An 88-Year-Old Man with Sudden Onset Abdominal Pain

An 88-year-old man presented to the emergency department with sudden onset of abdominal pain since 6 hours before. He was a known case of chronic renal failure that underwent hemodialysis three times a week. He also suffered from hypertension and benign prostatic hyperplasia. The patients’ on-arrival vital signs were as follows: systolic blood pressure: 100/60 mmHg, pulse rate: 88/minute, respiratory rate: 25/minute, oral temperature: 36◦C, oxygen saturation 93% in room air.  He had severely ill appearance on admission. Distended abdomen was considerable but had normal bowel sound and clearly, pain was disproportionate to physical examination. His electrocardiogram showed sinus rhythm and venous blood gas analysis revealed the following: pH=6.96, PaCO2=49 mmHg, HCO3=11 mEq/L, Base excess= -20.  The bedside ultrasonography showed echogenic particles in hepatic parenchyma and same findings that were passing through the portal vein. Chest and abdominal X-rays were reported as normal. The patient underwent abdominal and pelvic computed tomography (CT) scan with oral contrast.What is your diagnosis

Treatment Costs of Traffic Accident Casualties in a Third-level Hospital in Iran; a Preliminary Study

Introduction: The costs of traffic accidents in low- and middle-income countries are estimated to add up to $65 billion annually, which is a little higher than the amount they receive as a final aid for development. The present retrospective study aims to evaluate the treatment costs of the hospitalized injured individuals in traffic accidents. Methods: The present study was carried out in Imam Hossein Hospital, Tehran, Iran. The study population consisted of all the individuals injured in traffic accidents, admitted to the hospital wards. Data were collected by a trained emergency physician. Demographic data, injury mechanism, the type of vehicle, the admission ward of the patient, and treatment costs were collected. Results: A total of 200 patient files were evaluated (males: 89$1622.1. Statistical analyses showed that treatment costs in the neurosurgery ward was significantly higher than those in orthopedic and general surgery wards (df: 3; F=9.5, P=0.008). Conclusion: The results of the present study showed that the mean cost of each traffic accident victim in Tehran is approximately $1622.1 and these patients sustain significantly higher costs in neurosurgery ward

Report of 267 Cases of Scorpion Bite Referring to an Emergency Department during One Year

Scorpion bite is a common health problem in many parts of the world, including the Iran’s tropics. There are thousands of cases and a number of deaths due to scorpion bite every year in the country. The present study aims to provide further data regarding the details, complications and outcomes of scorpion bite cases referring to Razi Hospital, Ahwaz, from March 2011 to April 2012. A total of 267 patients (56.3% females) with a mean age of 35.2±15.8 years, were included in the study. The most common genus of scorpion involved was Hemiscorpius (69.3%) and the most frequent body part involved was the lower limb (38.9%). The frequency of hemolysis-induced renal insufficiency and death after scorpion bite were 1.9% and 1.1%, respectively. Of all the factors evaluated in this series only the old age was associated with higher possibility of renal insufficiency (P<0.001).

Knowledge of Emergency Medicine Residents in Relation to Prevention of Tetanus

Introduction: Knowledge of emergency medicine residents about the management of patients suspected of having tetanus favoring wounds is very important due to their responsibility for the treatment of such patients. The aim of the present study was to evaluate this knowledge and making sure of the adequacy of instructions they have received in relation to prevention of tetanus.  Methods: A reliable and reproducible questionnaire was used to evaluate knowledge of all the emergency medicine residents in Imam Hussein Hospital in Tehran, Iran, about conditions favoring tetanus (9 questions) and proper interventions in such conditions (12 questions). The questionnaires were completed and scored as poor and good. The Mann-Whitney U test was used to analyze data. Statistical significance was set at P<0.05. Results: In the present study, 73 emergency medicine residents were evaluated (45.2% male). Knowledge of 31 (42.5%) residents in relation to conditions favoring tetanus and 41 (56.2%) residents in correct therapeutic interventions was in good level. The most frequent incorrect answer was related to diabetic ulcers and wounds in patients with sepsis. There was an increase in scores of conditions favoring tetanus (P<0.001) and correct therapeutic interventions (P=0.001) with an increase in educational years. However, age (P=0.64), gender (P=0.31), job experience (P=0.38) and participation in educational courses (P=0.67) had no effect on the knowledge level of emergency medicine residents. Conclusion: According to the findings of the present study, the knowledge of emergency medicine residents about correct management of patients suspected of tetanus was low, which emphasizes the necessity of providing further instructions on prevention of tetanus in wound management.

An Epidemiologic Study of Pediatric Poisoning; a Six-month Cross-sectional Study

Introduction: Intentional and unintentional poisoning are among the most common reasons for referrals to emergency department (ED). Therefore, the present study was designed to evaluate epidemiologic features and effective risk factors of intentional and unintentional poisoning in children. Methods: This prospective cross-sectional study was carried out in ED of Loghman Hakim Hospital, greatest referral poison center of Iran, Tehran during March to August 2014. Demographic data, medical history, history of psychiatric disease in child, the cause of poisoning, parents’ educational level, household monthly income, location of residence, history of addiction or divorce in family, and the poisoning intentionality were gathered. Data were analyzed using SPSS 18 and appropriate statistical tests based on the purpose of study. Results: 414 participants with the mean age of 4.2 ± 3.43 years were included (57.5% male). Children in the 0-4 year(s) age range had the most frequency with 281 (67.9%) cases. 29 (7%) cases were intentional (62% female, 76% in the 10-14 years old group). Methadone with 123 (29.7%) cases was the most frequent toxic agent in general and in unintentional cases. 10-14 years of age (p = 0.001), and the history of psychiatric disease in children (p <0.001), had a direct correlation with probability of intentional poisoning. While, history of addiction in the family showed an indirect correlation with this probability (p = 0.045). Conclusion: Based on the results of this study, most cases of poisoning in the children were unintentional methadone intoxication in boys in the 0-4 age range with a history of a psychiatric disease, and those who had a history of addiction in the family. In addition, the most powerful risk factor for the children’s intentional poisoning was their history of psychiatric disease. The history of addiction in the child’s family had indirect correlation with intentional intoxications

Ultrasound-Guided Reduction of Distal Radius Fractures

Introduction: Distal radius fractures are a common traumatic injury, particularly in the elderly population. In the present study we examined the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to emergency department (ED). Methods: In this prospective case control study, eligible patients were adults older than 18 years who presented to the ED with distal radius fractures. 130 consecutive patient consisted of two group of Sixty-Five patients were prospectively enrolled for around 1 years. The first group underwent ultrasound-guided reduction and the second (control group) underwent blind reduction. All procedures were performed by two trained emergency residents under supervision of senior emergency physicians. Results: Baseline characteristics between two groups were similar. The rate of repeat reduction was reduced in the ultrasound group (9.2% vs 24.6%; P = .019). The post reduction radiographic indices were similar between the two groups, although the ultrasound group had improved volar tilt (mean, 7.6° vs 3.7°; P = .000). The operative rate was reduced in the ultrasound groups (10.8% vs 27.7%; P = .014). Conclusion: Ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures

Using Cervical Collar for Multiple Trauma Patients in Pre-Hospital Settings; a Letter to Editor

چکیده: زمینه و هدف: امروزه وقوع تروما علی­الخصوص آسیب­های گردنی يکي از مشکلات اساسي تهديدکننده سلامت جامعه است. در زمینه پیشگیری از آسیب­های بیشتر، مطالعات نتایج مختلفی را در ارتباط با استفاده از کلار گردنی بیان کرده­اند. هدف از انجام مطالعه حاضر بررسی اثرگذاری کلار گردنی در پایداری ستون فقرات گردنی پس از تروما می­باشد. مواد و روش­ها: این مطالعه به صورت توصیفی آینده­نگر، در مرکز آموزشی درمانی لقمان-ایران و بر روی تمامی بیماران با آسیب در ناحیه ستون فقرات گردنی طی سال­های 17-2016 مراجعه کننده به این مرکز انجام شد. بیماران به دو دسته استفاده و عدم استفاده کلار تقسیم­بندی شدند. چک لیستی برای هر بیمار تهیه و اطلاعات بیماران وارد آن گردید. بیمار از نظر عوارض عصبی مورد بررسی قرار گرفت. در ادامه تمامی داده­های حاصل از مصاحبه و معاینه بیماران وارد برنامه آنالیز آماری SPSS v18 شده و با استفاده از تست­های آماری مرتبط با اهداف مطالعه به تحلیل داده­ها پرداختیم. نتایج: در این مطالعه که بر روی 1000 بیمار با ترومای گردن انجام شد اکثریت بیماران (3/75 درصد) مرد بوده و اکثریت نیز در بازه سنی 40-20 سالگی (6/49) بودند. شایع­ترین مکانیسم منجر به ترومای سر و گردن سقوط از ارتفاع در 5/24 درصد بیماران بود. در میان موارد شکستگی، شایع­ترین شکستگی در این بیماران شکستگی مهره 7 در 4/7 درصد بیماران بود. همچنین مشاهده شد که 79 درصد بیماران پیش از تروما از کلار استفاده کرده بودند. نتایج نشان داد که کلار در زنان بیشتر از مردان مورد استفاده واقع شده بود. فراوانی افرادی که دچار اختلال هوشیاری شدند در نتیجه استفاده از کلار گردنی بیشتر بود و نیز در افرادی که کلار گردنی استفاده کرده بودند درصد فوتی نسبت به افرادی که کلار گردنی استفاده نکرده بودند بیشتر بود. نتیجه ­گیری: نتایج این مطالعه نشان داد استفاده از کلار نتوانسته بود میزان بروز ضایعات عصبی را کاهش معنی ­داری دهد.Relative neck fixation using neck collar for all trauma patients is among the pre-hospital measures emphasized by many of the existing protocols in dealing with these patients. As emergency medicine specialists, in many cases, at the time of trauma patients’ handover from pre-hospital staff we have seen that neck collar has not been used during the transfer of patients to the emergency department. Therefore, the authors of this letter decided to study the rate of neck collar use and its consequences on these patients in the emergency department of Loghman Hakim Hospital for 1 year to document this experience. The present study was performed on 1000 patients with multiple trauma (75.3% male, 50% aged 20-40 years). The most common mechanism of trauma was falling with 245 (24.5%) patients, and level of consciousness was 13 or higher (based on Glasgow coma scale) in 715 (71.5%) cases. 466 (46.6%) cases had midline neck tenderness at the time of admission. Neck radiography findings showed that 329 (32.9%) patients had at least one fracture in their cervical vertebrae or spinous process. Among the patients with fractures in the cervical vertebra, fracture had most commonly occurred in the 7th cervical vertebrae (4.7%). Evaluation of patients in terms of neck collar usage rate showed that only 790 (79%) patients had a neck collar when entering the emergency department and 210 (21%) patients did not. The results of imaging showed cervical vertebrae or spinous process fracture in 67 (32%) of the patients who had been transferred to the hospital without a collar. Also, 262 (33.2%) of those who had a collar upon arrival, had cervical vertebrae fractures. Out of the 210 patients who had been transferred to the hospital without a collar, 72 (34.3%) developed neurological deficits or whiplash injury, 2 (1%) died, and 136 (64.8%) were discharged from the hospital without any special complications. The results of this study confirm the assertion that all patients with multiple trauma in pre-hospital conditions will benefit from wearing neck collar during their transfer to emergency department

Pan vs. Selective Computed Tomography Scans in Management of Multiple Trauma Patients; a Brief Report

Introduction: Using pan or selective computed tomography (CT) scan in management of multiple trauma patient is a matter of debate. Therefore, the present study was designed aiming to compare the findings of pan and selective CT scans in management of multiple trauma patients.Method: This is a prospective cross-sectional study, on patients presented to the emergency department (ED) of Shohadaye Haftome Tir Hospital, Tehran, Iran, following blunt multiple trauma over a 1-year period, from March 2014 to March 2015. Findings regarding presence or absence of injury in head, face, neck, chest, abdomen and hip were compared between patients that underwent pan and selective CT using SPSS 21.Results: 443 patients with the mean age of 34.54 ± 17.88 years were evaluated (78% male). 248 (56%) patients underwent selective CT scan and 195 (44%) underwent pan CT scan. The 2 groups were similar regarding vital signs and mean age. Mean hospital length of stay was 21.05 ± 24.64 days for selective CT scan group and 18.18 ± 22.75 days for the other one (p = 0.209). A significant difference was only seen regarding findings of chest injury between the 2 groups (p < 0.001). In other cases a proper overlap was seen between findings of the 2 groups.Conclusion: Based on the results of the present study, it seems that doing selective CT scan yields results similar to pan CT in detection of head and face, neck and abdomen and hip injuries in multiple trauma patients. However, using pan CT in these patients led to 16% increase in detection and diagnosis of traumatic intra-thoracic injuries.

Screening Characteristics of Ultrasonography in Detection of Ankle Fractures

Introduction: Ankle fracture is one of the most common joint fractures. X-ray and physical examination are itsmain methods of diagnosis. Recently, ultrasonography (US) is considered as a simple and non-invasive methodof fracture diagnosis. This study evaluated the diagnostic accuracy of US in detection of ankle fracture in comparisonto plain radiography. Methods: In this diagnostic accuracy study, which was done in emergency departmentsof Imam Hossein and Shohadaye Tajrish hospitals, Tehran, Iran, during 2014, 141 patients with suspecteddiagnosis of distal leg or ankle fracture were examined by US and radiography (gold standard), independently.Screening performance characteristics of US in detection of distal leg fractures were calculated using SPSS version21. Results: 141 patients with the mean age of 34§11.52 years (range: 15–50) were evaluated (75.9% male).Radiography confirmed ankle fracture in 102 (72.3%) patients. There was a significant correlation between theresults of US and radiography [Agreement: 95%; kappa: 0.88 (95% CI: 0.80–0.97); P Ç 0.001]. The screening performancecharacteristics of US in detection ankle fracture were as follows: sensitivity 98.9% (95% CI: 93.5% -99.9%), specificity 86.4% (95% CI: 71.9%–94.3%), PPV 94.1% (95% CI: 87.1%–97.6%), NPV 97.4% (95% CI: 84.9%–99.8%), PLR 16 (95% CI: 7.3–34.8), and NLR 0.02 (95% CI: 0.003 – 0.182). The area under the ROC curve of USin this regard was 95.8 (95% CI: 91.9§99.7). Conclusion: According to the results of this study, we can use USas an accurate and non-invasive method with high sensitivity and specificity in diagnosis ofmalleolus fractures.However, the inherent limitations of US such as operator dependency should be considered in this regard

Characteristics of Methadone Intoxicated Children Presenting to Emergency Department; a Cross Sectional Study

Introduction: Each year a large number of patients present to emergency departments (EDs) following accidental or intentional poisoning with methadone. This study was designed with the aim of demographic evaluation of methadone poisoning in children presenting to ED and proposing preventive measures to parents and the healthcare system. Methods: This cross sectional study was carried out on children under the age of 12 years presenting to ED of a poisoning referral center. Demographic characteristics of the child and parents, cause of poisoning, form of drug consumed, dose consumed, the symptoms of the child on admission, clinical examination, laboratory findings, and final outcome were recorded and reported using descriptive statistics. Results: 179 cases were studied (59.2% boys). Cause of consumption was accidental in 175 (97.8%) cases and consumed drug dose was unknown in 53 (53.6%) cases. On admission 6 cases were in deep coma, 133 (74.3%) had miotic pupils, and 52 (29.1%) were affected with respiratory apnea and cyanosis. In 132 (73.8%) cases drugs were obtained from unapproved stores and form of drug consumed was syrup in 146 (81.6%) cases. 177 (98.9%) cases were discharged after 2 or3 days and 2 (1.1%) cases died. Conclusion: Based on the results of the present study, most cases of methadone poisoning were accidental, in children residing in poor and middle-class areas, with parents who had a low level of education and had obtained the drug from unapproved stores and stored it in improper containers or at improper places. Only 64.8% of the parents were educated regarding drug storage