Prevalence and Associated Factors of Acute Traumatic Coagulopathy; a Cross Sectional Study

Introduction: Acute traumatic coagulopathy (ATC) is defined as having evidence of coagulopathy in patients with severe trauma. The aim of this preliminary study was to assess the prevalence and associated factors of ATC in severely traumatic patients presenting to emergency department (ED). Methods: In this retrospective cross sectional study, all patients with severe traumatic injury and available coagulation profile, presenting to the EDs of two major trauma centers in Tehran, Iran, during one year, were studied. Rate of ATC was determined and the associations with various variables as well as outcome were analyzed using SPSS 21. Results: 246 patients with the mean age of 36.57±17.11 years were included (88.2% male). The mean injury severity score (ISS) was 21.83 ± 7.37 (16 – 54). Patients were resuscitated with 676.83 ± 452.02 (0 – 1500) ml intravenous fluid before arriving at the ED. The maximum and minimum frequencies of ATC were 31.3% based on PTT > 36s and 2.4% based on PT > 18s, respectively. There was a significant association between the occurrence of ATC (PT ratio > 1.2) and ISS > 23 (p = 0.001), abdominal abbreviated injury score (AIS) > 3 (p = 0.003), base deficit > 4 (p = 0.019), pulse rate > 90/minute (p = 0.041), and pH < 7.30 (p = 0.043). Conclusion: The frequency of ATC in the present series varied from 2.4% to 31.3% based on different ATC definitions. Abdominal AIS > 3 and base deficit > 4 were among the significant independent factors related to ATC occurrence based on stepwise logistic regression analysis.

A Comparative Study on the Sedative Effect of Oral Midazolam and Oral Promethazine Medication in Lumbar Puncture

How to Cite This Article: Derakhshanfar H, Modanlookordi M, Amini A, Shahrami A. A Comparative Study of the Sedative Effect of Oral Midazolam and Oral Promethazine Medication in Lumbar Puncture. Iran J Child Neurol. 2013 Spring;7(2):11-16. ObjectiveLumbar puncture (LP) essentially is a painful and stressful procedure that indicated for diagnosis and therapeutic purposes. One way to reduce the anxiety is to administer an oral premedication. The aim of this study is to compare clinical effects of oral midazolam and oral promethazine in LP.Materials & MethodsThis prospective randomized controlled clinical trial study wasperformed on 80 children aged 2-7 years that were candidate for LP. They were divided into two randomized equal groups. First group received oral midazolam syrup 0.5 mg/kg and the other group received oral promethazine syrup 1mg/kg. Level of sedation, hemodynamic changes and any other complications were monitored every 5 minutes from 30 minutes before the start of the procedure.ResultsMidazolam group and promethazine group were similar in age, gender and weight. Midazolam had significantly shorter onset of sedation and also shorter duration to maximal sedation. The two groups were similar with respect to sedative effect at all time. The only complication that was significantly more in midazolam group was nausea and vomiting.ConclusionMidazolam syrup and promethazine syrup have same sedative effect in children. Both of these medications are easy to use in preschool children and none of them appeared to be superior to another. References1. Ellenby MS, Tegtmeyer K, Lai S, Braner DA. Lumbar Puncture. N Engl J Med 2006;28;355(13):e12.2. Crock C, Olsson C, Phillips R, Chalkiadis G, Sawyer S, Ashley D, et al. General anesthesia or conscious sedation for painful procedures in childhood cancer: The family’s perspective. Arch Dis Child 2003;88(3):253−7.3. Holdsworth MT, Raisch DW, Winter SS, Frost JD, Moro MA, Doran NH, et al. Pain and distress from Bone marrow aspirations and lumbar punctures. Ann Pharmacother 2003;37(1):17-22.4. Ellis JA, Villeneuve K, Newhook K, Ulrichsen J. Pain Management Practices for Lumbar Punctures: Are We Consistent? J Pediatr Nurs 2007 Dec;22(6):479-87.5. Mathai A, Nazareth M, Raju RS. Preanesthetic sedation of preschool children: comparison of intranasal midazolam versus oral promethazin. Anesth Essays Res 2011;5(1):67-71.6. McCann ME, Kain ZN. The management of preoperative anxiety in children: an update. Anesth Analg 2001; 93(1): 98–105.7. Kain ZN, Caldwell-Andrews AA. Psychological preparation of children undergoing surgery. Anesth Clinic NA 2005;23:597–614.8. Wolf AR, Rosenbarum A, Kain ZN, Larsson P, Lönnqvist PA. The place of premedication in pediatric practice. Paediatr Anaesth 2009;19(9):817-28.9. Yuen VM, Hui TW, Irwin MG, Yuen MK. A Comparison of Intranasal Dexmedetomidine and Oral Midazolam for Premedication in Pediatric Anesthesia: A Double-Blinded Randomized Controlled Trial. Anesth Analg 2008;106(6):1715–21.10. Funk W, Jakob W, Riedl T, Taeger K. Oral preanaestheticmedication for children: double blind randomized study of a combination of midazplam and ketamine vs midazolam or ketamine alone. Br JAnaesth 2000;84(3):355-4011. Mazurek MS. Sedation and Analgesia for Procedures outside the Operating Room. Semin in Pediatr Surg 2004;13(3):166-173.12. Jo SH, Hong HK, Chong SH, Lee HS, Choe H. H1 antihistamine drug promethazine directly blocks hERG K+ channel. Pharmacol Res 2009;60(5):429-37.13. Gutstein HB, Johnson KL, Heard MB, Gregory GA. Oral Ketamine Preanesthetic Medication in children, Anesthesiology 1992;76(1):28-33.14. Almenrader N, Passariello M, Coccetti B, Haiber R, Pietropaoli P. Premedication in children: a comparison of oral midazolam and oral clonidine. Pediatr Anesth 2007;17(12):1143–9.15. Singh N, Pandey RK, Saksena AK, Jaiswal JN. A comparative evaluation of oral midazolam with oral sedatives as  premedication in pediatric dentistry. J Clin Pediatr Dent 2002;26(2):161-4.16. Naziri F, Alijanpour E, Rabei SM, Seifi S, Mir M, Hosseinpour M, et al. Comparison of oral Midazolam with oral Promethazine on decreasing anxiety of children when separated from their parents before anesthesia. J Babol Univ Medl Sci  2007;9(4):29-32.17. Parkinson L, Hughes J, Gill A, Billingham I, Ratcliffe J, Choonara I. A randomized controlled trial of sedation in the critically ill. Paediatr Anaesth 1997;7(5): 405-10. 18. Crean P. Sedation and neuromuscular blockade in paediatric intensive care;practice in the United Kingdom and North America. Paediatr Anaesth 2004;14(6):439-42.19. Schmidt AP, Valinetti EA, Bandeira D, Bertacchi MF, Simões CM, Auler JO Jr. Effects of preanesthetic administration of midazolam, clonidine, or dexmedetomidine on postoperative pain and anxiety in children. Paediatr Anaesth 2007;17(7):667-74.20. Pfeil N, Uhlig U, Kostev K, Carius R, Schröder H, Kiess W, et al. Antiemetic edications in children with presumed infectious gastroenteritis--harmacoepidemiology in Europe and Northern America. J Pediatr 2008;153(5):659-62

Evaluation of Morning Report Sessions in Emergency Departments of Teaching Hospitals Affiliated With Shahid Beheshti University of Medical Sciences

مقدمه: معاونت آموزشی و امور دانشجویی وزارت بهداشت و درمان و آموزش پزشکی کشور پروژه ملی تحت عنوان "پروژه تعیین معیارها و شاخص های آموزش بالینی در مراکز و بیمارستانهای آموزشی" با هدف ارائه مجموعه استانداردهای آموزش بالینی طراحی و اجرا نمود که حاصل آن استخراج و معرفی استانداردهای آموزش بالینی پزشکی در مورد کلینیک سرپایی، راندهای آموزشی، گراند راند، گزارش صبحگاهی و ژورنال کلاب بود که پائیز سال 1388 ابلاغ گردید. در این مجموعه 96 استاندارد با قید "باید" و 139 استاندارد با قید "بهتر است" به عنوان استانداردهای مناسب کشور ایران پیشنهاد شده است. مطالعه حاضر با هدف ارزشیابی جلسات گزارش صبحگاهی گروه طب اورژانس بیمارستانهای آموزشی تحت پوشش دانشگاه علوم پزشکی شهید بهشتی بر اساس استانداردهای اعلام شده از سوی معاونت آموزشی وزارت بهداشت درمان و آموزش پزشکی انجام گرفت. روش کار: مطالعه مقطعی حاضر جهت ارزشیابی استانداردهای آموزش بالینی در حیطه گزارش صبحگاهی با استفاده از 3 فهرست وارسی و یک لیست مستندات جمع آوری اطلاعات صورت گرفت که در مجموع 54 استاندارد گزارش صبحگاهی را پوشش می داد. فهرست وارسی اول بصورت حضوری و با مشاهده مستقیم در گزارش صبحگاهی تکمیل شد و شامل 37 سوال بود. فهرست وارسی دوم که شامل 26 سوال بود، ضمن مصاحبه با معاون آموزشی یا رئیس بخش های اورژانس تکمیل شد. فهرست وارسی سوم شامل 10 سوال بود که با پرسش از دستیار ارشد بخش تکمیل گردید. سپس نمره نهایی مطلق و درصد آن در استانداردهای اجباری و ترجیحی تعیین و رتبه بندی شد. برای آنالیز داده ها از نرم افزار 21  SPSS و سطح معنی داری 05/0 استفاده شد. يافته ها: یافته های حاصل از 50 مورد گزارش صبحگاهی در در بخش اورژانس بیمارستان امام حسین و 94 مورد گزارش صبحگاهی در بخش اورژانس بیمارستان شهدا تجریش مورد تجزیه و تحلیل قرار گرفت. در بخش اورژانس بیمارستان امام حسین میانگین امتیاز در استانداردهای اجباری 5/89 درصد و استانداردهای ترجیحی 7/45 درصد بود. در بخش اورژانس بیمارستان شهدا تجریش میانگین امتیاز در استانداردهای اجباری 6/73 درصد و استانداردهای ترجیحی 60 درصد بود. میانگین امتیاز کسب شده در استانداردهای اجباری در بخش اورژانس بیمارستان امام حسین بطور معنی داری بیشتر از اورژانس شهدا تجریش بود (025/0=p). وضعیت اجرای استانداردهای ترجیحی اگرچه در بیمارستان شهدا تجریش بهتر از بیمارستان امام حسین بود، ولی این اختلاف از نظر آماری معنی دار نبود (1/0=p). در مجموع میانگین کل امتیاز کسب شده در مورد تمام استانداردهای گزارش صبحگاهی در بخش اورژانس بیمارستان شهدا تجریش 8/66 درصد و بخش اورژانس بیمارستان امام حسین 6/67 درصد بود که اختلاف معنی دار نداشتند (92/0=p). نتيجه گيری: بر اساس یافته های مطالعه حاضر میانگین کل امتیاز کسب شده در مورد تمام استانداردهای گزارش صبحگاهی در بخش اورژانس بیمارستان های شهدا تجریش و امام حسین در سطح متوسطی قرار داشتند. میانگین امتیاز کسب شده در استانداردهای اجباری در بخش اورژانس بیمارستان امام حسین بطور معنی داری بیشتر از اورژانس شهدا تجریش بود. وضعیت اجرای استانداردهای ترجیحی اگرچه در بیمارستان شهدا تجریش بهتر از بیمارستان امام حسین بود، ولی اختلاف از نظر آماری معنی دار نبود.Introduction: The present cross-sectional study was done to evaluate the standards of clinical training regarding morning report and data gathering was done using 3 assessment lists and a list of evidence, which covered 54 standards of morning report in total. The first assessment list, which included 37 questions, was filled in person by direct observation during morning report. The second assessment list included 26 questions and was filled by interviewing either education chief executive or department head of the emergency department (ED). The third assessment list consisted of 10 questions and was filled by questioning the chief resident of the department. Then the final absolute score and its percentage were determined and ranked based on obligatory and preferred standards. SPSS version 21 was used for data analysis and 0.05 was considered as significance level. Methods: The present cross-sectional study was done to evaluate the standards of clinical training regarding morning report and data gathering was done using 3 assessment lists and a list of evidence, which covered 54 standards of morning report in total. The first assessment list, which included 37 questions, was filled in person by direct observation during morning report. The second assessment list included 26 questions and was filled by interviewing either education chief executive or department head of the emergency department (ED). The third assessment list consisted of 10 questions and was filled by questioning the chief resident of the department. Then the final absolute score and its percentage were determined and ranked based on obligatory and preferred standards. SPSS version 21 was used for data analysis and 0.05 was considered as significance level. Results: Findings resulting from 50 morning reports in ED of Imam Hossein Hospital and 94 morning reports in ED of Shohadaye Tajrish Hospital were analyzed. In ED of Imam Hossein Hospital, mean score was 89.5% regarding obligatory standards and 45.7% in preferred standards. In ED of Shohadaye Tajrish Hospital, mean score was 73.6% for obligatory standards and 60% for preferred standards. Mean score of Imam Hossein Hospital was significantly higher than Shohadaye Tajrish Hospital regarding obligatory standards (p = 0.025). Although preferred standards were carried out better in Shohadaye Tajrish Hospital, compared to Imam Hossein Hospital, this difference was not statistically significant (p = 0.1). In total, mean score of the hospitals considering all standards of morning report, was 66.8% in Shohadaye Tajrish Hospital and 67.6% in Imam Hossein Hospital, which were not significantly different (p = 0.92). Conclusion: Based on the findings of the present study, mean total score of all the standards regarding morning report in EDs of Shohadaye Tajrish and Imam Hossein Hospitals was average. Mean score of obligatory standards was significantly higher in ED of Imam Hossein Hospital, compared to ED of Shohadaye Tajrish Hospital. Although the score regarding preferred standards was higher in Shohadaye Tajrish Hospital, compared to Imam Hossein Hospital, this difference was not statistically significant.

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.

The Effect of Emergency Department Overcrowding on Efficiency of Emergency Medicine Residents’ Education

Introduction: Creating a calm and stress-free environment affects education significantly. The effects of the emergency department overcrowding (EDO) on the training of emergency medicine residents (EMR) is a highly debated subject. Therefore, this study aimed to evaluate the effect of EDO on efficiency of EMR’s education. Methods: In this cross-sectional study, the effects of overcrowding on EMR’s education in the resuscitation room and acute care unit. Data collection was done using a questionnaire, which was filled out by the second year EMRs.  The crowding level was calculated based on the national emergency department overcrowding scale (NEDOCS). The relationship between the two studied variables was evaluated using independent sample t-test and SPSS 21 statistical software. Results: 130 questionnaires were filled out during 61 shifts. 47 (77.05%) shifts were overcrowded. The attend’s ability to teach was not affected by overcrowding in the resuscitation room (p=0.008). The similar results were seen regarding the attend’s training ability in the acute care unit. Conclusion: It seems that the emergency department overcrowding has no effect on the quality of education to the EMRs

Prevalence of Stroke in neonates who admitted with seizures in neonatal intensive care unit

How to Cite This Article: Farhadi R, Alaee AR, Alipour Z, Abbaskhanian A, Nakhshab M, Derakhshanfar H. Prevalence of Stroke in NeonatesWho Admitted With Seizures in Neonatal Intensive Care Unit. Iran J Child Neurol. Autumn 2015;9(4):41-47.AbstractObjectivePrevalence of neonatal stroke has been reported 1/2300-1/4000 live births and accounts for 12-20% of the cases of neonatal seizures. Although stroke has been introduced as the second cause of the neonatal seizures in literatures, it may remain unclear in diagnostic evaluations of seizure in neonates. This study was performed to assess the prevalence of stroke in neonates with seizure.Materials & MethodsIn this cross-sectional study, all neonates ≥ 28 weeks of gestation with a diagnosis of seizures admitted to the NICU of Boo-Ali Sina Hospital in Sari, north of Iran, were enrolled. Brain CT scan and a Transcranial Doppler ultrasonography were performed for the all cases. In cases that stroke were reported in one or two above modalities, an MRI was also performed and prevalence of stroke was reported. Putative risk factors of stroke were analyzed with univariate and multivariate statistical methods.ResultsFrom 174 newborn infants, 75.3% of neonates were male. Prevalence of stroke was 8%, 2.3% and 3.4% in Doppler ultrasonography, CT scan and MRI reports respectively. Umbilical venous catheterization was the risk factor of stroke in the univariate and multivariate analysis (P= 0.001; OR, 10.39; 95% CI, 2.72-39.77). The most common form of seizure was focal clonic seizures (78.6%) in neonates with stroke.ConclusionInvestigation of stroke as an etiology of neonatal seizures is essential because seizure may be the only symptom of neonatal cerebral infarction. Doppler ultrasonography can be a valuable diagnostic tool at first in critically ill neonates or in situations that MRI is not available primarily. Further studies with notice to outcome assessment of these infants recommended.

Measuring Serum Level of Ionized Magnesium in Patients with Migraine

How to Cite This Article: Assarzadegan F, Asadollahi M, Derakhshanfar H, Kashefizadeh A, Aryani O, Khorshidi M. Measuring Serum Level of Ionized Magnesium in Patients with Migraine. Iran J Child Neurol. Summer 2015;9(3):13-16.AbstractObjectiveMigraine is known as one of the most disabling types of headache. Among the variety of theories to explain mechanism of migraine, role of serum magnesium is of great importance. Serum magnesium, as a pathogenesis factor, was considerably lower in patients with migraine. We established this study to see if serum ionized magnesium, not its total serum level, was different in migraineurs from normal individuals.Materials & MethodsIn this case control study, all participants were recruited from Neurology Clinic of Imam Hossein Hospital, Tehran, Iran. Ninety-six people were entered in the study, 48 for each of case and control groups. The two groups were matched by age and sex. Migrainous patients were selected according to the criteria of International Headache Society. Various characteristics of headache were recorded based on patients’ report. Controls had no history of migraine or any significant chronic headaches. Serum ionized magnesium level was measured in both of the case and control groups and the results were compared to each other. P value of <0.05 was considered as significant.ResultsCase group consisted of 13 males, 35 females, and control group included 14 males, as well as 34 females. Mean age was 33.47± 10.32 yr for case and 30.45 ±7.12 yr for control group. Twenty-eight patients described the intensity of their headaches as moderate; 15 patients had severe and the 5 remainders had only mild headaches. Mean serum level of ionized Mg was 1.16± 0.08 in case group and 1.13± 0.11 in control group of no significant difference (P >0.05).ConclusionSerum ionized magnesium, which is the active form of this ion, was not significantly different in migraineurs and those without migraine. This may propose a revision regarding pathogenesis of migraine and question the role of magnesium in this type of headache

Effect of Positive End-Expiratory Pressure on Central Venous Pressure in Patients under Mechanical Ventilation

Introduction: Finding the probable governing pattern of PEEP and CVP changes is an area of interest for in-charge physicians and researchers. Therefore, the present study was designed with the aim of evaluating the relationship between the mentioned pressures. Methods: In this quasi-experimental study, patients under mechanical ventilation were evaluated with the aim of assessing the effect of PEEP change on CVP. Non-trauma patients, over 18 years of age, who were under mechanical ventilation and had stable hemodynamics, with inserted CV line were entered. After gathering demographic data, patients underwent 0, 5, and 10 cmH2O PEEPs and the respective CVPs of the mentioned points were recorded. The relationship of CVP and PEEP in different cut points were measured using SPSS 21.0 statistical software. Results: 60 patients with the mean age of 73.95 ± 11.58 years were evaluated (68.3% male). The most frequent cause of ICU admission was sepsis with 45.0%. 5 cmH2O increase in PEEP led to 2.47 ± 1.53 mean difference in CVP level. If the PEEP baseline is 0 at the time of 5 cmH2O increase, it leads to a higher raise in CVP compared to when the baseline is 5 cmH2O (2.47 ± 1.53 vs. 1.57 ± 1.07; p = 0.039). The relationship between CVP and 5 cmH2O (p = 0.279), and 10 cmH2O (p = 0.292) PEEP changes were not dependent on the baseline level of CVP. Conclusion: The findings of this study revealed the direct relationship between PEEP and CVP. Approximately, a 5 cmH2O increase in PEEP will be associated with about 2.5 cmH2O raise in CVP. When applying a 5 cmH2O PEEP increase, if the baseline PEEP is 0, it leads to a significantly higher raise in CVP compared to when it is 5 cmH2O (2.5 vs. 1.6). It seems that sex, history of cardiac failure, baseline CVP level, and hypertension do not have a significant effect in this regard

Rehydration: Comparison of Isotonic and Hypotonic Saline with Dextrose in Children

Introduction: Early rehydration with bolus fluid can be life saving. We compared isotonic saline with a hypotonic fluid which was composed of saline 0.9%, dextrose, and bicarbonate in our clinical setting.Materials and Methods: 71 children entered to this study , 41 cases received isotonic saline and the remaining 30 cases received hypotonic fluid which was composed of 750 cc saline 0.9%, 28 cc bicarbonate 7.5%, and 222cc dextrose 5% for resuscitation fluid challenge at a dose of 20ml/kg over 20 minutes that could be repeated up to 3 times as needed. Serum sodium (Na), potassium (K), blood sugar (BS) and bicarbonate (HCo3) were measured before initiating rehydration and after 3 hours. T independent test was used to compare the values between the two groups and T paired test in each group in SPSS 16. The level of significance was set at 0.05.Results: Serum Na, K, BS, and HCo3 were 134±5, 3.8 ±0.6, 90±16, and 11.6±3.6 before and 135±4, 3.7±0.5, 73±13, and 15±3 three hours after rehydration in the isotonic group, respectively.In the isotonic rehydrated group, BS drop and HCo3 rise significantly (p<0.001). Serum Na, K, BS, and HCo3 were 134±6, 3.6±0.6, 91±15, and 10.1±1.9 before and 136±3, 3.6±0.4, 94±10, and 15±2 three hours after rehydration in the hypotonic saline group, respectively. Serum sodium increased 2meq/dl (p<0.04) and bicarbonate increased 4.9 meq/l (P< 0.001).Conclusions: The hypotonic serum containing 115meq/l of sodium chloride combined with 25meq/l of sodium bicarbonate and dextrose 1.1% is not associated with a decrease in BS or hyponatremia. It also increases serum HCo3 prominently.Keywords: Hypotonic Solutions; Isotonic Solutions; Dehydration; Child