Correlation between Central Venous Pressure and Inferior Vena Cava Sonographic Diameter; Determining the Best Anatomic Location

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

Management of Deep Vein Thrombosis in Emergency Departments; Time to Change the Viewpoint

Clot formation within a deep vein is called deep vein thrombosis (DVT). It occurs in about 100 persons per 100,000 population each year in the United States and leads to about 600,000 pulmonary thromboembolism (PTE) cases and also causes 60,000 deaths annually. For many years, unfractionated heparin (UFH) and warfarin have been used for treatment of DVT and prevention of PTE. This approach needs hospitalization and necessitates close monitoring by partial thromboplastin time (PTT) measurement. By development of low molecular weight heparin (LMWH) the need for laboratory monitoring was resolved. In addition, some investigators also claimed that it is accompanied with less bleeding risk and better outcome. Accordingly, outpatient management of DVT became possible and nowadays American College of Chest Physicians (ACCP) advocates outpatient therapy for DVT. This method has been shown to be safe and effective in presence of home adequacy criteria. Home adequacy is defined by ACCP as “well-maintained living conditions, strong support from family or friends, phone access, and ability to quickly return to the hospital if there is deterioration”. Yet, many physicians in Iran prefer to hospitalize all DVT patients because of their belief in the impossibility of outpatient treatment

Anaphylaxis as a Rare Side Effect of Pantoprazole; a Case Report

Anaphylaxis is a serious life-threatening allergic reaction. Any medication may potentially trigger anaphylaxis, but reaction to pantoprazole is rare. Our case is a 21 year-old girl with anaphylactic reaction to pantoprazole a short time after prescription

برپایی بیمارستان صحرایی؛ گزارشی از یک مانور آمادگی مواجهه با بلایا

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. حوادث متعددی مثل زلزله، سیل، سونامی و جنگ سبب بروز بحران های فراگیر می گردند که سبب آسیب های جسمی، روحی و روانی متعددی می شوند. کشور ما ایران نیز در معرض انواع بلایای طبیعی می باشد و لازم است که آمادگی لازم برای مدیریت هر یک از این موارد بحرانی کسب شود. هدف از ارائه این گزارش کوتاه انتقال تجربه حاصل از مشکلات بوجود آمده در برپایی بیمارستان صحرایی و لزوم اتخاذ تدابیر لازم برای آمادگی کافی و مناسب در مقابل مشکلات احتمالی در مواقع بحران می باشد. بر اساس یافته های مطالعه حاضر، عدم تخصیص بودجه های مصوب جهت برپایی مانورهای آمادگی در برابر بلایا، کمبود چادر های مناسب برپایی بیمارستان صحرایی، مدیریت غیر صحیح نیروهای انسانی داوطلب، مشکلات پشتیبانی در زمینه تغذیه پرسنل و نقایص موجود در زمینه مباحث امنیتی و کنترل نظم منطقه از مهمترین مشکلات موجود در زمینه برپایی یک بیمارستان صحرایی در مانور مذکور بودند

Accidental intravenous bolus infusion of potassium chloride in a young man with hypokalemic periodic paralysis

Hypokalemic periodic paralysis is anautosomal dominantdisease characterized by muscle weakness or paralysis with a matching fall in blood potassium levels. Paralysis attacks often occur in adolescence and are induced by strenuous exercise followed by rest, high carbohydrateor high sodiummeal content, sudden changes in temperature, and even excitement, noise, flashing lights and cold temperatures. Despite global daily use of intravenous and oral potassium in the treatment of patients, data about intravenous bolus potassium is rare. Here we report a 29-year-old man complaining of weakness in the upper and lower limbs. By initial diagnosis of periodic hypokalemic paralysis, potassium chloride was ordered by oral route. After a few minutes, we heard patient screaming in pain. He complained of severe acute pain in peripheral intravenous line, palpitation and dyspnea. We noticed that potassium chloride vial was infused directly via cubital vein in few minutes erroneously. Physical exam revealed sinus tachycardia and hypertension. We began hyperkalemia treatment immediately. With appropriate treatment,the patient was discharged with good condition after 12 hours of admission

Value of Manchester Acute Coronary Syndromes Decision Rule in the Detection of Acute Coronary Syndrome; a Systematic Review and Meta-Analysis

Introduction: There is still no consensus on the value of Manchester Acute Coronary Syndromes (MACS) decision rule in detecting acute coronary syndrome (ACS). Therefore, the purpose of the present systematic review and meta-analyzes is to summarize the clinical evidence in the evaluation of  the value of MACS in the diagnosis of ACS.Methods: A literature search was performed on the Medline, Embase, Scopus, and Web of Science databases. Outcomes included acute myocardial infarction (AMI) and major adverse cardiac event (MACE).  Data were analyzed in the STATA 14.0 statistical program and the results were reported as summary receiver operating characteristics (SROC), sensitivity, specificity, positive and negative likelihood ratio, and diagnostic odds ratio with 95% confidence interval (95% CI).Results: Finally, 8 articles included in the meta-analysis. The area under the SROC of MACS was excellent in rule out of AMI (AUC = 0.99, 95% CI: 0.97 to 0.99) and MACE (AUC = 0.97, 95% CI: 0.95 to 0.98). The sensitivity and specificity of the troponin-only MACS/history electrocardiogram alone MACS (HE-MACS) in the rule out of AMI were0.99 (95% CI: 0.98-0.99) and 0.22 (95% CI: 0.11-0.37), respectively, and for  the original MACS were in order 0.99 (95% CI: 0.98-0.99) and 0.26 (95% CI: 0.20-0.34),. The sensitivity and specificity of the troponin-only MACS / HE-MACS in the rule out of MACE were 0.94 (95% CI: 0.92-0.96) and 0.22 (95% CI: 0.12-0.39) compared to the 0.99 (95% CI: 0.98-0.99) and 0.27 (95% CI: 0.22-0.33) for the original MACS.Conclusion: The findings of this study showed that original MACS, troponin-only MACS, and HE-MACS are able to rule out AMI and MACE. However, further studies are needed in developing countries to confirm its external validity

تاثیر استفاده از چک لیست بر بهبود کیفیت شرح حال گیری بیماران ترومایی

Introduction: To date, no study with a proper sample size has been done to evaluate the efficiency of using pre-designed checklists in history taking of trauma patients in Iran. Therefore, the present study was designed to evaluate the pre-designed checklist’s effects on the quality of history taking in trauma patients referred to the emergency department (ED). Methods: In the present prospective cross-sectional study, data of the trauma patients presented to the ED were recorded either with or without using a checklist, randomly. The designed checklist consisted of personal data, trauma mechanism, wound characteristics and trauma severity, severity and location of injuries, and the patient’s diagnostic and therapeutic plans. The quality of data gathering in each evaluated item was divided into 3 groups of complete recording, incomplete recording, and not recorded. Data recording quality was compared between the 2 groups using chi square or exact Fisher’s test. In all analyses, p < 0.05 was defined as significance level. Results: In the preset study, patient data were gathered without using a checklist in 795 and using a checklist in 384 cases. Complete and accurate data recording in all items was more frequent in the group that had used the checklist (p < 0.001). Recording injury location without using a checklist was complete in only 20.8% of the cases. This rate increased to 95.6% when the checklist was used. In addition, complete and accurate recording of the diagnostic plan increased from 9% to 72.8%, and complete and accurate recording of the therapeutic plan raised from 14% to 68.7%. The improvements in data recording quality was significant in all cases. Conclusion: It seems that using pre-designed checklists for history taking in trauma patients, leads to a significant increase in quality of data recording and history taking. مقدمه: تاکنون مطالعه ای با حجم نمونه قابل قبول به منظور کارایی استفاده از چک لیست های از پیش طراحی شده در جمع آوری داده های پزشکی بر بالین بیماران ترومایی در کشور انجام نشده است. بر این مبنا مطالعه حاضر با هدف بررسی تاثیر استفاده از چک لیست از پیش طراحی شده بر کیفیت ثبت شرح حال بیماران ترومایی مراجعه کننده به بخش اورژانس طراحی شد. روش کار: در مطالعه مقطعی آینده نگر حاضر ثبت داده های بیماران ترومایی مراجعه کننده به بخش اورژانس به صورت تصادفی به دو روش استفاده از چک لیست و بدون استفاده از آن انجام پذیرفت. چک لیست طراحی شده حاوی قسمت های اطلاعات فردی، مکانیسم تروما، عمق تشریحی و شدت تروما، اندازه ضایعات، محل ضایعات و برنامه تشخیصی و درمانی بیمار بود. وضعیت تکمیل داده ها در هر یک از آیتم های مورد بررسی به سه طبقه ثبت کامل، ثبت ناقص و عدم ثبت تقسیم گردید. مقایسه وضعیت تکمیل داده ها بین دو گروه، با استفاده از آزمون کای دو یا تست دقیق فیشر انجام شد. در تمامی آنالیزها 05/0>p به عنوان سطح معنی داری تعریف شد. يافته ها: در پژوهش حاضر داده های 795 بیمار بدون استفاده از فرم و 384 بیمار با استفاده از آن جمع آوری شد. ثبت کامل و دقیق داده ها در تمامی آیتم های مورد مطالعه در گروه استفاده کننده از چک لیست بیشتر بود (001/0>p). ثبت محل ضایعه بدون استفاده از فرم تنها در 8/20 درصد موارد به طور صحیح و کامل ثبت شد. این میزان با استفاده از فرم به 6/95 درصد افزایش یافت. همچنین ثبت کامل و دقیق برنامه تشخیصی از 9 درصد به 8/72 درصد و ثبت کامل و دقیق برنامه درمانی از 14 درصد به 7/68 درصد رسید. این بهبود در وضعیت ثبت داده بیماران در تمامی موارد معنی دار بود. نتيجه گيری: به نظر می رسد استفاده از چک لیست های از پیش طراحی شده در جمع آوری اطلاعات بالینی بیماران ترومایی، باعث بهبود چشمگیر ثبت داده ها و کیفیت شرح حال گیری می گردد

Cause of Death in Emergency Department; a Brief Report

مقدمه: این مطالعه با هدف شناخت اپیدمیولوژیک علل مرگ ومیر در بخش اورژانس بیمارستان امام خمینی شهرستان ارومیه طراحی شده است. روش کار: این مطالعه مقطعی بر روی پرونده کلیه بیماران فوت شده در بخش اورژانس بیمارستان امام خمینی شهرستان ارومیه طی بازه زمانی فروردين تا اسفند سال 1392 انجام شد. اطلاعات دموگرافیک و علل فوت استخراج و در نهایت توسط نرم افزار SPSS 21 مورد تجزیه و تحلیل آماری قرار گرفت. يافته ها: در طی یک سال مطالعه، 396 مورد فوت شده در بخش اورژانس ثبت شد، که در کل پرونده 207 بیمار مورد بررسی قرار گرفت (68 درصد مرد). میانگین سنی افراد فوت شده، 2/5 ±1/63 سال بود (حداقل 3 و حداکثر 94). 159 بیمار در 24 ساعت اول و 48 بیمار در 24 ساعت بعد از مراجعه فوت نموده بودند. شایعترین علت مرگ به ترتیب بیماریهای تنفسی (5/27 درصد)، قلبی (3/21 درصد) و تروما (14 درصد ) براورد گردیدند. نتيجه گيری: بر اساس نتایج مطالعه حاضر به نظر میرسد که بیماری های تنفسی، قلبی-عروقی و تروما شایعترین علت مرگ ومیر در اورژانس باشند، فلذا برنامه ریزی مناسب،آموزش پرسنل و تجهیز کردن مناسب بخش های اورژانس میتواند در کاهش موارد مرگ و میر تاثیر گذار باشد.Introduction: This epidemiologic study was aimed to identify the causes of death in the emergency department of Imam Khomeini hospital in Urmia, Iran. Methods: This cross sectional study was carried out on the profiles of all of the dead patients in the emergency department of Imam Khomeini Hospital in Urmia, Iran who were admitted from April 2013 to March 2014. Demographic data and causes of death were extracted and were then statistically analyzed using SPSS 21. Results: During the studied year, 396 patients were dead in the emergency department, 207 of which were studied (68% male). Mean age for the dead patients was 63.1±5.2 years (minimum 3 and maximum 94). 159 patients were dead in the first 24 hours after admission and 48 in the next 24 hours. The most common causes of death were figured to be respiratory illnesses (27.5%), heart diseases (21.3%) and trauma (14%). Conclusion: Based on the results of this study, it seems that respiratory illnesses, heart diseases and trauma are the most common causes of death in the emergency department. Therefore, proper planning, educating the staff and equipping the department appropriately can be effective in reducing the death rate

Evaluating the Rate of Violence Against Pre-hospital Emergency Personnel; a Cross-sectional Study

مقدمه: خشونت در محل کار یک مشکل جهانی با شیوع رو به افزایش میباشد. تمام پرسنل درمانی در معرض خشونت قرار دارند اما با توجه به شرایط خاص اورژانس پیش بیمارستانی ، این افراد، در معرض خشونت محل کار بیشتری نسبت به کارکنان سایر بخشهای درمانی قرار دارند. روش کار: این مطالعه از نوع مقطعی و جامعه مورد مطالعه کارکنان بخش فوریت پزشکی استان آذربایجان شرقی بود. روش نمونه گیری به صورت نمونه گیری تصادفی ساده انجام گرفت. نتایج: در مجموع از تعداد ۷۷ نفر شرکت کننده، تمام افراد از جنس مرد بودند. متوسط سن شرکت کنندگان 5/7 ± 4/34 سال و متوسط سابقه کار 7/5 ± 6/9 سال بود. بیش از نیمی از پرسنل اورژانس پیش بیمارستانی طی یکسال گذشته، دو یا بیش از ۲ بار در هفته مورد آزار بیمار قرار گرفته بودند و در ۵/۳۲ درصد موارد پرسنل تکنسین اورژانس پیش بیمارستانی توسط همراه بیمار مورد آزار قرار گرفته بودند. نتیجه گیری: میزان خشونت علیه تکنسین های عملیاتی فوریت پزشکی بالاست.Introduction: Workplace violence is a global problem the prevalence of which is increasing. All healthcare personnel are subject to violence, but considering the special conditions of pre-hospital emergency, its personnel are exposed to a higher rate of workplace violence compared to other healthcare workers. Methods: This was a cross-sectional study and the study population consisted of pre-hospital emergency personnel of East-Azerbaijan province, Iran. The sampling method was simple random sampling. Results:  A total of 77 participants were included all of whom were male. The average age of the participants was 34.4 ± 7.5 years and their average work experience was 9.58 ± 5.7 years. More than half of the pre-hospital emergency personnel had faced violence by patients twice a week or more throughout the previous year. In 32.5% of the cases, pre-hospital emergency medical technicians had experienced violence by a patient’s friend or relative. Conclusion: The rate of violence against pre-hospital emergency medical technicians is high

An interesting case of aluminum phosphide poisoning

Ingestion and inhalation of phosphine are 2 forms of toxicity and their clinical manifestation is extremely wide. A 22-year-old girl was admitted with complaints of nausea, vomiting and epigastric pain after eating lunch. She had a history of celiac disease. On arrival, she was alert and hemodynamically stable. There was not any abdominal tenderness or guarding. Food poisoning treatment initiated but after 1 hour her condition deteriorated with hypotension, tachycardia, and epigastric pain. Venous blood gas (VBG) showed severe metabolic acidosis. She denied any drug ingestion again. New Electrocardiogram (ECG) showed extensive inferolateral ST elevation myocardial infarction (STEMI). Bicarbonate plus dopamine was initiated. After 8 hours of admission, rhythm became ventricular fibrillation (VF) and cardiopulmonary resuscitation (CPR) began. Peritoneal dialysis was performed. Next morning frequent VF occurred again but CPR was unsuccessful. Family found aluminum phosphide (AIP) tablets in her purse. Early diagnosis and supportive treatment may be effective but the most important factor is the dose of ingestion