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

Bedside Ultrasonography versus Brain Natriuretic Peptide in Detecting Cardiogenic Causes of Acute Dyspnea

Acute dyspnea is a common cause of hospitalization in emergency departments (ED).Distinguishing the cardiac causes of acute dyspnea from pulmonary ones is a major challenge for responsible physicians in EDs. This study compares the characteristics of bedside ultrasonography with serum level of blood natriuretic peptide (BNP) in this regard. Methods: This diagnostic accuracy study compares bedside ultrasonography with serum BNP levels in differentiating cardiogenic causes of acute respiratory distress. Echocardiography was considered as the reference test. A checklist including demographic data (age and sex), vital signs, medical history, underlying diseases, serum level of BNP, as well as findings of chest radiography, chest ultrasonography, and echocardiography was filled for all patients with acute onset of dyspnea. Screening characteristics of the two studied methods were calculated and compared using SPSS software, version 20. Results: 48 patients with acute respiratory distress were evaluated (50% female). The mean age of participants was 66.94 ± 16.33 (28-94) years. Based on the results of echocardiography and final diagnosis, the cause of dyspnea was cardiogenic in 20 (41.6%) cases. Bedside ultrasonography revealed the cardiogenic cause of acute dyspnea in 18 cases (0 false positive) and BNP in 44 cases (24 false positives). The area under the ROC curve for bedside ultrasonography and BNP for differentiating the cardiogenic cause of dyspnea were 86.4 (95% CI: 74.6-98.3) and 66.3 (95% CI: 49.8-89.2), respectively (p = 0.0021). Conclusion: It seems that bedside ultrasonography could be considered as a helpful and accurate method in differentiating cardiogenic causes of acute dyspnea in emergency settings. Nevertheless, more study is needed to make a runaway algorithm to evaluate patients with respiratory distress using bedside ultrasonography, which leads to rapid therapeutic decisions in a short time

Diagnostic Accuracy of Optic Nerve Ultrasonography and Ophthalmoscopy in Prediction of Elevated Intracranial Pressure

Introduction: Elevated intracranial pressure (ICP) is a major and potentially lethal disorder in patients admitted to the emergency department (ED). Several methods are being used to investigate for elevated ICP. Here we assessed and compared the diagnostic accuracy of two existing tools of ophthalmoscopy and optic nerve ultrasonography in detection of elevated ICP. Methods: 131 participants with probable elevation of ICP referred to the emergency department of Al-Zahra Hospital, Isfahan, Iran, from 2012 to 2014, were enrolled. Brain computed tomography (CT) scan, ultrasonography of optic nerve sheath, and ophthalmoscopy were performed for them. The optic nerves sheath with diameter more than 5 millimeters was considered as elevated ICP. Widening of optic nerve, ocular venous engorgement, blurring, hemorrhage over optic disk, elevation of optic disk, and retinal venous tortuosity were recorded as evidences of ICP rising in ophthalmoscopy. Diagnostic accuracy of the two tools in prediction of ICP rising were compared with the results of brain CT scan as a gold standard. Results: The mean age of participants was 46.29 ± 10 years (77% male). The number of diagnosed elevated ICPs with ophthalmoscopy and ultrasound were 98 (74.8%) and 102 (77.9%) cases, respectively. The calculated sensitivity and specificity of ophthalmoscopy and ultrasonography in detection of ICP rising were 100.0% (95% CI: 88.6-100.0) and 35.4% (95% CI: 26.0-46.2), 100.0% (95% CI: 84.0-100.0) and 31.9% (95% CI: 23.0-41.7), respectively. Conclusion: The present study reveals that bedside ultrasonography of optic nerve sheath and ophthalmoscopy have enough accuracy for screening of patients with probable elevation of ICP. Of course, it should be considered that despite of high sensitivity of both tools, their specificity is low

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.

علت تروما و پيامد نهايي حاصل از آن در بیماران مراجعه کننده به بخش اورژانس؛ یک مطالعه مقطعی

Introduction: Today trauma is considered as the first cause of death and disability of active population in developed and developing countries. Using preventive procedures in trauma events are effective when acute information and statistics present regarding types of trauma and their outcomes in the society. Thus, the present study was designed to assess the prevalence of trauma reasons and its outcome in traumatic patients hospitalized in three emergency departments of Isfahan, Iran. Methods: This cross- sectional study was performed on 1363 patients referred to three emergency departments of Isfahan during October, November, and December of 2010. Data collecting was done by using a checklist including demographic data, trauma mechanism and location, patients' transportation, anatomic site of injury, and patients' outcome after 24 hours. The data was analyzed using SPSS 16. Results: 1363 traumatic patients with mean age of 30.5 ±17.35 years (73.6% male) were studied. The mean time from event to reaching the ambulance was 9±7.81 minutes and average time of patient's transportation to the hospital 27.07±14.49. Motor vehicle crashes and falling from height were the most common trauma mechanisms and mortality (p<0.001). The rate of mortality and hospitalization in men respectively were 7 and 3.4 times more than women, (p=0.04). 1235 patients (90.6%) were discharged with good general condition. The rate of mortality and intensive care need were estimated 0.66% (9 patients) and 6.82% (93 patients), respectively. The most numbers of death were happened in 15-24 years (p<0.001) and the most hospitalizations in 25-44 years (p<0.001). Chest and head traumas were the most common causes of death. Conclusion: The study shows that motor vehicle crashes and falling form height in more than 80% of cases were the most frequent causes of trauma in patients referred to the emergency departments of these three hospitals. Also, the above mentioned were the most frequent mechanisms of trauma in died and intensive care needed patients. Above 90% of patients were discharged with good general condition.مقدمه: تروما اولین علت مرگ و میر و از علل اصلی از کار افتادگی و معلولیت جمعیت فعال در کشورهای در حال توسعه می باشد. بر طبق پیش بینی های سازمان جهانی بهداشت تا سال 2020 میلادی، حوادث ناشی از تصادفات به تنهایی دومین علت سال های از دست رفته زندگی در سراسر جهان را به خود اختصاص خواهند داد. استفاده از روش های پیشگیری کننده در زمینه وقوع تروما زمانی موثر واقع می شود که اطلاعات و آمار دقیقی درباره میزان بروز انواع مکانیسم های تروما و نتایج حاصل از آنها در جامعه موجود باشد. لذا مطالعه حاضر با هدف بررسی شیوع علل مختلف تروما و پیامد نهایی حاصل از آنها در بیماران ترومایی بستری شده در اورژانس سه مرکز آموزشي و درماني شهر اصفهان طراحی شده است. روش کار: این مطالعه مقطعی در بیماران ترومایی که در فاصله زمانی اول مهر ماه تا پایان آذر ماه 1389 به اورژانس سه بیمارستان شهر اصفهان مراجعه کرده بودند صورت گرفت. جمع آوری اطلاعات از طریق چک لیستی مشتمل بر داده های دموگرافیک، مکانیسم تروما، محل رویداد حادثه، نحوه انتقال بیماران، محل آناتومیک آسیب و پیامد نهایی بیماران بعد از 24 ساعت انجام شد. داده ها در نرم افزار آماری SPSS و با روش های آمار توصیفی و تحلیلی آنالیز شدند. يافته ها: 1363 بیمار با میانگین سنی 35/17±5/30 سال طی این مدت به اورژانس های سه مرکز مورد مطالعه مراجعه کرده بودند (73.6% مرد). میانگین فاصله زمانی وقوع حادثه تا حضور آمبولانس اورژانس پیش بیمارستانی بر بالین بیماران 81/7±9 دقیقه و میانگین مدت زمان انتقال بیمار به بیمارستان 49/14±07/27 دقیقه بود. تصادف با وسیله نقلیه موتوری و سقوط از ارتفاع به ترتیب شایع ترین مکانیسم های تروما و در عین حال شایع ترین علت مرگ و میر بودند (001/0>p). میزان مرگ و میر و بستری مردان به ترتیب 7 و 4/3 برابر زنان بود (04/0= p). 1235 بیمار (6/90 درصد) با حال عمومی خوب ترخیص شدند. مرگ و میر و نیاز به بخش مراقبت های ویژه به ترتیب 66/0 ( 9 بیمار) و 82/6 (93 بیمار) درصد برآورد گردید. بیشترین میزان فوت مربوط  به گروه سنی 24-15 سال (001/0>p) و بیشترین میزان بستری مربوط به گروه 44-25 سال بود (001/0>p). بیشترین میزان فوت به دنبال ترومای قفسه سینه و سپس ترومای سر و صورت اتفاق افتاده بود. نتيجه گيری: تصادف با وسایل نقلیه موتوری و سقوط از ارتفاع به تنهایی بیش از 80 درصد از علل مراجعه بیماران به واحد های ترومای اورژانس سه بیمارستان مورد مطالعه را به خود اختصاص داده بودند. این در حالی است که همین دو علت شایعترین مکانیسم تروما در بیماران فوت شده و نیازمند بستری در بخش مراقبت های ویژه نیز بودند. بیش از 90 درصد بیماران با حال عمومی خوب از بخش اورژانس یا سایر بخش های بستری ترخیص شدند

Establishing Emergency Medicine in Iran: a Post-implementation Perspective

In the 1990s, a comprehensive evaluation of national emergency care (EC) system was performed by the Iranian Ministry of Health and Medical Education (I-MOHME) to identify gaps in timely and proper EC delivery. It was then concluded that a refurbished patient-centered specialty, namely emergency medicine (EM), could reduce or close these gaps

Comparison of academic engagement in medical assistants in Isfahan University of Medical Sciences

Introduction: Academic enthusiasm as a main priority is focal point of the trustees of the higher education and it faces important challenges such as decline, burnout and lack of academic progress, tendency to deviant behaviors and the risk of dropping out. Therefore, this study endeavors to investigate the status of desire to study in medical assistants in Isfahan University of Medical Sciences. Methods: This descriptive-analytical study was carried out through a standard questionnaire. Qualitative data were described and analyzed using distribution and frequency percentage, and quantitative data were described and analyzed using mean and standard deviation. Results: The average score of the total desire to study was 178.48±38.22. The mean and standard deviation of the total desire to study score was 171.21±40.65 for male Assistants and 186.1734.38 for female assistants. The average score of the desire to study in students under 30 years old was 183.92±38.65, in the age group of 30 to 40 years it was 168.8±38.21, and in the age group of 40 years and above it was 197.7±28.75. Conclusion: Academic enthusiasm as a new approach can affect various aspects of education, continuing education, providing services, especially in the field of medicine

Diagnostic validity of ultrasonography in evaluation of pulmonary thromboembolism

Background: Diagnosis of pulmonary embolism (PE) remains difficult due to its nonspecific symptoms and signs. Therefore, many patients die undiagnosed or untreated. We decided to study the sensitivity, specificity, and accuracy of ultrasonography in the diagnosis of pulmonary thromboembolism. Materials and Methods: In this prospective study, 77 patients with clinically suspected PE in the emergency department of Isfahan Al-Zahra Hospital were enrolled from September 2011 to September 2012. At first, they were evaluated by thoracic ultrasonography (TUS) and then divided into four groups based on their TUS findings. Multi-slice computed tomography (MSCT) was the reference method in this study performed within 24 h from admission. MSCT scans were interpreted by a radiologist who was unaware of the TUS results. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPVs) of thoracic ultrasonography were determined. Results: PE diagnosis was confirmed by MSCT in 25 patients and 54 hypoechoic lesions were detected by TUS with the average size of 16.4 mm × 11.1 mm. In our study, sensitivity, specificity, PPV, NPV, and accuracy of TUS for PE diagnosis were 84%, 94.2%, 87.5%, and 92.5%, respectively. Conclusion: TUS is an inexpensive, safe and easily available method for timely diagnosis and treatment of PE in emergency department and its NPV is high for cases with low scores for Wells criteria who had a normal or possible TUS findings. It is also specific in the diagnosis of PE in cases with high scores Wells criteria who have confirmed or probable TUS findings

Cause and Final Outcome of Trauma in Patients Referred to the Emergency Department; a Cross Sectional Study

Introduction: Today trauma is considered as the first cause of death and disability of active population in developed and developing countries. Using preventive procedures in trauma events are effective when acute information and statistics present regarding types of trauma and their outcomes in the society. Thus, the present study was designed to assess the prevalence of trauma reasons and its outcome in traumatic patients hospitalized in three emergency departments of Isfahan, Iran. Methods: This cross- sectional study was performed on 1363 patients referred to three emergency departments of Isfahan during October, November, and December of 2010. Data collecting was done by using a checklist including demographic data, trauma mechanism and location, patients' transportation, anatomic site of injury, and patients' outcome after 24 hours. The data was analyzed using SPSS 16. Results: 1363 traumatic patients with mean age of 30.5 ±17.35 years (73.6% male) were studied. The mean time from event to reaching the ambulance was 9±7.81 minutes and average time of patient's transportation to the hospital 27.07±14.49. Motor vehicle crashes and falling from height were the most common trauma mechanisms and mortality (p&lt;0.001). The rate of mortality and hospitalization in men respectively were 7 and 3.4 times more than women, (p=0.04). 1235 patients (90.6%) were discharged with good general condition. The rate of mortality and intensive care need were estimated 0.66% (9 patients) and 6.82% (93 patients), respectively. The most numbers of death were happened in 15-24 years (p&lt;0.001) and the most hospitalizations in 25-44 years (p&lt;0.001). Chest and head traumas were the most common causes of death. Conclusion: The study shows that motor vehicle crashes and falling form height in more than 80% of cases were the most frequent causes of trauma in patients referred to the emergency departments of these three hospitals. Also, the above mentioned were the most frequent mechanisms of trauma in died and intensive care needed patients. Above 90% of patients were discharged with good general condition.</p