Comparison of Intravenous Ketamine with Morphine in Pain Relief of Long Bones Fractures: a Double-Blind Randomized Clinical Trial

Introduction: The selective medication for pain control in many clinical situations is morphine but its complications prevent its widespread use. Ketamine has been introduced as an alternative for morphine in some studies. However, the efficacy of its solitary use has not yet been evaluated. Therefore, the present study was undertaken to evaluate the effect of ketamine alone in relieving pain in trauma patients referring to an emergency unit. Methods: In this double-blind clinical trial, patients with long bone fractures were randomly divided into two groups of treatment with intravenous (IV) morphine at a dose of 0.1 mg/kg and treatment with IV ketamine at a dose of 0.5 mg/kg. Pain severity of the patients was recorded before and 10 minutes after injection based on numeric rating scale. The means in the two groups were compared using independent t-test. Then the Kaplan-Meier curve and log rank analysis were used to evaluate the success of treatment. Results: A total of 126 patients were included in this study. The mean ages of the patients in the morphine and ketamine groups were 33.6±14.3 and 35.1±13.5 years, respectively (P=0.54). After therapeutic intervention, the pain severity significantly decreased in ketamine (2.7±1.8; P<0.0001) and morphine (2.4±1.5; P<0.0001) groups, with a similar effect of both medications on alleviating pain (P=0.28). The success rate of the treatment at 10-minute interval in groups receiving ketamine and morphine were 59 (93.65%) and 61 (96.8%) patients, respectively (P=0.62). Conclusion: The results of the present study showed that administration of ketamine at a low dose (0.5 mg/kg) results in a significant decrease in the severity of acute pain in patients with fractures of long bones. This palliative effect is very similar to that of morphine.

Synergistic Effects of Citalopram and Morphine in the Renal Colic Pain Relief; a Randomized Clinical Trial

Introduction: Although the synergistic effects of opioids and other analgesic drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) have been established in relieving acute pain due to renal calculi, no studies today have evaluated the concomitant administration of opiates and other drugs with analgesic effects, such as serotonin re-uptake inhibitors. Considering the high prevalence of renal colic, the present study was carried out to compare the effect of concomitant prescription of morphine and a placebo with that of morphine and citalopram on the management of acute pain due to renal calculi. Methods: The present double-blind randomized clinical trial was carried out from October 2012 to March 2013 in the Al-Zahra educational Hospital in Isfahan, Iran. A total of 90 patients with acute renal colic pain were randomly divided into two groups of 45 subjects. The subjects in one group received morphine/ placebo and another one morphine/citalopram. The patients’ pain severity was determined by visual analogue scale (VAS) before and 20 minutes after administration of medications. In case of persistent pain the second or even third dose was administered and the pain severity was once again determined. Data were analyzed with STATA 11.0 using chi-squared, two-way ANOVA, Bonferroni post hoc test, and log rank test. Results: The decrease in pain severity in the morphine/citalopram group was significantly compared to the morphine/placebo group and the time before administration of the medications (p<0.001). In contrast, administration of morphine/placebo did not have a significant effect on pain severity at this interval (p=0.32). Kaplan-Meier curve showed that the first injection was successful in relieving pain in 15 (33.3%) and 26 (57.8%) subjects in the morphine/placebo and morphine/citalopram groups, respectively. The second injection of these medications resulted in therapeutic success in 35 (87.8%) and 42 (95.6%) subjects in the above groups, respectively. Log rank test showed a significant difference in the treatment success between the two groups (p=0.001). Conclusion: It seems that the combination of citalopram and morphine sulfate causes increased efficacy and higher success rate in pain control of patients presented to the emergency department with a complaint of renal colic

Compilation and evaluation of clinical practice guidelines for comprehensive approaches to patients with acute chest pain in the emergency room at Al-Zahra Hospital in Isfahan

Introduction & Aim: This study aimed to develop a standardof clinical guidelines for dealing with patients withacute chest pain in the emergency department at Al-ZahraHospital in Isfahan.Methods: In the first phase, a comprehensive approachand guidelines for patients with unstable angina referredto the emergency department, according to experts fromthe heart and emergency medicine and using valid sourceswas developed. In the second phase, the guidelines ereevaluated in a clinical trial. In this trial, 100 patients wererandomly assigned into intervention and control groups.The waiting time for the first visit, paraclinical measures,appropriate treatment; the physician’s satisfaction withtreatment, the patient’s admission to the emergencyroom, number of visits and treatment outcome; the patient’ssatisfaction from emergency services and treatmentoutcome were compared between two groups.Results: The mean of patients waiting time to receive thefirst visit, paraclinical measures, and appropriate treatmentin the intervention group were significantly lowerthan the control group (P-value<0.05). The mean of physician’ssatisfaction score from the treatment process, patient’sadmission to the emergency room, number of visitsand outcome of treatment in the intervention group wassignificantly higher than the control group (P-value<0.05).The mean patient satisfaction score from the emergencyservices in the intervention group was significantly higherthan the control group (P-value=0.0001).Conclusions: The developed guidelines for dealing withpatients with acute chest pain in the emergency roomsignificantly reduce the patient’s waiting time in receivingcare and improve the satisfaction of the physicians andthe patients

Reverse Triage to Increase the Hospital Surge Capacity in Disaster Response

Introduction: Successful and effective management of large-scale disasters and epidemics requires pre-established systematic plans to minimize the damage and control the situation. With an increasing number of people in need of urgent medical care, hospitals must improve their response capacity, being at the forefront of responding to disasters and incidents. One way to develop the hospital capacity in disaster response is by reverse triage (RT). Objective: The current study was conducted to investigate the role of RT to create additional hospital surge capacity in one of the major referral academic hospitals of Isfahan, Iran. Method: This cross-sectional study was conducted in 2015 at Al-Zahra Subspecialty Hospital, Isfahan, Iran. The ten most common diseases leading to hospitalization in each ward of the hospital in 2014 were reviewed and, based on the prevalence, sorted and listed. Academic instructions for making a decision and possibility of early discharge was written and approved by an expert panel. On a day that was not set previously, the pre-selected in-charge person of each department was asked to run the RT following the instructions, and the number and percentage of those who were eligible for discharge via RT were determined. Results: The total BOR in Al-Zahra Hospital in 2014 was about 80%, so it was estimated that almost 140 out of 700 beds are vacant. The results showed that by using RT, 108 (20%) hospitalized cases could be discharged, and considering the bed occupancy rate of about 80% and 140 vacant beds, a total of 248 beds could be provided following RT. Conclusion: Running RT in 41 wards and units of Isfahan Al-Zahra Hospital, on average, added 108 beds to the hospital capacity. This increment is not the same in all wards, as the role of intensive care units in RT for surge capacity is insignificant

Effect of Implementation of Standard Clinical Practice Guideline on Management of Gastrointestinal Bleeding Patients in Emergency Department; a Cross-Sectional Study

Introduction: A clinical practice guideline (CPG) is developed with the aim of improving the quality of health care and reducing unnecessary interventions, hospitalization time, and related costs. Objective: This study attempted to design a standard protocol for gastrointestinal bleeding (GIB) patients. Method: This was a cross-sectional study conducted during 2013 and 2014 in an educational medical center in Isfahan, Iran. A checklist containing questions about waiting time for the services, hospitalization time, and costs was completed for the GIB patients. After this primary data gathering, a CPG was designed, codified, underwent several revisions, and finally implemented. Thereafter, the checklist was completed by GIB patients and compared with the previous ones. Result: Fifty patients in each of the two phases were included. The mean age and sex of the studied patients were not different. The time from emergency departments (ED) arrival until the first visit (14 ± 9.8 Vs. 19.4 ± 13.4 minutes; p = 0.03), hospitalization (73.7 ± 49.2 Vs. 116.2 ± 7.2 hours; p=0.003) and costs (1.3 ± 0.81 Vs. 3.68 ± 3.51 million rials; p < 0.001) were significantly reduced following the CPG implementation. The time from admission until conducting endoscopy was not different in the two study periods (16.5 ± 7.8 Vs. 23.9 ± 24.5 hours, p = 0.89). Conclusion: The implementation of the CPG for the management of GIB patients in the ED resulted in a reduction in the waiting time for the services and, further, reduction of hospitalization time and related costs

Effect of Implementation of Standard Clinical Practice Guideline on Management of Gastrointestinal Bleeding Patients in Emergency Department; a Cross-Sectional Study

Introduction: A clinical practice guideline (CPG) is developed with the aim of improving the quality of health care and reducing unnecessary interventions, hospitalization time, and related costs. Objective: This study attempted to design a standard protocol for gastrointestinal bleeding (GIB) patients. Method: This was a cross-sectional study conducted during 2013 and 2014 in an educational medical center in Isfahan, Iran. A checklist containing questions about waiting time for the services, hospitalization time, and costs was completed for the GIB patients. After this primary data gathering, a CPG was designed, codified, underwent several revisions, and finally implemented. Thereafter, the checklist was completed by GIB patients and compared with the previous ones. Result: Fifty patients in each of the two phases were included. The mean age and sex of the studied patients were not different. The time from emergency departments (ED) arrival until the first visit (14 ± 9.8 Vs. 19.4 ± 13.4 minutes; p = 0.03), hospitalization (73.7 ± 49.2 Vs. 116.2 ± 7.2 hours; p=0.003) and costs (1.3 ± 0.81 Vs. 3.68 ± 3.51 million rials; p < 0.001) were significantly reduced following the CPG implementation. The time from admission until conducting endoscopy was not different in the two study periods (16.5 ± 7.8 Vs. 23.9 ± 24.5 hours, p = 0.89). Conclusion: The implementation of the CPG for the management of GIB patients in the ED resulted in a reduction in the waiting time for the services and, further, reduction of hospitalization time and related costs

Comparison of the Analgesic Effect of Intravenous Acetaminophen and Morphine Sulfate in Rib Fracture; a Randomized Clinical Trial

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

Reverse Triage to Increase the Hospital Surge Capacity in Disaster Response

Introduction: Successful and effective management of large-scale disasters and epidemics requires pre-established systematic plans to minimize the damage and control the situation. With an increasing number of people in need of urgent medical care, hospitals must improve their response capacity, being at the forefront of responding to disasters and incidents. One way to develop the hospital capacity in disaster response is by reverse triage (RT). Objective: The current study was conducted to investigate the role of RT to create additional hospital surge capacity in one of the major referral academic hospitals of Isfahan, Iran. Method: This cross-sectional study was conducted in 2015 at Al-Zahra Subspecialty Hospital, Isfahan, Iran. The ten most common diseases leading to hospitalization in each ward of the hospital in 2014 were reviewed and, based on the prevalence, sorted and listed. Academic instructions for making a decision and possibility of early discharge was written and approved by an expert panel. On a day that was not set previously, the pre-selected in-charge person of each department was asked to run the RT following the instructions, and the number and percentage of those who were eligible for discharge via RT were determined. Results: The total BOR in Al-Zahra Hospital in 2014 was about 80%, so it was estimated that almost 140 out of 700 beds are vacant. The results showed that by using RT, 108 (20%) hospitalized cases could be discharged, and considering the bed occupancy rate of about 80% and 140 vacant beds, a total of 248 beds could be provided following RT. Conclusion: Running RT in 41 wards and units of Isfahan Al-Zahra Hospital, on average, added 108 beds to the hospital capacity. This increment is not the same in all wards, as the role of intensive care units in RT for surge capacity is insignificant

QT Interval in Pregnant and Non-pregnant Women

Introduction: Prolongation of QT interval might result in dangerous cardiac arrhythmias, including Torsades de Pointes (TdP), consequently leading to syncope or death. A limited number of studies carried out in this respect to date have shown that QT interval might increase during pregnancy. On the other hand, it has been shown that each pregnancy might result in an increase in the risk of cardiac accidents in patients with long QT interval. Therefore, the present study was undertaken to compare QT intervals in pregnant and non-pregnant women. Methods: Pregnant women group consisted of 40 women in the second and third trimesters of pregnancy and the non-pregnant control group consisted of healthy women 18-35 years of age. All the patients underwent standard 12-lead electrocardiogram (ECG). The QT interval was measured for each patient at lead II. The mean corrected QT interval (QTc) and QT dispersions (QTd) were compared between the two groups. Results: Mean heart rates in the pregnant and non-pregnant groups were 98.55±14.09 and 72.53±13.17 beats/minutes (P<0.001). QTd and QTc means were in the normal range in both groups; however, these variables were 49.50±12.80 and 43.03±18.47 milliseconds in the pregnant group and 39.5±9.59 and 40.38±17.20 milliseconds in the control group, respectively (P<0.001). Conclusion: The QT interval was longer in pregnant women compared to non-pregnant women; however, it was in the normal range in both groups. Therefore, it is important to monitor and manage risk factors involved in prolongation of QT interval and prevent concurrence of these factors with pregnancy

Correlation of Patients’ Baseline Characteristics with Success Rate of Cardiopulmonary Resuscitation; a Cross-Sectional Study

Introduction: Many advances have been made in method, applied medications and the skill of the treatment staff for performing cardiopulmonary resuscitation (CPR), yet the rate of mortality following cardiac arrest is still high, which is affected by many factors. Objective: This study was designed and performed aiming to evaluate the effective factors in the success rate of CPR. Method: This cross-sectional study was performed on patients who had undergone CPR in Dr. Shariati Hospital, Isfahan, Iran, from March 2017 to March 2018. A pre-designed checklist was used for data gathering, which included questions regarding demographic data and medical history of the patients, data related to CPR and the final outcome of resuscitation. Results: A total of 190 patients with the mean age of 69.4±17.7 years were evaluated in the present study, 115 (60.5%) of which were male. Overall, 28.9% of CPRs were initially successful and 5.3% of the cases were finally discharged from the hospital. There was no significant correlation between CPR success and age, sex, hospitalization ward, time interval between hospitalization and cardiac arrest, the number of CPR attempts, or working shift (p > 0.05). On the other hand, CPR success significantly correlated with underlying illnesses and the first cardiac rhythm recorded before the initiation of resuscitation (p < 0.05). Conclusion: Based on the findings of the present study, it seems that underlying illness and the initial cardiac rhythm recorded correlate with the probability of CPR success