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This study aimed to compare the diagnostic accuracy of heart, lung and inferior vena cava (IVC) ultrasonography modalities, alone and combined, for possible added accuracy in diagnosing acute decompensated heart failure (ADHF), in a group of patients with the final diagnosis of ADHF based on plasma level of B-type natriuretic peptide (BNP) as the standard. The present study is a diagnostic accuracy study, which was carried out in the emergency department of Imam Khomeini hospital, affiliated to Tehran University of Medical Sciences, in 2014–2015. All patients over 18 years old, who were referred to emergency department with complaint of acute dyspnea were regarded as eligible and no exclusion criteria were considered. All ultrasounds were performed by a trained emergency medicine resident and then saved and classified for each patient, separately, and reviewed by the attending emergency medicine physician. In this study, patients with BNP levels higher than 500 pg/ml were considered positive for dyspnea caused by heart failure. A total of 120 patients with an average age of 60.83 ± 16.528 years were studied, 64 (53%) of which were male. In total, 47.5% of patients had a BNP level over 500 pg/ml. Among patients with positive ultrasound, 94.7% were true positive and among those with a negative ultrasound, 61.4% were true negative. Based on the findings, B-line ≥ 10 has the highest specificity and left ventricular ejection fraction (LVEF)

In this study, the impact of contrast-enhanced abdominopelvic CT scan interpretations by emergency medicine team on patients’ morbidity and mortality was evaluated and their interpretations were compared to radiologists’ reports. During a 3-month period, all patients who had undergone a contrast-enhanced abdominopelvic CT scan at the emergency department enrolled in this study. All CT scans were interpreted blindly by the emergency medicine (ED) attending physicians and the patients were treated accordingly. Radiologists reported all the CT scans within 12 h. Radiologists’ reports were put into the agreement or disagreement group retrospectively. A panel of experts further evaluated the disagreement groups’ medical charts and placed them in clinically significant or insignificant group based on the follow-up for 28 days. In this study, 170 CT scans were interpreted. The agreement rate was 68.2%. In the clinically significant disagreement group, eight patients did not receive the required treatment and three patients were over treated. Although the overall mortality rate was 5, none could have been prevented by a prompt radiologist’s report. The disagreement group had longer hospital stay (p = 0.006) and transfer to other wards (p = 0.035). The inter-rater reliability between emergency medicine attending physicians and attending radiologists was substantial (kappa = 0.77) and statistically significant (p

Clinical assessment and classification of shock is extremely difficult to conduct on critically ill patients especially upon arrival at the emergency department. Resuscitative point-of-care ultrasound could be used for rapid initial diagnosis and better management. In this study, the results of using the RUSH (Rapid Ultrasound in Shock) exam to determine the type of shock in the emergency department are compared to the final diagnosis of patients. This was a single-center prospective study in which all patients with an unknown type of shock and no prior treatment were included. Parallel to the standard resuscitative management and diagnosis of the emergency team, the RUSH exam was performed blindly on the patient by an emergency medicine staff who was not part of the patient's caregiving team. The results of the RUSH exam were then compared to the final diagnosis of the patients and the 48-h outcome. Twenty-five patients were enrolled in this study. The overall kappa correlation of the RUSH exam compared with the final diagnosis was 0.84 which is an almost perfect agreement. The overall sensitivity of the RUSH exam was 88 % and the specificity was 96 %. Although the mortality rate was 64 %, there was not a significant relationship between mortality and the protocol used for diagnosis. The RUSH exam could be used in emergency wards to detect types of shock.

Introduction This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management. Methods This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18-year-old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1 mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant. Results Fifty patients with the mean age of 31.28 ± 8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on-arrival mean pain scores in two groups were, lidocaine: 7.9 ± 1.4 and morphine: 8.0 ± 1.4 (p = 0.57) and after 1 hour were, lidocaine: 2.28 ± 1.2 and morphine: 3.2 ± 1.7. Although the pain score decreased significantly in both group (p = 0.027), there were not any clinically and statistically significant difference between the two groups (p = 0.77). Patients' satisfaction with pain management in both groups were almost similar (p = 0.49). Conclusion The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain.

Requesting non-enhanced brain CT scans for trauma and non-trauma patients in ER is very common. In this study, the impact of incorrect brain CT scan interpretations by emergency medicine team on patients’ primary and secondary outcome was evaluated in the setting where neuroradiologist reports are not always available. During a 3-month period, 450 patients were enrolled and followed for 28 days. All CT scans were interpreted by the emergency medicine team, and the patients were managed accordingly. Neuroradiologists’ reports were considered as gold standard, and the patients were then grouped into the agreement or disagreement group. A panel of experts further evaluated the disagreement group and placed them in clinically significant and insignificant. The agreement rate between emergency medicine team and neuroradiologists was 86.4 %. The inter-rater reliability between emergency team and neuroradiologists was substantial (kappa = 0.68) and statistically significant (p < 0.0001). Only five patients did not receive the necessary management, and among them, only one patient died, and 12 patients received unnecessary management including repeated CT scan, brain MRI, and lumbar puncture. Forty-one patients were managed clinically appropriate in spite of misinterpretation. A 28-day follow-up showed a mortality rate of 0.2 %; however, expert panel believed the death of this patient was not related to the CT scan misinterpretation. We conclude that although the disagreement rate in this study was 13.6 %, primary and secondary outcomes were not clinically jeopardized according to the expert panel idea and 28-day follow-up results.

Objective Intravenous morphine has been used as a common method of pain control in emergency care. Nebulized fentanyl is also an effective temporary substitute. This study was designed to compare the effectiveness of nebulized fentanyl with intravenous (IV) morphine on management of acute limb pain. Methods This was a placebo-controlled, double-blind randomized clinical trial. Ninety emergency department patients with moderate to severe pain aged 15 to 50 years were blocked randomized and enrolled in this study. Forty-seven patients in the experimental group received nebulized fentanyl (4 μ g/kg) and IV normal saline as placebo, and the remaining 43 patients in the control group received IV morphine (0.1 mg/kg) and nebulized normal saline as placebo. All participants' pain scores were assessed by Numerical Rating Scale before and after intervention at 5-, 10-, 15-, 30-, 45-, and 60-minute intervals. Patients' vital sign and possible adverse effects were recorded respectively. Finally, all participants were assessed for their satisfaction. Results The mean initial pain score in the experimental group was 8.7 and 8.4 in the control group ( P = .1). Pain relief in both groups after 5 and 10 minutes were similar ( P = .72). Although the pain relief was significantly greater with fentanyl at 15 minutes, this difference is not clinically significant. Pain management in both groups was successful and was more than 3 scores reduction in Numerical Rating Scale. Patient satisfaction in both groups was similar. No adverse effects were reported in the experimental group. Conclusion This study suggests that nebulized fentanyl is a rapid, safe, and effective method for temporary control of acute limb pain in emergency department patients.

Background Deep vein thrombosis (DVT) is prevalent in the emergency departments. Nearly 60% of them may lead to pulmonary embolism. A complete color-flow duplex ultrasound (CFDU), performed by the radiologists, is the most common diagnostic method used to detect DVT. A limited B-mode compression technique (BMCT) can also be useful for the emergency specialists visiting suspicious cases. Objectives The purpose of this study was to compare the sensitivity, specificity, and accuracy of a BMCT done by emergency medicine residents with that of a CFDU in diagnosing the proximal DVT of lower extremities. Methods This prospective study was conducted on 74 patients (41 men and 33 women) presenting with painful and swollen lower limbs in the emergency department of Imam Khomeini Hospital. First, the affected lower extremity was examined by a BMCT carried out by one of the 2 emergency medicine residents. Then, the CFDU was performed by a radiologist blinded to the results of the BMCT. The sensitivity, specificity, and accuracy of the BMCT were compared with that of the CFDU as a gold standard. Results The mean age of the patients was 55.16 ± 17.4 years. Positive results were reported in 35 patients (47.3%) using the 2 tests. Compared with CFDU, BMCT had a sensitivity, specificity, accuracy, positive predictive values, and negative predictive values of 100%. Conclusion These findings suggest that BMCT performed by the emergency medicine specialists to diagnose proximal DVT of lower extremities is not only an acceptable method but also less time-consuming when compared with CFDU.

The aim of this study was to compare pain levels from arterial blood gas (ABG) sampling performed with or without application of lidocaine via jet injector.Pain is still a primary concern in the emergency department. Arterial blood gas sampling is a very painful procedure. No better technique for decreasing the pain of the ABG procedure has been presented. An ideal local anesthesia procedure for ABG sampling should be rapid, easily learned, inexpensive, and free of needlestick risk.We evaluated the effectiveness of a lidocaine jet injection technique in achieving satisfactory pain control in patients undergoing ABG sampling. Forty-two patients were randomized to 2 groups: group A, which received lidocaine by jet injection (0.2 mL of lidocaine 2%), and group B, a control group that received a topical application of 1 mL of lidocaine gel 2% 2 minutes before the ABG sampling. Pain was assessed on a 10-cm visual analog scale (0, absence of pain; 10, greatest imaginable pain).The pain visual analog scale score during ABG sampling was considerably lower in group A compared with group B (1.29 ± 0.90 vs 4.19 ± 1.43; P.001). The number of attempts required for ABG sampling was significantly lower in group A compared with group B (1.29 ± 0.46 vs 2.1 ± 0.12; P = .009). All residents reported ease of use with the lidocaine jet injection procedure (P.05).Lidocaine jet injection provides beneficial and rapid anesthesia, resulting in less pain and a greater rate of successful ABG sampling. Therefore, it is recommended for use before ABG sampling to decrease the patient's pain and the number of unsuccessful attempts and to enhance the patient's satisfaction.

Objective The present study aims to assess the influence of ultra-low doses of opioid antagonists on the analgesic properties of opioids and their side effects. Methods In the present randomized, double-blind controlled trial, the influence of the combination of ultra-low-dose naltrexone and morphine on the total opioid requirement and the frequency of the subsequent side effects was compared with that of morphine alone (added with placebo) in patients with trauma in the upper or lower extremities. Results Although the morphine and naltrexone group required 0.04 mg more opioids during the study period, there was no significant difference between the opioid requirements of the 2 groups. Nausea was less frequently reported in patients receiving morphine and naltrexone. Conclusion The combination of ultra-low-dose naltrexone and morphine in extremity trauma does not affect the opioid requirements; it, however, lowers the risk of nausea.

Background The efficacy and safety of enoxaparin in outpatient treatment of deep vein thrombosis have been well studied. The present study aimed to compare the efficacy of a 10-mg loading dose of warfarin with 5 mg of the drug and enoxaparin in achieving the international normalized ratio (INR) range. Methods This randomized clinical trial was performed in the emergency department (ED) of our study. International normalized ratio was checked daily for 7 days and on the 14th day. Based on the patient's INR on the third day, the doses were adjusted. Patients received enoxaparin (1.5 mg/kg per day) simultaneously until the therapeutic range of INR was achieved for 2 consecutive days. Result The side effects were compatible in both groups. There was a significant difference in the INR rates of the 2 groups recorded on the third, fourth, and seventh days. Conclusion The 10-mg loading dose of warfarin induces the therapeutic range of INR earlier than the 5-mg dose without causing any significant difference in the side effects. More cases in the 10-mg group had INR levels higher than 3; the very dose, therefore, is recommended as the loading dose in cases of outpatients with deep vein thrombosis referring to the ED. Tight control of INR, after the third day of treatment, is also recommended in these cases.