Infantile Apparent Life-Threatening Events, an Educational Review

Many physicians have received a frantic call from anxious parents stating that their child had stopped breathing, become limp, or turned blue but then had recovered quickly. An apparent life-threatening event (ALTE) is defined as “an episode that is frightening to the observer, and is characterized by some combination of apnea, color change, marked change in muscle tone, choking, gagging, or coughing”. The incidence of ALTE is reported to be 0.05% to 6%. The knowledge about the most common causes and factors associated with higher risk of ALTE could be resulted in a more purposeful approach, improving the decision making process, and benefiting both children and parents. The aim of this review article was to report the epidemiology, etiology, evaluation, management, and disposition of ALTE. Infants with an ALTE might present no signs of acute illness and are commonly managed in the emergency settings that often require significant medical attention; hence, the emergency medicine personnel should be aware of the its clinical importance. There is no specific treatment for ALTE; therefore, the clinical evaluations should be focused on the detection of the underlying causes, which will define the outcomes and prognosis. ALTE is a confusing entity, representing a constellation of descriptive symptoms and signs; in other words, it is not a diagnosis. There are multiple possible etiologies and difficulties in evaluating and managing infants with these events, which are challenges to primary care physicians, emergency medicine specialists, and subspecialty pediatricians. The evaluation of these events in infants includes a detailed history, appropriate physical examination, diagnostic tests guided by obtained clues from the history and physical examination, and observation in the emergency department

Patients’ Attitude toward Breaking Bad News; a Brief Report

Introduction: Delivering bad news is a stressful moment for both physicians and patients. The purpose of this investigation was to explore the patients’ preferences and attitudes toward being informed about the bad news. Methods: This cross-sectional study was done on patients admitted to Imam Khomeini Hospital, Sari, Iran, from September 2014 to February 2015. Patient attitude regarding breaking bad news was evaluated using a reliable and valid questionnaire. Results: 130 patients were evaluated (61.5% male, mean age = 46.21 ± 12.1 years). 118 (90.76%) participants believed that the patient himself/herself should be informed about the disease’s condition. 120 (92.30%) preferred to hear the news from a skillful physician and 105 (80.76%) believed that emergency department is not a proper place for breaking bad news. Conclusion: Based on the results of the present study, most participants believed that the most experienced and skillful physician should inform them completely regarding their medical condition. At the same time they declared that, it is best to hear bad news in a calm and suitable place and time rather than emergency department or hospital corridors during teaching rounds

Applications of End-Tidal Carbon Dioxide (ETCO2) Monitoring in Emergency Department; a Narrative Review

Capnograph is an indispensable tool for monitoring metabolic and respiratory function. In this study, the aim was to review the applications of end-tidal carbon dioxide (ETCO2) monitoring in emergency department, multiple databases were comprehensively searched with combination of following keywords: “ETCO2”, “emergency department monitoring”, and “critical monitoring” in PubMed, Google Scholar, Scopus, Index Copernicus, EBSCO and Cochrane Database

Isolated Oculomotor Nerve Palsy Following Minor Head Trauma; a Case Report

Isolated third nerve palsy develops in numerous intracranial pathologies such as closed head trauma, tumor, and aneurysm. This report describes a 61 years old female with an abrasion on the left forehead and ptosis of the left eye. Initial computed tomography did not reveal any causative cerebral and vascular lesions or orbital and cranial fractures. High-resolution and multi-axial enhanced Magnetic resonance imaging (MRI) can be helpful in diagnosis and monitoring of patients with this rare phenomenon

Comparison of APACHE II and SAPS II Scoring Systems in Prediction of Critically ill Patients’ Outcome

Introduction: Using physiologic scoring systems for identifying high-risk patients for mortality has been considered recently. This study was designed to evaluate the values of Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiologic Score (SAPS II) models in prediction of 1-month mortality of critically ill patients.Methods: The present prospective cross sectional study was performed on critically ill patients presented to emergency department during 6 months. Data required for calculation of the scores were gathered and performance of the models in prediction of 1-month mortality were assessed using STATA software 11.0.Results: 82 critically ill patients with the mean age of 53.45 ± 20.37 years were included (65.9% male). Their mortality rate was 48%. Mean SAPS II (p < 0.0001) and APACHE II (p = 0.0007) scores were significantly higher in dead patients. Area under the ROC curve of SAPS II and APACHE II for prediction of mortality were 0.75 (95% CI: 0.64 - 0.86) and 0.72 (95% CI: 0.60 - 0.83), respectively (p = 0.24). The slope and intercept of SAPS II were 1.02 and 0.04, respectively. In addition, these values were 0.92 and 0.09 for APACHE II, respectively.Conclusion: The findings of the present study showed that APACHE II and SAPS II had similar value in predicting 1-month mortality of patients. Discriminatory powers of the mentioned models were acceptable but their calibration had some amount of lack of fit, which reveals that APACHE II and SAPS II are partially perfect

The effect of intravenous metoclopramide on pain, nausea, discomfort, and ease of insertion of nasogastric tube in emergency department: a double-blind randomized clinical trial

Background: Placement of nasogastric tube (NGT) is a routine procedure in the emergencydepartments, which can be uncomfortable, painful, and cause nausea. The aim of this study was to investigate the effect of intravenous metoclopramide on the ease of NGT insertion, as well as reduction of patients’ pain, nausea, and discomfort during NGT insertion in the emergency department.Methods: In this randomized, double-blind, placebo-controlled trial, 80 patients referred to Imam Khomeini Hospital, Mazandaran Province, Iran were enrolled. Data were collected from December 2015 to March 2016. Participants were selected via convenience sampling and randomly divided into two equal groups (placebo and intervention groups). In metoclopramide and placebo groups, 10 mg of metoclopramide and 10 mg of normal saline solution were administered, respectively. All of the NGT was inserted 15–20 mins after the intravenous infusion. Patient-reported pain, discomfort, and nausea were evaluated using visual analogue scale (VAS), at four time points including before (T0), immediately (T1), 30 min after (T2), and 1hr after the NGT placement (T3). The ease of NGT insertion was evaluated as easy, moderate, and difficult to pass.Results: None of the patients had pain, nausea, and discomfort in T0. Additionally, for those who received intravenous metoclopramide, pain intensity significantly decreased compared with the placebo group in T1 (37.7 vs 55.0), T2 (26.2 vs 41.7), and T3 (20.5 vs 33.7), respectively (P < 0.001). Nausea intensity decreased significantly over time among patients in the interventiongroup compared with the placebo group in T1 (32.7 vs 43.2), T2 (19.5 vs 31.2), and T3 (9.0 vs 21.7), respectively (P < 0.001). The intensity of patients’ discomfort decreased significantlyamong patients in the intervention group compared with the placebo group in T1 (39.5 vs 54.0), T2 (28.7 vs 40.2), and T3 (26.2 vs 39.6), respectively (P < 0.001). Patients in the intervention group had easier placement of NGT compared with the placebo group (Easy: 40.0% vs 0.0%, Moderate: 45.0% vs 62.5%, and Difficult: 15.0% vs 37.5%; P < 0.001).Conclusion: Based on the results of the present study, it seems that intravenous metoclopramide can be used as a promising modality for improving the ease of NGT placement and reducing patients’ pain, nausea, and discomfort during NGT insertion in the emergency department

The Effect of Intravenous Metoclopramide on Pain, Nausea, Discomfort, and Ease of Insertion of Nasogastric Tube in Emergency Department: A Double-blind Randomized Clinical Trial

Background: Placement of nasogastric tube (NGT) is a routine procedure in the emergency departments, which can be uncomfortable, painful, and cause nausea. The aim of this study was to investigate the effect of intravenous metoclopramide on the ease of NGT insertion, as well as reduction of patients’ pain, nausea, and discomfort during NGT insertion in the emergency department. Methods: In this randomized, double-blind, placebo-controlled trial, 80 patients referred to Imam Khomeini Hospital, Mazandaran Province, Iran were enrolled. Data were collected from December 2015 to March 2016. Participants were selected via convenience sampling and randomly divided into two equal groups (placebo and intervention groups). In metoclopramide and placebo groups, 10 mg of metoclopramide and 10 mg of normal saline solution were administered, respectively. All of the NGT was inserted 15–20 mins after the intravenous infusion. Patient-reported pain, discomfort, and nausea were evaluated using visual analogue scale (VAS), at four time points including before (T0), immediately (T1), 30 min after (T2), and 1 hr after the NGT placement (T3). The ease of NGT insertion was evaluated as easy, moderate, and difficult to pass. Results: None of the patients had pain, nausea, and discomfort in T0. Additionally, for those who received intravenous metoclopramide, pain intensity significantly decreased compared with the placebo group in T1 (37.7 vs 55.0), T2 (26.2 vs 41.7), and T3 (20.5 vs 33.7), respectively (P < 0.001). Nausea intensity decreased significantly over time among patients in the intervention group compared with the placebo group in T1 (32.7 vs 43.2), T2 (19.5 vs 31.2), and T3 (9.0 vs 21.7), respectively (P < 0.001). The intensity of patients’ discomfort decreased significantly among patients in the intervention group compared with the placebo group in T1 (39.5 vs 54.0), T2 (28.7 vs 40.2), and T3 (26.2 vs 39.6), respectively (P < 0.001). Patients in the intervention group had easier placement of NGT compared with the placebo group (Easy: 40.0% vs 0.0%, Moderate: 45.0% vs 62.5%, and Difficult: 15.0% vs 37.5%; P < 0.001). Conclusion: Based on the results of the present study, it seems that intravenous metoclopramide can be used as a promising modality for improving the ease of NGT placement and reducing patients’ pain, nausea, and discomfort during NGT insertion in the emergency department

Diagnostic Accuracy of Ascites Fluid Gross Appearance in Detection of Spontaneous Bacterial Peritonitis

Introduction: Spontaneous bacterial peritonitis (SBP) as a monomicrobial infection of ascites fluid is one of the most important causes of morbidity and mortality in cirrhotic patients. This study was aimed to determine the diagnostic accuracy of ascites fluid color in detection of SBP in cirrhotic cases referred to the emergency department. Methods: Cirrhotic patients referred to the ED for the paracentesis of ascites fluid were enrolled. For all studied patients, the results of laboratory analysis and gross appearance of ascites fluid registered and reviewed by two emergency medicine specialists. The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ration of the ascites fluid gross appearance in detection of SBP were measured with 95% confidence interval. Results: The present project was performed in 80 cirrhotic patients with ascites (52.5 female). The mean of the subjects’ age was 56.25±12.21 years (35-81). Laboratory findings revealed SBP in 23 (29%) cases. Fifty nine (73%) cases had transparent ascites fluid appearance of whom 17 (29%) ones suffered from SBP. From 21 (26%) cases with opaque ascites appearance, 15 (71%) had SBP. The sensitivity and specificity of the ascites fluid appearance in detection of SBP were 46.88% (Cl: 30.87-63.55) and 87.50% (95% Cl: 75.3-94.14), respectively. Conclusion: It seems that the gross appearance of ascites fluid had poor diagnostic accuracy in detection of SBP and considering its low sensitivity, it could not be used as a good screening tool for this propose

The Effect of Oral Tamsulosin vs. Oral Tamsulosin and Oral Isosorbide Dinitrate in Acute Urinary Retention Patients Due to Benign Prostatic Hyperplasia: A Double-Blind Clinical Trial Study

Introduction: Acute urinary retention due to benign prostatic enlargement is one of the clinical complaints that patients refer to the emergency department. Selective α-blockers are used after urinary catheterization. Recently, the use of nitrate compounds has been shown to relieve bladder neck and to treat acute urinary retention. Objective: The aim of this study was to survey the addition of Isosorbide di nitrate to tamsulosin in the treatment of acute urinary retention in patients with benign prostatic hyperplasia. Methods: This is a randomized, double-blind placebo-controlled clinical trial. In all, 78 patients with benign prostatic hyperplasia-related acute urinary retention referred to the emergency department were divided into two groups and randomly assigned to receive either 0.4 mg tamsulosin plus placebo or 0.4 mg tamsulosin plus isosorbide dinitrate 40 mg extended-release tablets daily for 3 days. At the same first visit, the catheter was removed and the ability to void in same time and 1 month later was assessed in each group. Results: After catheter removal, 27 (67.5%) patients in the tamsulosin plus placebo group and 31 (81.6%) in the tamsulosin plus isosorbide dinitrate group voided successfully after 3 days (p = 0.155). After 1 month, 20 (50.0%) patients taking tamsulosin plus placebo and 23 (60.5%) taking tamsulosin plus isosorbide dinitrate could void, yet indicating no significant difference (p = 0.350). Conclusions: Addition of isosorbide dinitrate to α-blockers has advantage in improving benign prostatic hyperplasia-related acute urinary retention versus tamsulosin alone, although was not statistically significant

مقایسه مورفین و استامینوفن تزریقی در کنترل درد بیماران مشکوک به کله سیستیت حاد؛ یک کارآزمایی بالینی

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. مقدمه: کله سیستیت حاد یکی از شایعترین اورژانس های جراحی و از علل مهم شکم حاد در تمام دنیا می باشد. از مهمترین اقدامات لازم برای این بیماران در بخش اورژانس کنترل درد حاد شکم تا زمان رسیدن به تشخیص قطعی است. لذا، مطالعه حاضر با هدف مقایسه اثرات ضد دردی استامینوفن تزریقی و مورفین در کنترل درد ناشی از کله سیستیت حاد طراحی شده است. روش کار: مطالعه حاضر از نوع کارآزمایی بالینی تصادفی شده یک سوکور می باشد که به بررسی و مقایسه اثر دو داروی مورفین سولفات و استامینوفن تزریقی در کنترل درد بیماران مشکوک به کله سیستیت حاد بالای 18 سال و با علائم حیاتی پایدار پذیرش شده در بخش اورژانس پرداخته است. جهت جمع آوری اطلاعات از چک لیستی از پیش طراحی شده شامل اطلاعات دموگرافیک، شدت درد در بدو ورود و دقایق 30 و 60 و 90 بعد از تزریق، علایم حیاتی بدو ورود، وجود یا عدم وجود عوارض جانبی و یافته های بالینی استفاده شد. در نهایت دو گروه با استفاده از نرم افزار آماری SPSS 18 مورد مقایسه از جهت میزان کنترل درد و عوارض قرار گرفتند. يافته ها: در مجموع 70 بیمار با میانگین سنی 3/16 ± 2/55 سال به صورت راندوم به دو گروه 35 نفری وارد شدند (4/61 درصد زن). 38 (3/54 درصد) بیمار فقط یک معیار سونوگرافیک کله سیستیت حاد را داشتند حال آنکه 32 (7/45 درصد) بیمار دو معیار یا بیشتر را داشتند. میانگین شدت درد در دقایق 30، 60 و90 بعد از تزریق دارو در دو گروه تفاوت معنی دار آماری داشت (05/0 < p). میزان عوارض تهوع (617/0 = p) و استفراغ  (150/0 = p) بعد از تزریق در دو گروه مورد مطالعه تفاوت معنی داری نداشت . تب در گروه استامینوفن تزریقی به طور معنی داری کاهش پیدا کرده بود  (001/0 > p). نتيجه گيری: بر اساس یافته های مطالعه حاضر، داروی مورفین در مقایسه با استامینوفن کارایی بیشتری در کاهش شدت درد بیماران طی 30 دقیقه را دارد، بطوریکه نمره VAS  بیماران 30 دقیقه پس از تزریق مورفین کاهش معنی داری داشت. اما در دقایق 60 و 90 بعد از تزریق علی رغم تفاوت معنی دار آماری کنترل درد بین دریافت کنندگان دو داروی مورد مطالعه، این مقادیر از نظر کلینیکی معنی دار نبودند. با این وجود داروی استامینوفن تزریقی در کنترل تب بیماران نیز به طور همزمان تاثیر گذار بوده است