Comparing the Therapeutic Effects of Dexamethasone-Metoclopramide with Ketorolac in Relieving Headache in Patients with Acute Migraine Attacks Presenting to the Emergency Department

Introduction: Migraine is a frequent chief complaint of patients in the emergency department. A wide range of treatments are used for acute migraine. Objective: This study aimed to compare the therapeutic effects of a combination of metoclopramide + dexamethasone with those of ketorolac for treatment of acute migraine in the emergency department. Method: This quasi-experimental study enrolled patients identified as migraine headache cases admitted to the emergency departments of Shohadaye Tajrish and Sina hospitals, Tehran, Iran. The patients were divided into two groups and treated with either 8 mg Dexamethasone + 10 mg Metoclopramide or 60 mg ketorolac, and then compared regarding the rate of pain control based on visual analogue scale (VAS) on arrival and 1 and 2 hours afterward. Results: Overall, 86 patients were recruited, of whom 50 were male (58.1%). Their mean age was 37.6 ± 10.3 years. Thirty-five (40.7%) were in the ketorolac group and 51 (59.3%) were in the dexamethasone + metoclopramide group. Treatment success was defined as a reduction of at least 3 points in pain severity in comparison to the admission time. One hour after administration of medications, the reported pain intensity was 4.7 ± 2.0 and 6.2 ± 2.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. By the second hour, pain intensity was 3.4 ± 1.2 and 2.9 ± 1.3 in ketorolac group and dexamethasone + metoclopramide group, respectively. The two groups did not show a significant difference in terms of the reported pain at this time (p= 0.04). Conclusion: Based on our findings, the pain reduction time was relatively shorter for ketorolac in acute migraine, but the final response was identical in the two groups

Diagnostic value of standard electrocardiogram in acute right ventricular myocardial infarction

Myocardial infarction (MI) (i.e., heart attack) is the irreversible death (necrosis) of heart muscle secondary to prolonged lack of oxygen supply (ischemia) which accounts for a large number of deaths in the hospital. Diagnosis of myocardial infarction is confirmed based on clinical manifestations and electrocardiographic changes along with increased cardiac enzymes. Electrocardiogram (ECG) is one of the safest and easiest methods in the first place. Therefore, this study aimed to investigate the diagnostic value of standard electrocardiogram in the diagnosis of acute right ventricular infarction following lower cardiac infarction. This research was carried out at a time interval of one and a half years to diagnose acute primary infarction. In this method, the diagnostic value of ST↓ in lead I, ST↓ in lead aVL and I ST↓ + aVL, compared with ST↑ in lead V4R was investigated for diagnosis of right ventricular infarction. ST↑ in the lead V4R is a gold standard for the detection of right ventricular MI. All the patients who had the inclusion criteria were allowed to participate in the study. A total of 66 patients participated in the study. Accordingly, 58 (87%) were male and 8 (13%) were female. The mean age of the population was 54.9 ± 11.41. According to the ST↑ standard in lead V4R, 26 patients (39%) had right ventricular myocardial infarction. There was no significant relationship between angina pectoris and premature infarction (P-Value = 0.869). In this study, the right ventricular was most commonly involved in right coronary artery (RCA) (78%). There was no significant relationship between the occlusion of right coronary artery and right ventricular infarction in 60 patients (P-Value = 0.94). The results showed that electrocardiogram manifestations help determine the occlusion site and the area at risk (ST↓ in lead aVL and aVL + I, sensitivity = 96%). In myocardial infarction, symptoms such as the ST-Segment elevation in lead aVR and ST-Segment depression in the lower leads are possible. Accordingly, in the lower infarction, ST changes in the leads V1-V6 are helpful in detecting patients at risk. Thus, the use of electrocardiogram in acute myocardial infarction (AMI) helps detect more invasive patients and prevents extensive myocardial damage and other complications

Unnecessary Brain CT scan of Traumatic Pediatric Patients; How to Reduce the Numbers?

There are considerable rates of pediatrics trauma referring emergency department following a traumatic event. The worried parents are requesting for the most sensitive diagnostic test, so emergency physicians ask them to underwent brain computed tomography (CT) scan. Lower threshold of decision making regarding use of brain CT scan results in huge number of normal imaging. On the other hand, radiation exposer of the child may accompanied with lots of side effects in future. It may highlight a question that “how to reduce the numbers of unnecessary brain CT scan of traumatic pediatric patients?

Evaluation of Emergency Medical Technicians Intermediate Prediction about Their Transported Patients Final Disposition in Emergency Department of Imam Khomeini Hospital

This was a prospective cross-sectional study of consecutive transported patients by emergency medical service (EMS) to a referral hospital. The goal of this study was the evaluation of emergency medical technician intermediate prediction about their transported patients disposition in Emergency Department of Imam Khomeini Hospital. 2950 patients were transported to this hospital, Questionnaires were submitted in 300 of consecutive patient transports and completed data were obtained and available upon arrival at hospital for 267 of these cases. Emergency medical technicians intermediate (EMT-I) were asked to predict whether the transported patient would require admission to the hospital, and if so, what will be their prediction of patient actual disposition. Their predictions were compared with emergency specialist physicians. EMT-I predicted that 208 (78%) transports would lead to admission to the hospital, after actual disposition, 232 (%87) patients became admitted. The sensitivity of predicting any admission was 65%, with positive predictive value (PPV) of 39% and specificity of 86% with negative predictive value (NPV) of 94%. The sensitivity of predicting trauma patients (56.2% of total patients) was 55% with PPV of 38%, specificity of 86% and for Non-trauma patients' sensitivity was 80% with PPV of 40% and specificity of 82%. EMT-I in our emergency medical system have very limited ability in prediction of admission and disposition in transported patients and their prediction were better in Non-trauma patients. So in our EMS, the pre-hospital diversion and necessity of transporting policies should not be based on EMS personnel disposition

Frequency and types of the medication errors in an academic emergency department in Iran: The emergent need for clinical pharmacy services in emergency departments

Objective: Emergency departments (EDs) are characterized by simultaneous care of multiple patients with various medical conditions. Due to a large number of patients with complex diseases, speed and complexity of medication use, working in under-staffing and crowded environment, medication errors are commonly perpetrated by emergency care providers. This study was designed to evaluate the incidence of medication errors among patients attending to an ED in a teaching hospital in Iran. Methods: In this cross-sectional study, a total of 500 patients attending to ED were randomly assessed for incidence and types of medication errors. Some factors related to medication errors such as working shift, weekdays and schedule of the educational program of trainee were also evaluated. Findings: Nearly, 22% of patients experienced at least one medication error. The rate of medication errors were 0.41 errors per patient and 0.16 errors per ordered medication. The frequency of medication errors was higher in men, middle age patients, first weekdays, night-time work schedules and the first semester of educational year of new junior emergency medicine residents. More than 60% of errors were prescription errors by physicians and the remaining were transcription or administration errors by nurses. More than 35% of the prescribing errors happened during the selection of drug dose and frequency. The most common medication errors by nurses during the administration were omission error (16.2%) followed by unauthorized drug (6.4%). Most of the medication errors happened for anticoagulants and thrombolytics (41.2%) followed by antimicrobial agents (37.7%) and insulin (7.4%). Conclusion: In this study, at least one-fifth of the patients attending to ED experienced medication errors resulting from multiple factors. More common prescription errors happened during ordering drug dose and frequency. More common administration errors included dug omission or unauthorized drug

Jejunal Perforation Following Blunt Abdominal Trauma; a Case Report

Introduction: The possibility of intestinal injury for all patients presenting to emergency department (ED) with blunt abdominal trauma, despite minimal physical signs should be considered. To highlight the patient management, hear, we report a case of hollow viscus injuries resulting from blunt abdominal trauma referring to a teaching hospital in Tehran, Iran. Case presentation: A 30-year-old man presented to the ED after “falling into a hole” with his back and had direct blunt abdominal trauma by a heavy bag of cement. In physical examination, there was a mild abdominal tenderness on right upper quadrant. On bedside ultrasonography, there was small free fluid in his Morison’s pouch without hypotension. So abdominal CT scan was performed which revealed free fluid in pelvic, perihepatic, and perisplenic spaces. Mural hematoma of proximal part of jejunum with mural wall hypodensity in mid jejunal loop were also revealed. The patient underwent surgery, and there was damage to the colon serosa and jejunal perforation which was primarily repaired. Conclusion: The presented case highlights the importance of obtaining history and physical exam and paying attention to the nature and mechanism of injury. Emergency physicians should be aware of hollow viscus injury in traumatic patients. Any delay in diagnosis and operative management are associated with an increase in mortality

Evaluation of Emergency Medicine Residents Competencies in Electrocardiogram Interpretation

An electrocardiogram (ECG) leads physicians to diagnose many potentially life-threatening cardiac, metabolic, electrolyte, and toxicological conditions. This study was designed to evaluate the competency of emergency medicine residents (EMRs) in comparison with cardiologists in the interpretation of ECG when an interpretation checklist is used. This clinical trial was done in the emergency wards of the first grand general hospital of Iran. Patients were categorized in three classes of disorder severity based on ECG abnormalities. The two stages of the study included the survey phase (Stage I), training phase and intervention phase (Stage II). Accuracy of ECG interpretation by EMRs and cardiologists was compared before and after using a Daily ECG Check List (DECKList). One hundred and fifty ECGs were evaluated in Stage I, before DECKList usage, and 150 ECGs were evaluated in stage II, after DECKList usage by EMRs. Mean age of participants was 60.13 years in Stage I and 61.66 years in Stage II. Stage I and II were similar to each other in terms of disorder severity (P=0.22). Mean the ECG interpretation score was significantly different between Stages I and II (P<0.001). Concordance of ECG diagnosis between EMRs and cardiologists was significantly different in Stages I and II (P<0.01). In first-year EMRs, ECG diagnosis scores in stages I and II were not changed significantly. However, ECG interpretation scores increased significantly in first-year EMRs (P=0.04). In second-year EMRs, both ECG interpretation and ECG diagnosis scores improved significantly (P<0.05 and P<0.01, respectively). In third year EMRs, ECG interpretation was not improved but ECG diagnosis based on two methods improved significantly (P<0.05). The significant increase in accuracy of ECG interpretation and final diagnosis can be attributed to the utilization of a checklist by EMRs especially in the first year and second residents

Determining the Topics and Content of CME Programs in Five Selected Subjects: Comparing the View Points of Experts and Target Group a Tehran University of Medical Sciences Experience

Introduction: One of the most appropriate methods for needs assessment is to assess learners' needs and arrange the educational programs based on their viewpoints. The aim of this study was to determine the topics and content of Continuing Medical Education (CME) programs in five selected subjects by medical education experts and target group, based on the real needs of General Practitioners (GPs) in order to revise CME national programs. Methods: In this cross-sectional applied study, 700 GPs covered by Medical Sciences Universities in Tehran province were studied. A questionnaire consisting of two parts of demographic features and 80 scientific questions regarding their knowledge in five domains of clinical pharmacology, skin diseases, toxicology, emergencies, and forensic medicine was used. The questionnaires were delivered to physicians' offices by trained personnel using a list or by direct referral to offices and then gathered. Three topics in each subject and 15 standard educational contents in total were developed for the target group. Results: There was almost a complete relationship between the opinion of experts and target group in forensic medicine. Some of the first five priorities of the two groups overlapped in skin diseases, forensic medicine, and emergencies. No common viewpoints were observed between experts and target group in pharmacology. In toxicology, there was no common viewpoint in the first three selections of the two groups. Conclusion: Real educational needs of GPs in receiving new information in order to promote their competencies and knowledge were different from those considered by experts. It is recommended to design the educational content for the target groups in the health care field based on their real deficiencies in knowledge and practice and by assessing their views and knowledge