, 39% had intermediate, and 51% had high satisfaction. In Birjand satisfaction rate was intermediate in 16% and high in 84% of those studied in Birjand. The highest satisfaction rate in Yazd was regarding cooperation of emergencies center with the patient and their manners in facing them. The lowest satisfaction rate belonged to following the condition of the patient until the arrival of ambulance and the waiting time for ambulance arrival. In Birjand, the lowest satisfaction rate belonged to the quality and existence of equipment in the emergency team. Conclusion: The results of the present study showed that satisfaction level of EMS recipients in Yazd and Birjand was intermediate. The lowest satisfaction rate belonged to following the condition of the patient until the arrival of ambulance and the waiting time for ambulance arrival in Yazd, and the quality of equipment in Birjand. 

Traumatic Injuries Caused by Fall in the Elderly Referred to the Emergency Department; an Epidemiologic Study

Monavar Afzal Aghaee, Salehe Norouzi, Maryam Sadat Mousavi, Ali Khorsand Vakilzadeh

Iranian Journal of Emergency Medicine, Vol. 3 No. 3 (2016), 21 September 2016, Page 114-109

Introduction: Falling and its resulting injuries are among the important problems of the elderly all over the world and bring about a considerable rise in financial and care burdens for health care systems. To gain accurate data for prevention or treatment planning, the present study aimed to epidemiologically assess the injuries resulting from falling in elderly patients presenting to emergency department (ED).

Methods: The present study is a retrospective cross-sectional study carried out on elderly patients presenting to ED of Imam Reza Hospital, Mashhad, Iran, during 2011 and 2012 following falling. Consecutive sampling was used and patients over the age of 60 were included. Demographic data, accident characteristics, hospitalization duration, type of injury and fracture, frequency of visits and final outcome of the patients were recorded using descriptive statistics. Results: 1033 patients with the mean age of 73.37 ± 9.07 years (range: 60 – 106) were studied during 2 years. 64.8% were female and the female to male ratio was 1.83 (69.5% married). Mean age of the injured women (73.07 ± 8.89) was not significantly different from that of injured men (73.92 ± 9.36) (p = 0.156). Most patients (56.6%) were in the 60-74 years age group. Frequency of accidents was higher in summer (29.6%) and was the highest in September. Mean duration of hospitalization was 5.05 ± 6.96 days (range: 1 hour-98 days). The longest duration of hospitalization was due to femur fraction. Mean frequency of revisits was not significantly different between women (1.34 ± 0.84) and men (1.48 ± 1.43) (p = 0.078). Evaluation of falling locations revealed falling from the same level in 73.6% of cases, falling from a height in 23% of cases, objects falling on the patient in 2.7% of cases and other cases were undefined. 65.7% of females had fallen from the same level and 78.9% of males had experienced falling of objects (p < 0.001). In assessing the type of fracture based on gender, fractures of femur (34.4%), forearm (34%), and shoulder (8.9%) in women and femur (48.3%), forearm (13.7%), and leg (10.6%) in men were the most common types, respectively (p < 0.001). In total, 2.7% of falling cases had led to death. Comparison of mean age between those who survived (73.20 ± 8.97) and those who died (97.57 ± 10.50) showed a significant difference (p < 0.001). Most patients that died were in the 75-89 years age group (50%) and male (53.6%). Conclusion:Based on the results of the present study, the highest frequency of falling in the elderly happened in married women with the mean age of 73 years, in summer (September), following same level falling between 1pm and 6 pm. The most common injury caused by falling in this population was fraction of upper and lower extremities and mortality rate due to falling was 2.7%.

Letter to Editor

Assessment of Emergency Departments of Shahid Beheshti University of Medical Sciences Training Centers

Afshin Amini, Hamed Aminiahidashti, Abolghasem Laali

Iranian Journal of Emergency Medicine, Vol. 3 No. 3 (2016), 21 September 2016, Page 85-83

Emergency department of each hospital is active 24 hours a day and usually has the highest number of daily visitors in the health center. The visitors present with a variety of problems and expectations in various times and the physicians and staff should be present in this unit at all times during day and night, on weekdays and weekends. Patients with any financial and social position and race are visited in this department and only the severity and type of their disease determines the order of their treatment. Currently, one of the concerns of the authorities of health care in different countries is developing an efficient emergency department with high capacity for responding to the vast number of visitors, which obviously correlates with adhering to the standards and principles in this regard. Therefore, improving its efficiency has gained importance more than ever. Periodical evaluation of the emergency department can reveal the existing problems and show them to the responsible authorities, which can help relieve them. In a descriptive cross-sectional study in 2005 and 2008, the condition of emergency department was evaluated in 6 hospitals supervised by Shahid Beheshti University of Medical Sciences including Mofid, Loghmane Hakim, Taleghani, Shahid Modarres, Shohadaye Tajrish, and Imam Hossein using 340 indices extracted from Iranian accreditation standards and American Academy Of Emergency Medicine standards. The findings of the study showed that in 2005, Loghmane Hakim Hospital with a total score of 129, Imam Hossein with 128, and Mofid with 125 points were adhering to the evaluated standards the most. In 2008, the accreditation score of all the hospitals had raised. The changes in total score of Loghmen Hakim, Taleghani, Modarres, Shohadaye Tajrish, Mofid, and Imam Hossein hospitals were 3, 52, 19, 22, 13, and 84, respectively. The highest improvement in score belonged to Imam Hossein, Taleghani, and Shohadaye Tajrish hospitals. Maybe improvement of emergency services and their management in Tehran, especially in teaching hospitals, has helped moving towards the standards. Many factors including the rise in the number of certified emergency medicine specialists in Iran, the raise in the budget considered for improving emergency departments, and better education of emergency department staff have led to this. The important point in this study is improvement of data registration systems as well as information management systems that have increased the speed of information access and have led to better cooperation between different hospital units, including emergency physicians, and the patients. This has resulted in the improvement of services provided on one hand and increased patient satisfaction on the other. It seems that repeating these kinds of evaluation and increasing reinforcement mechanisms can help in keeping or even accelerating this trend. 

Brief Report

Establishing a Field Hospital; a Report on a Disaster Maneuver

Gholamreza Faridaalaee, Mohammad Irajian

Iranian Journal of Emergency Medicine, Vol. 3 No. 3 (2016), 21 September 2016, Page 118-115

Numerous disasters such as earthquake, flood, tsunami, and war bring about broad crises that cause numerous physical, mental and psychological damages. Iran is also prone to various disasters and needs to be equipped for their management. The aim of this brief report is sharing the experience gained by facing the limitations in establishing a field hospital and emphasizing the need to take necessary measures for being properly equipped in facing probable problems arising at times of disaster. Based on the findings of the present study, not giving enough budget to holding maneuvers for preparing against disasters, shortage of proper tents for establishing a field hospital, mismanagement of volunteers, problems in preparing food for the staff, security problems, and difficulties in holding discipline were among the most important problems arising in establishing a field hospital in this maneuver. 


Evidence Based Medicine; Receiver Operating Characteristic Curve and Area under the Curve

Saeed Safari, Alireza Baratloo

Iranian Journal of Emergency Medicine, Vol. 3 No. 3 (2016), 21 September 2016, Page 121-119

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.