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

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

Adverse Effects of Intratracheal Intubation by Emergency Medicine Residents; a Cross-Sectional Study

Introduction: Airway management of patients is among the responsibilities of an emergency medicine specialist. To decrease the adverse effects of intubation, sufficient knowledge of the drugs used and proper skill in intratracheal intubation is needed. Therefore, the present study was carried out aiming to evaluate the success rate and adverse effects of intratracheal intubation by emergency medicine residents. Methods: This cross-sectional study was done during 18 months in the emergency department (ED) of Imam Hossein Hospital, Tehran, Iran. All the residents who had spent at least 6 months of their education program in ED and had passed the 2-month specialized course in anesthesiology rotation were included in the study using census method. The researcher, who was a senior emergency medicine resident, would be present at the time of intubation and would gather the required data using a pre-designed checklist. Hypoxia, hypotension, aspiration, esophageal intubation, right main bronchus intubation, fracture of teeth, and tracheal rupture were considered as the studied adverse effects. In addition, more than 3 attempts for intratracheal intubation was considered unsuccessful intubation. Results: Finally, the findings of 100 patients with the mean age of 63.4 ± 16.8 years were analyzed (57% female). Attempts for intratracheal intubation were successful in all cases and 81 patients were intubated on first attempt, 15 on second attempt and 4 on third attempt. There was no unsuccessful intubation that needed more than 3 attempts among the residents. Success rate of intubation was 31 (83%) cases among first year residents, 52 (94%) cases in second year residents and 17 (100%) cases for third year residents. This difference among residents in various levels was statistically significant (p = 0.0014). Hypoxia, esophageal intubation, aspiration, hypotension, and right main bronchus intubation, were the most common adverse effects observed, respectively. No fracture of teeth or tracheal rupture case was observed. Rates of esophageal intubation (p = 0.002) and right main bronchus intubation (p = 0.023) were significantly different among residents of different levels. Number of attempts and adverse effects of intratracheal intubation were significantly related in this study as 75 (88%) cases of the observed adverse effects were seen in those who were intubated on the first attempt. Meanwhile, adverse effects were seen in only 6 (7%) cases that were intubated on the second or third attempt (p < 0.001). Conclusion: Attempts for intratracheal intubation was successful in all the patients but the difference in number of attempts was statistically significant between the residents of various levels. Hypoxia, esophageal intubation, aspiration, hypotension, and right main bronchus intubation, were the most common adverse effects observed, respectively. No fracture of teeth or tracheal rupture case was observed

عوارض لوله گذاری داخل تراشه توسط دستیاران طب اورژانس؛ یک مطالعه مقطعی

Introduction: Airway management of patients is among the responsibilities of an emergency medicine specialist. To decrease the adverse effects of intubation, sufficient knowledge of the drugs used and proper skill in intratracheal intubation is needed. Therefore, the present study was carried out aiming to evaluate the success rate and adverse effects of intratracheal intubation by emergency medicine residents. Methods: This cross-sectional study was done during 18 months in the emergency department (ED) of Imam Hossein Hospital, Tehran, Iran. All the residents who had spent at least 6 months of their education program in ED and had passed the 2-month specialized course in anesthesiology rotation were included in the study using census method. The researcher, who was a senior emergency medicine resident, would be present at the time of intubation and would gather the required data using a pre-designed checklist. Hypoxia, hypotension, aspiration, esophageal intubation, right main bronchus intubation, fracture of teeth, and tracheal rupture were considered as the studied adverse effects. In addition, more than 3 attempts for intratracheal intubation was considered unsuccessful intubation. Results: Finally, the findings of 100 patients with the mean age of 63.4 ± 16.8 years were analyzed (57% female). Attempts for intratracheal intubation were successful in all cases and 81 patients were intubated on first attempt, 15 on second attempt and 4 on third attempt. There was no unsuccessful intubation that needed more than 3 attempts among the residents. Success rate of intubation was 31 (83%) cases among first year residents, 52 (94%) cases in second year residents and 17 (100%) cases for third year residents. This difference among residents in various levels was statistically significant (p = 0.0014). Hypoxia, esophageal intubation, aspiration, hypotension, and right main bronchus intubation, were the most common adverse effects observed, respectively. No fracture of teeth or tracheal rupture case was observed. Rates of esophageal intubation (p = 0.002) and right main bronchus intubation (p = 0.023) were significantly different among residents of different levels. Number of attempts and adverse effects of intratracheal intubation were significantly related in this study as 75 (88%) cases of the observed adverse effects were seen in those who were intubated on the first attempt. Meanwhile, adverse effects were seen in only 6 (7%) cases that were intubated on the second or third attempt (p < 0.001). Conclusion: Attempts for intratracheal intubation was successful in all the patients but the difference in number of attempts was statistically significant between the residents of various levels. Hypoxia, esophageal intubation, aspiration, hypotension, and right main bronchus intubation, were the most common adverse effects observed, respectively. No fracture of teeth or tracheal rupture case was observed. مقدمه: از جمله مسئولیت های اصلی یک متخصص طب اورژانس مدیریت راه هوایی در بیماران است. برای کاهش عوارض اینتوباسیون، نیاز به دانش کافی نسبت به داروهای مورد استفاده و همچنین مهارت کافی در انجام لوله گذاری داخل تراشه می باشد. لذا مطالعه حاضر به منظور ارزیابی میزان موفقیت و عوارض لوله گذاری داخل تراشه توسط دستیاران طب اورژانس انجام شد. روش کار: این مطالعه مقطعی طی 18 ماه در بخش اورژانس مرکز پزشکی آموزشی درمانی امام حسین، تهران، ایران انجام گرفته است. کلیه دستیارانی که  حداقل 6 ماه از زمان شروع دوره آموزشی خود را در بخش اورژانس سپری کرده بودند و دوره دو ماهه آموزشی اختصاصی در دوره چرخشی بیهوشی را گذرانده بودند به شیوه سرشماری و پیاپی وارد مطالعه شدند. فرد محقق که دستیار ارشد رشته طب اورژانس بود به صورت ناظر در هنگام انجام پروسیجر لوله گذاری حضور یافته و اطلاعات مورد نظر را از طریق یک چک لیست از پیش تهیه شده جمع آوری می کرد. هیپوکسی، هایپوتانسیون، آسپیراسیون، لوله گذاری داخل مری، لوله گذاری داخل برونش راست، شکستگی دندان و پارگی تراشه به عنوان عوارض مورد مطالعه در نظر گرفته شدند. همچنین تلاش برای لوله گذاری داخل تراشه بیش از 3 بار عدم موفقیت در نظر گرفته شد. يافته ها: در نهایت یافته های حاصل از 100 بیمار با میانگین سنی 8/16 ± 4/63 سال مورد تجزیه و تحلیل قرار گرفتند (57 درصد زن). تلاش جهت لوله گذاری داخل تراشه در تمام بیماران موفقیت آمیز بود و از بین موارد مورد مطالعه، 81 بیمار در تلاش اول، 15 بیمار در تلاش دوم و 4 بیمار در تلاش سوم لوله گذاری شدند. موارد عدم موفقیت که نیاز به بیش از 3 بار تلاش باشد نیز در بین دستیاران دیده نشده است. میزان موفقیت در لوله گذاری داخل تراشه دستیاران سال اول 31 مورد (83 درصد)، دستیاران سال دوم 52 مورد (94 درصد) و دستیاران سال سوم 17 مورد (100 درصد) بود. این تفاوت در بین دستیاران سطوح مختلف از نظر آماری معنی دار بود (0014/0=p). هیپوکسی، لوله گذاری داخل مری، آسپیراسیون، هایپوتانسیون و لوله گذاری داخل برونش راست به ترتیب شایعترین عوارض مشاهده شده در این مطالعه بودند. هیچ موردی از شکستگی دندان و پارگی تراشه مشاهده نگردید. میزان لوله گذاری داخل مری (002/0=p) و لوله گذاری داخل برونش اصلی راست (023/0=p) در بین دستیاران سطوح مختلف تفاوت معنی داری داشت. تعداد دفعات تلاش و میزان عوارض لوله گذاری داخل تراشه در این مطالعه معنادار بود به طوری که 75 مورد (88 درصد) از عوارض مشاهده شده در بیمارانی که یک بار تلاش برای لوله گذاری داخل تراشه انجام گرفت، دیده شد. در حالی که میزان عوارض در مواردی که در تلاش دوم و سوم لوله گذاری انجام گرفت تنها 6 مورد (7 درصد) بود (001/0> p). نتيجه گيری: تلاش جهت لوله گذاری داخل تراشه در تمام بیماران مورد مطالعه موفقیت آمیز بود ولی تفاوت تعداد دفعات تلاش در بین دستیاران سطوح مختلف از نظر آماری معنی دار بود. هیپوکسی، لوله گذاری داخل مری، آسپیراسیون، هایپوتانسیون و لوله گذاری داخل برونش راست به ترتیب شایعترین عوارض مشاهده شده در این مطالعه بودند. هیچ موردی از شکستگی دندان و پارگی تراشه مشاهده نگردید

Comparison of the diagnostic accuracy of CT scan with oral and intravenous contrast versus CT scan with intravenous contrast alone in the diagnosis of blunt abdominal trauma

Purpose: Abdominal CT scan using oral and intravenous (IV) contrast is helpful in the diagnosis of intra-abdominal injuries. However, the use of oral and IV contrast delays the process of diagnosis and increases the risk of aspiration. It has also been shown that CT scan with IV contrast alone is as helpful as CT scan with oral and IV contrast and rectal CT scan in detecting abdominal injuries. Therefore, the present study aims to prospectively compare the diagnostic value of CT scan with oral and IV contrast versus CT scan with IV contrast alone in the diagnosis of blunt abdominal trauma (BAT). Methods: Altogether 123 BAT patients, 60 (48.8%) women and 63 (51.2%) men with the mean age of (40.4 ± 18.7) years who referred to the emergency department of Imam Khomeini Educational and Medical Center in Sari, Iran (a tertiary trauma center in north of Iran) from November 2014 to March 2017 and underwent abdominal CT scans + laparotomy were investigated. Those with penetrating trauma or hemodynamically unstable patients were excluded. The participants were randomly allocated to two groups: abdominal CT scan with oral and IV contrast (n = 63) and CT scan with IV contrast alone (n = 60). No statistically significant difference was found between two groups regarding the hemodynamic parameters, age, gender, injury mechanisms (all p > 0.05). The results of CT scan were compared with that of laparotomy results. The collected data were recorded in SPSS version 22.0 for Windows. Quantitative data were presented as mean and SD. Results: The sensitivity and specificity of CT scan using oral and IV contrast in the diagnosis of BAT were estimated at 96.48 (95% CI: 90.73 – 99.92) and 92.67 (95% CI: 89.65 – 94.88), respectively; while CT scan with IV contrast alone achieved a comparable sensitivity and specificity of 96.6 (95% CI: 87.45 – 99,42 and 92.84 (95% CI: 89.88 – 95.00), respectively. Conclusion: CT scan with IV contrast alone can be used to assess visceral injuries in BAT patients with normal hemodynamics to avoid diagnostic delay

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

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

Prognostic value of clinical signs and CT-scan findings in renal colic patients referred to emergency department of Imam hospital in sari in 2021

Background: The aim of this study was to investigate the positive predictive value of CT scan findings and clinical signs in choice of clinical management of renal colic patients referred to the emergency department of Imam Hospital in Sari in 2020-2021. Method: A cross-sectional study was performed on all patients with renal colic who were admitted to the emergency department in Sari Imam Khomeini Hospital, in 2021. 167 patients with acute renal colic in terms of clinical manifestations, laboratory findings, and CT scan findings were evaluated.Results: In the present study, 55 patients (32.9%) underwent TUL treatment and 112 patients (67.1%) had spontaneous excretion. 48.9% of people with clinical symptoms of abdominal pain and 27% of people without symptoms of abdominal pain finally underwent TUL treatment (p = 0.008). The incidence of TUL in patients with stone size> 5 mm was significantly higher than those with stones ≤5 mm (P <0.001) and the majority of patients with stones in the upper and middle third of the ureter were in the TUL group. The majority of patients had spontaneous excretion despite stones in the lower third and UVJ (p = 0.021).&nbsp

Diagnostic Accuracy of Quick Stick for Identifying Traumatic Patients in Need of Tetanus Prophylaxis; a Cross-sectional Study

Introduction: Based on the existing studies, measuring serum level of immunoglobulin for making decisions regarding prescription of tetanus prophylaxis seems logical and cost effective. Therefore, the present study was done with the aim of evaluating the diagnostic accuracy of tetanus quick stick (TQS) in comparison with ELISA method in this regard.Methods: The present diagnostic accuracy study was carried out on trauma patients presenting to emergency department, who were in need of receiving tetanus prophylaxis due to dirty wounds or injuries. Patients’ blood was evaluated regarding presence of anti-tetanus antibody via TQS and ELISA methods and screening performance characteristics of TQS in identifying the cases in need of receiving prophylaxis was calculated compared to ELISA as the reference test.Results: 148 patients with the mean age of 34.58 ± 15.86 years (4-86) were studied (87.8% male). Agreement rate between the results of TQS and ELISA was 0.78 based on calculation of kappa coefficient. Sensitivity, specificity and area under the ROC curve of TQS were estimated to be 100 (95% CI: 96.50 – 100), 66.66 (95% CI: 38.68 – 86.01), and 0.83 (95% CI: 0.68 – 0.98), respectively. If TQS was used, the cost of treatment regarding use of tetabulin could have a 91.7% reduction.Conclusion: Based on the findings of the present study, TQS has good diagnostic accuracy in comparison with ELISA and considering its 100% sensitivity and negative predictive value in cases with dirty wound, it can be considered as a reliable tool for screening patients that do not need to receive anti-tetanus prophylaxis

Comparison of Kocher and Modified Hippocratic Methods in Reduction of Anterior Shoulder Dislocation; a Quasi Experimental Study

Introduction: Various methods have been designed for shoulder reduction and Kocher method (flexion, adduction and external rotation) and traction counter-traction are introduced as the oldest methods. Therefore, the present study was designed aiming to compare these two methods in reduction of anterior shoulder dislocation. Methods: This quasi experimental study was conducted on 16 to 60 year-old patients presenting to emergency department following anterior shoulder dislocation during 1 year. Patients underwent reduction via Kocher or traction counter-traction methods and were compared regarding reduction time, pain relief rate, success rate and neurological vascular complications. Results: 150 patients with the mean age of 32.11 ± 11.3 years were randomly divided into 2 groups of traction counter-traction (67 individuals) and Kocher (83 individuals) (86.7% male). The 2 groups were similar regarding age (p = 0.52) and sex (p = 0.679). There was no significant difference regarding pain relief after reduction between the 2 groups (p > 0.05). Mean reduction time was 72.27 ± 15.08 seconds in the traction group and 62.34 ± 24.35 seconds in the rotation group (p < 0.0001). In addition, duration of hospitalization was 3.00 ± 0.48 hours in traction group versus 3.08 ± 0.61 hours in the other group (p = 0.382). The frequency of failure in reduction cases was 1 (1.49%) in the traction group and 6 (7.22%) in the rotation group (p = 0.129). Finally, 2 (2.40%) cases of mild injury of brachial plexus in the ulnar nerve path occurred in the rotation group and no neurological complication was seen in the traction group. Conclusion: According to the results of the present study, Kocher and traction counter-traction methods were similar regarding pain relief after reduction and total duration of hospitalization, but reduction time was shorter in Kocher method and treatment failure rate was reported to be higher in this method