Lead Toxicity Resulting from Chronic Ingestion of Opium

A 32-year-old man presented to the emergency department (ED) with lower abdominal pain and constipation. He related chronic ingestion of large amounts of opium. Physical examination showed mild abdominal tenderness and gingival discoloration. Diagnostic studies showed a mild hypochromic, microcytic anemia with basophilic stippling of the red blood cells. Abdominal imaging showed no intra-abdominal pathology. A diagnosis of lead toxicity was confirmed through serum lead levels. The patient was put on chelation therapy and his signs and symptoms started to resolve. As a comprehensive search for other sources of lead was unsuccessful, opium adulterants were considered as the culprit. Chemical analysis of the opium confirmed this. Contaminated drugs have been reported as a source of exposure to toxins such as arsenic or lead. While other reports deal with patients from clinics, this report illustrates lead toxicity from ingestion of contaminated opium in the ED

Design and implementation of location-based service for targeted advertising

Nowadays, mobile phones have been increasingly advertised. These performance advertisement tools altered to be one of the beneficial factors in order to promote products and services in national or local companies. One of the outstanding features of mobile phones is that everybody has accessibility in different circumstances and times. Companies struggle to draw customers attention by providing information, stimulating text or image to advertise their products by which high cost have been consumed. In this study, a system is designed and implemented for efficient and effective interaction between companies and customers. It is worth mentioning here this system has some great feature like being aware of text, owning mobile user Interface and presenting location-based service. These features enable companies to design an advertisement in a purposeful way. Such these advertisements can effectively be sent to the population company which are on target. Finally, the system was evaluated. Reduction in cost and effectiveness of advertising are grounded in the result of the study

Saline Flush versus Chest x ray in Confirmation of Central Venous Catheter Placement; a Diagnostic Accuracy Study

Introduction: Central venous catheterization (CVC) is a commonly performed procedure in critically ill patients of emergency department. This study was designed to compare the diagnostic accuracy of saline flush with CXR in confirmation of above-the-diaphragm CVC placement. Methods: This prospective cross sectional study was conducted on adult patients in need of CVC placement in emergency department. Placement Confirmation was performed with saline flush method and CXR, then chest computed tomography (CT) was performed as the gold standard. The screening performance characteristics of the two methods were calculated and compared using SPSS 21 and STATA 11. Results: 103 cases with the mean age of 57.18±9.3 (35 -80) years were studied (52.4% male). The mean duration of procedure was 2.5±1.24 in saline flush and 32.11±5.52 minutes in CXR method (P<0.001(. The area under the ROC curves for saline flush and CXR in confirmation of CVC placement were 0.90 (95%CI: 0.70 – 0.100) and 0.80 (95%CI: 0.55 – 0.100), respectively (p = 0.317). The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of  saline flush were 80%, 100%, 100, 98.9%, Infinity, and 0.01, respectively. These measures were 60%, 100%, 100%, 98%, Infinity, and 0.02 for CXR, respectively. Conclusion: It seems that saline flush method could be considered as a safe, rapid, and accurate bedside method for CVC placement confirmation in emergency department

Volunteered geographic information in crisis management

During the disaster, rescue groups are responsible for tasks that require different types of information to optimize their activities. Preparation and distribution of information are very sensitive. The acquisition of new data and events such as degraded buildings and injured people in some cases using conventional methods is very difficult. With the advancement of technology, people familiar with social networks and smartphones, people produce and generate large amounts of data. This phenomenon is called Volunteered geographic information. Today, this data collected and shared with sites and social networks for free. This paper pays service that Volunteered geographic information provided to crisis management. Experience has shown that the system cannot work without regard to environmental considerations. The current system of data collection, updating and spatial data infrastructure, cannot consider emergency situations. In particular, companies such as Ushahidi and OSM's activities will be described. This article is based on articles and activities conducted in this field and provides the category and in the end, discussed and determine the factors affecting the performance of them

The effect of training on the promotion of emotional intelligence and its indirect role in reducing job stress in the emergency department

Objective: The present study aimed at evaluating the role of training in improving emotional intelligence (EI) skills and assessing its indirect effect on reducing job stress in emergency medicine residents (EMRs). Methods: In the present study, 20 EMRs were trained for EI skills while 22 EMRs received no training. Then, all participants’ EI level and job stress were assessed and compared before and after the intervention using the Bar-On Emotional Quotient Inventory(EQ-I) and the Osipow job stress questionnaire, respectively. Results: The results of the present study revealed that the EI level in the training group with a mean score of 338.27 ± 27.57 was significantly higher than the control group with a mean score of 320.50 ± 28.50 after training intervention (P = 0.043). In addition, job stress in the training group with a mean score of 170.82 ± 16.11 was significantly lower than the control group with a mean score of 183.30 ± 22.21 (P=0.045). Moreover, in the training group, the relationship between EI and job stress was inverse and significant (r = -0.746, P<0.001), but in the control group it was non-significant (r = 0.017, P=0.938). Conclusion: According to the results of the present study, training for EI skills can play a significant role in improving EI and reducing stress in EMRs

Rectal Thiopental versus Intramuscular Ketamine in Pediatric Procedural Sedation and Analgesia; a Randomized Clinical Trial

Introduction: Physicians frequently deal with procedures which require sedation of pediatric patients. Laceration repair is one of them. No study has been performed regarding the comparison between induction of sedation with sodium thiopental and ketamine in laceration repair. Therefore, the present study was aimed to comparison of induced sedation by rectal sodium thiopental and muscular injection of hydrochloride ketamine in pediatric patients need laceration repair. Methods: The presented study is a single-blinded clinical trial performed through 2013 to 2014 in Ayatollah Kashani and Alzahra Hospitals, Isfahan, Iran. Patients from 3 months to 14 years, needed sedation for laceration repair, were entered. Patients were sequentially evaluated and randomly categorized in two groups of hydrochloride ketamine with dose of 2-4 milligram per kilogram and sodium thiopental with dose of 25 milligram per kilogram. Demographic data and vital signs before drug administration and after induction of sedation, Ramsey score, time to onset of action, and sedation recovery time were evaluated. Chi-squared, Mann-Whitney, and Non-parametric analysis of covariance tests were used. P<0.05 was considered as a significant level. Results: In this study 60 pediatric patients were entered. 30 patients with mean age of 42.8±18.82 months were received sodium thiopental and the rest with mean age of 30.08±16.88 months given ketamine. Mann-Whitney test was showed that time to onset of action in sodium thiopental group (28.23±5.18 minutes) was significantly higher than ketamine (7.77±4.13 minutes), (p<0.001). The sedation recovery time in ketamine group (29.83±7.70) was higher than sodium thiopental. Depth of sedation had no significant difference between two groups based on Ramsey score (p=0.87). No significant difference was seen between two groups in the respiratory rate (df=1, 58; F=0.002; P=0.96) and heart rate (df=1, 58; F=0.98; P=0.33). However, arterial oxygen saturation level (df=1, 58; F=6.58; P=0.013) was significantly higher in ketamine group. Conclusion: The findings of the present study show that Although the recovery time from sedation by ketamine is more than sodium thiopental, it’s fast-acting function without effecting on the oxygen saturation level causes that ketamine is considered as the better choice for induction of sedation in pediatric patients need laceration repair. In addition, long-term effect of ketamine provides more time for the physician to do the procedure and this issue decreases the need probability to the repeated-dose. However, effectiveness of both drugs to decrease the agitation was equal, based on the Ramsey score

Comparing the Antiemetic Effects of Ondansetron and Metoclopramide in Patients with Minor Head Trauma

Introduction: Nausea and vomiting are the most common complications after minor head trauma that increases the risk of intracranial pressure rising. Therefore, the present study was aimed to compare the antiemetic effects of metoclopramide and ondansetron in the treatment of post-traumatic nausea and vomiting. Methods: The study was a controlled, randomized, double blind clinical trial, which was conducted in the first 6 months of 2014 in emergency department Al-Zahra and Kashani Hospitals in Isfahan, Iran. The patients with minor head trauma associated with nausea and vomiting were randomly divided into 2 groups: treatment with metoclopramide (10mg/2ml, slow injection) and treatment with ondansetron (4mg/2ml, slow injection). The comparison between the 2 groups was done regarding antiemetic efficacy and side effects using SPSS 21 statistical software. Results: 120 patients with minor head trauma were distributed and studied into two groups of 60 patients (mean age 35.6±14.1 years; 50.0% male). Administration of both ondansetron and metoclopramide significantly reduced the severity of nausea (P<0.001). Changes in the severity of nausea in both groups before and after the treatment revealed that nausea had been decreased significantly in both groups (P < 0.001). The incidence of fatigue (p=0.44), headache (p=0.58) and dystonia (p=0.06) had no significant difference in the two groups but the incidence of drowsiness and anxiety in the metoclopramide group was significantly higher (P < 0.001). Conclusion: The present study indicated that the treatment effectiveness of ondansetron and metoclopramide are similar. However, incidence of drowsiness and anxiety in the metoclopramide was considerably higher. Since these complications can have adverse effects on the treatment of patients with brain injury, it is suggested that it may be better to use ondansetron in these patients

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

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.

Analgesic Effects of Ketamine Nebulizer vs. Intravenous Morphine in Limb Trauma Patients in Pre-Hospital Emergency Setting; A Randomized Double-Blinded Clinical Trial

Background: Limb trauma is one the main causes of emergency room (ER) referrals and patients often complain of pain from the very moment of arrival. Objective: We decided to compare the analgesic effect of ketamine nebulizer with intravenous (IV) morphine in trauma patients referred to ER. Methods: In this clinical trial study trauma patients referred to ER of Alzahra and Kashani hospitals in Isfahan, Iran were selected. All trauma patients older than 18 years with limb pain who had a pain score ≥ 7 based on visual analogue scale (VAS) criteria were included. During pre-hospital management, patients were divided into two groups of receiving ketamine nebulizer with a dose of 1.6 mg/kg and receiving IV morphine with a dose of 0.1 mg/kg. Pain score, vital signs and complications were recorded 5 and 15 minutes after receiving the first dose of drug and also at the time of arrival to ER. Results: Finally, the records of 391 patients were analysed. There was no significant difference between the two groups in terms of pain intensity, vital signs before intervention, the first 5 and 15 minutes after and the time of arrival in ER (P>0.05). But the changing of VAS scores in different times was significant in both groups (P<0.001). There was a significant difference between the two groups in complications including nausea and vomiting (P<0.001), and also delirium (P=0.010). Conclusion: Using ketamine nebulizer can produce similar analgesic effects as IV morphine in trauma patients referred to ER

The Effects of Different Doses of Submucosal vs. Intravenous Ketamine for Conscious-sedation in Children Candidates for Diagnostic-Therapeutic Procedures in Emergency Department

Introduction: Ketamine is a commonly used medicine for reducing pain and stress in patients, including children in emergency department (ED). The intravenous (IV) injection of ketamine is gold standard though difficult in children, but other routes are also possible. Objective: This study was conducted to compare the effects of the submucosal at different doses versus IV injections of ketamine on sedation with proper consciousness in children candidates for diagnostic-therapeutic procedures in ED. Methods: This randomized clinical trial was conducted with 4 groups; groups 1, 2 and 3 respectively received 4, 3 and 2 mg/kg of submucosal ketamine and group four 1.5 mg/kg of IV ketamine. Eligible subjects selected from 46 patients of children’s age as the candidates for subcutaneous wound healing were randomly assigned to the four groups and followed up 5, 10, 15 and 30 minutes after the injection. The Ramsay score was obtained by measuring the heart rate, the breathing rate, the time to start affecting and duration of the effect. The data were ultimately analyzed in SPSS and Excel. Results: The baseline data were matched and confounding variables eliminated included age, gender, weight and hemodynamics. Compared to other doses of submucosal ketamine, 4 mg/kg was found to exert its effect the fastest (4.08±1.01 minutes) (p<0.05) and for the longest duration (23.09±1.12 minutes) (p<0.05). The Ramsay score in groups 1 and 4, i.e. 5.9, was significantly higher than that in groups 2 and 3 (p<0.05). Conclusions: The results showed that 4 mg/kg and 3 mg/kg of submucosal ketamine are appropriate alternatives to IV ketamine. Although the time to start affecting was shorter in the intravenous group compared to in the other groups, the duration of the effect was the longest with 4 mg/kg of submucosal ketamine. Surgeon satisfaction scores were found to be very good and not significantly different between groups 1, 2 and 4. Vomiting was also prevalent with no significant differences between the four groups