Publications by authors named "Farhad Heydari"

19 Publications

  • Page 1 of 1

Topical ketamine as a local anesthetic agent in reducing venipuncture pain: A randomized controlled trial.

Am J Emerg Med 2021 Apr 3;48:48-53. Epub 2021 Apr 3.

Department of General Surgery, Ealing Hospital, London North West University Healthcare NHS Trust, London, Uxbridge Road, Southall UB1 3HW, UK.

Aim: Pain control is an important aspect of ED patient management, and there are many different protocols used around the world influenced by both availability of local resources as well as staff competency and experience. This study aims to evaluate the use of topical ketamine in acute pain reduction by directly comparing it to lidocaine-prilocaine (EMLA) cream.

Materials And Methods: In this randomized clinical trial, 300 adult patients classified as level 4 or 5 by ESI triage system were enrolled. These patients were divided randomly into three groups. The site of venipuncture was covered with 2 g of topical ketamine cream 10% in group one, 2 g of 5% EMLA cream in group two, and finally, in group 3 (control group), was covered with placebo (2 g of cold cream). The primary end point of the study was reported pain severity with secondary end points being onset of local anesthesia as well as any side effects noted.

Results: The data gathered showed pain score during venipuncture in both intervention groups were significantly lower when compared to the control group (P < 0.05). However, pain score did not differ between the 2 intervention groups (P = 0.395). There was no statistically significant difference between the ketamine or EMLA in onset of local anesthesia (P = 0.419). We noted itching and irritation was significantly higher in the EMLA group when compared to ketamine(P < 0.05).

Conclusion: This study showed that local cutaneous ketamine is as effective as EMLA in relieving pain during venipuncture.
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http://dx.doi.org/10.1016/j.ajem.2021.03.055DOI Listing
April 2021

Diagnostic accuracy of ultrasonography for diagnosis of elbow fractures in children.

Eur J Trauma Emerg Surg 2021 Mar 24. Epub 2021 Mar 24.

Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Background: Elbow injuries and fractures are a common pathology in the pediatric emergency unit. X-ray and CT scan of the elbow are the standard diagnostic procedures, which increase exposure to radiation in children. Previous studies have shown that fractures can also be visualized by ultrasound (US); thus, this study aimed to evaluate the diagnostic accuracy of elbow US compared with radiography for the diagnosis of elbow fracture in children.

Materials And Methods: This was a prospective observational study of patients aged 2-14 years that presented to emergency departments with a suspected elbow fracture requiring radiographic evaluation. Elbow US for diagnosing elevated posterior fat pad or lipohemarthrosis was performed. All patients underwent elbow radiography and received clinical follow-up. Initial or follow-up X-ray or CT scan was used as the reference standard for fracture diagnosis.

Results: Seventy-five patients with a mean age of 6.51 ± 3.68 years were enrolled in the study. Twenty-eight (37.3%) patients had positive results for fracture. The sensitivity, specificity, and accuracy of US in the diagnosis of elbow fractures were 92.9% (95% CI 76.5-99.1%), 89.4% (95% CI 76.9-96.5%) and 90.7% (95% CI 81.7-96.2%). In patients with fracture, US demonstrated a lipohaemarthrosis in 20 patients (71.4%), elevated posterior fat pad in 19 patients (67.9%), cortical disruption in 10 patients (35.7%), and effusion in three patients (10.7%).

Conclusion: Our results showed high diagnostic accuracy for the ultrasonography diagnosis of an elbow fracture, which allows us to confirm ultrasonography imaging of the elbow as a safe alternative in the primary evaluation of pediatric elbow injuries.
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http://dx.doi.org/10.1007/s00068-021-01648-6DOI Listing
March 2021

Comparing Sedative Effect of Dexmedetomidine versus Midazolam for Sedation of Children While Undergoing Computerized Tomography Imaging.

J Pediatr Neurosci 2020 Jul-Sep;15(3):245-251. Epub 2020 Nov 6.

Neuroscience Research Center, Department of Epidemiology and Biostatistics, Qom University of Medical Sciences, Qom, Iran.

Background: Pediatric anxiety and restlessness may create issues and difficulties in performing accurate diagnostic studies even noninvasive ones, such as radiological imaging. There are some agents that will help to get this goal. This study aimed to compare the intranasal effect of dexmedetomidine (DEX) and midazolam (MID) for sedation parameters of children undergoing computerized tomography (CT) imaging.

Materials And Methods: A double-blind clinical trial was conducted on 162 eligible children who underwent CT imaging. These patients were divided into two groups including MID ( = 81) with dose of 0.3 mg.kg and DEX ( = 81) with dose of 3 μg.kg, which was consumed intranasally. The mean blood pressure (MBP), respiratory rate (RR), heart rate (HR), and oxygen saturation (O2Sat) in children were recorded. Then, time of initiation, level of sedation, and duration effect of medication were measured at 0, 10, 20, and 30 min. Parents and clinician satisfaction score was asked. All data were analyzed using the Statistical Package for the Social Sciences (SPSS) software by test and chi-square test.

Results: Decreasing in MBP and HR was higher in DEX group than MID group ( < 0.001), whereas decrease of O2Sat in MID group was higher than DEX group (0.009). Starting time of sedation (22.72 ± 11.64 vs. 33.38 ± 10.17, = 0.001) was lower in DEX group. Parents ( < 0.001) and physician ( < 0.001) satisfaction score was higher in DEX group than the MID group.

Conclusion: Using 3 μg/kg intranasal DEX for sedation of 1-6-year-old children was a suitable method to undergo noninvasive studies such as CT imaging. Intranasal DEX is superior to MID due to higher sedation satisfactory, faster starting effect of sedation, and lower side effects and complications. Nevertheless, in children with hemodynamic instability DEX is not an appropriate choice.
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http://dx.doi.org/10.4103/jpn.JPN_107_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847110PMC
November 2020

Traumatic Brain Injury in Older Adults Presenting to the Emergency Department: Epidemiology, Outcomes and Risk Factors Predicting the Prognosis.

Adv J Emerg Med 2020 15;4(2):e19. Epub 2019 Aug 15.

Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: The continuing-to-grow number of older adults with traumatic brain injury (TBI) presenting to emergency departments (EDs) and hospitals necessitates the investigation of TBI in these patients.

Objective: The present study was conducted to investigate the epidemiology of TBI and the factors affecting intracranial lesions and patient outcomes in older adults.

Method: The present retrospective cross-sectional study was performed between March 2016 and March 2018. The study population comprised all TBI patients with a minimum age of 60 years presenting to the ED. The eligible candidates consisted of patients presenting to the ED within 24 hours of the occurrence of traumas and requiring head CT scan as part of their examination. The patients' baseline information was also recorded.

Results: A total of 306 older adult patients with a mean age of 70.61±8.63 years, of whom 67.6% were male, underwent CT scan for TBI during the study period. Falls were the major cause of head injuries, and intracranial lesions were observed in 22.9% (n=70) of the patients. Subdural hematoma (SDH) was observed as the most prevalent injury in 27.6% of the patients, 22.9% (n=16) were transferred to the operating room, and 7.5% (n=23) died. Moreover, the severity of trauma was significantly different between the two genders (P=0.029). Midline shift, SDH, subarachnoid hemorrhage (SAH) and moderate-to-severe head injuries were also significantly associated with poor outcomes (P<0.05).

Conclusion: Death from TBIs was more likely in the patients with SDH, SAH and midline shift or in those with an initial Glasgow coma scale (GCS) of below 13. These predictions are clinically relevant, and can help improve the management of older adults with TBI.
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http://dx.doi.org/10.22114/ajem.v0i0.170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163265PMC
August 2019

Prospective Evaluation of Safe Observation Period after Asymptomatic Penetrating Thoracic Injury: 1 Hour is Enough.

Adv J Emerg Med 2019 22;3(4):e39. Epub 2019 Jun 22.

Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: The observation period was recently challenged by some studies; and it has been suggested that a 1-hour observation period may be sufficient to allow safe discharge in asymptomatic patients with penetrating thoracic injury (PTI) and normal initial Chest X-Ray (CXR).

Objective: The current study was performed to investigate if in asymptomatic and hemodynamically stable patients with PTIs who has an initial normal evaluation, 1-hour observation interval is safe to detect clinically significant injuries and is it possible to discharge these patients safely after a negative Extended - Focused Assessment with Sonography in Trauma (E-FAST) at hour1 instead of hour 3.

Method: This cross-sectional study was performed on asymptomatic patients with penetrating thoracic injury, referred to emergency department (ED) and normal initial CXR and the Extended Focused Assessment with Sonography in Trauma (E-FAST). The second E-FAST was done 1 hour after the first one and the third repeat E-FAST and control CXR then performed 3 hours post-injury. 24 hours follow up by phone call was done for each patient after discharge.

Results: Finally, 117 patients with the average ages of 25.9 ± 7.8 years were enrolled of whom 92.5% were male. Eight patients developed PTX or HTX during first hour of observation that were diagnosed by E-FAST or CT scan requested by the in-charge physician. One hundred-nine patient completed E-FAST and radiograph studies at times zero, 1 h, and 3 h. One patient had a normal initial evaluation but demonstrated a PTX on the 3-h managed without intervention. The rate of delayed abnormality after an initially normal study was 7.7 % (9/117). No discharged patients returned to our ED with delayed manifestations of either PTX or HTX.

Conclusion: The results of our study have shown that asymptomatic patients with PTI with negative initial evaluation and no deterioration at intervals, about 1 hour may be sufficient for detection of clinically significant pathology, considered for safe and early discharge.
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http://dx.doi.org/10.22114/ajem.v0i0.148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6789061PMC
June 2019

Comparison of Analgesic Effects of Nebulized Morphine with Fentanyl Transdermal Patch and Oral Methadone for Cancer Patients in Terminal Stages; a Double-blind Randomized Controlled Study.

Adv J Emerg Med 2019 30;3(3):e23. Epub 2019 Apr 30.

Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: Recent years have witnessed widespread reports on the effectiveness of nebulized morphine for dyspnea, yet there is no evidence for its effectiveness in analgesic therapy.

Objective: This study aims to compare effectiveness and side effects of inhalation morphine with oral methadone and transdermal fentanyl in sequential days in end stage cancer patients.

Method: This double-blind, randomized controlled study conducted between April and September 2017. Ninety eligible cancer patients presenting to Sayed al-Shohada Hospital were selected non-randomly according to inclusion criteria and then divided to 3 groups in random order. Pain severity was scored by Visual Analog Scale (VAS). Patients were followed up for 3 days and then data were analyzed by SPSS. The benchmark of success was set as marking 4 or below on VAS and a reduction ratio of 50 percent.

Results: Pain severity was equal for 3 groups before the first administration (p>0.05), but it decreased significantly from 8.45 (range 6-10) at baseline to 2.46 (range 1-4) at the end of the 3 day in the nebulized group. The decrease ratio was equal to 70.8% after three days (p<0.05). Pain severity reduced from 8.45 (range 7-10) to 1.8 (range 1-3) (p<0.05) in the methadone group, and reduced from 8.5 (range 6-10) to 2.13 (range 1-3) in the fentanyl group.

Conclusion: Our study showed that nebulized morphine, just like oral methadone and transdermal fentanyl, is effective, safe, and well-tolerated for pain management in patients with cancer.
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http://dx.doi.org/10.22114/ajem.v0i0.129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683586PMC
April 2019

Effect of Implementation of Standard Clinical Practice Guideline on Management of Gastrointestinal Bleeding Patients in Emergency Department; a Cross-Sectional Study.

Adv J Emerg Med 2018 1;2(4):e42. Epub 2018 Oct 1.

Emergency Medicine Research Center, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: A clinical practice guideline (CPG) is developed with the aim of improving the quality of health care and reducing unnecessary interventions, hospitalization time, and related costs.

Objective: This study attempted to design a standard protocol for gastrointestinal bleeding (GIB) patients.

Methods: This was a cross-sectional study conducted during 2013 and 2014 in an educational medical center in Isfahan, Iran. A checklist containing questions about waiting time for the services, hospitalization time, and costs was completed for the GIB patients. After this primary data gathering, a CPG was designed, codified, underwent several revisions, and finally implemented. Thereafter, the checklist was completed by GIB patients and compared with the previous ones.

Results: Fifty patients in each of the two phases were included. The mean age and sex of the studied patients were not different.The time from emergency departments (ED) arrival until the first visit (14 ± 9.8 Vs. 19.4 ± 13.4 minutes; p = 0.03), hospitalization (73.7 ± 49.2 Vs. 116.2 ± 7.2 hours; p=0.003) and costs (1.3 ± 0.81 Vs. 3.68 ± 3.51 million rials; p < 0.001) were significantly reduced following the CPG implementation. The time from admission until conducting endoscopy was not different in the two study periods (16.5 ± 7.8 Vs. 23.9 ± 24.5 hours, p = 0.89).

Conclusion:
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http://dx.doi.org/10.22114/AJEM.v0i0.97DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548148PMC
October 2018

Diagnostic Accuracy of Focused Assessment with Sonography for Blunt Abdominal Trauma in Pediatric Patients Performed by Emergency Medicine Residents versus Radiology Residents.

Adv J Emerg Med 2018 8;2(3):e31. Epub 2018 May 8.

Department of Thoracic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: Focused assessment with sonography for trauma (FAST) has been shown to be useful to detect intraperitoneal free fluid in patients with blunt abdominal trauma (BAT).

Objective: We compared the diagnostic accuracy of FAST performed by emergency medicine residents (EMRs) and radiology residents (RRs) in pediatric patients with BAT.

Method: In this prospective study, pediatric patients with BAT and high energy trauma who were referred to the emergency department (ED) at Al-Zahra and Kashani hospitals in Isfahan, Iran, were evaluated using FAST, first by EMRs and subsequently by RRs. The reports provided by the two resident groups were compared with the final outcome based on the results of the abdominal computed tomography (CT), operative exploration, and clinical observation.

Results: A total of 101 patients with a median age of 6.75 ± 3.2 years were enrolled in the study between January 2013 and May 2014. These patients were evaluated using FAST, first by EMRs and subsequently by RRs. A good diagnostic agreement was noted between the results of the FAST scans performed by EMRs and RRs (κ = 0.865, P < 0.001). The sensitivity, specificity, positive and negative predictive values, and accuracy in evaluating the intraperitoneal free fluid were 72.2%, 85.5%, 52%, 93.3%, and 83.2%, respectively, when FAST was performed by EMRs and 72.2%, 86.7%, 54.2%, 93.5%, and 84.2%, respectively, when FAST was performed by RRs. No significant differences were seen between the EMR- and RR-performed FAST.

Conclusion: In this study, FAST performed by EMRs had acceptable diagnostic value, similar to that performed by RRs, in patients with BAT.
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http://dx.doi.org/10.22114/AJEM.v0i0.89DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549207PMC
May 2018

Effect of Intramuscular Ketamine versus Haloperidol on Short-Term Control of Severe Agitated Patients in Emergency Department; A Randomized Clinical Trial.

Bull Emerg Trauma 2018 Oct;6(4):292-299

Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Objective: To evaluate the efficacy and safety of intramuscular ketamine and haloperidol in sedation of severely agitated patients in emergency department (ED).

Methods: This randomized, double-blind clinical trial study was performed on agitated patients referring to two university educational hospitals. Patients were randomly assigned to receive intramuscular (IM) haloperidol (5 mg) or IM ketamine (4 mg/kg). The primary outcome was time to adequate sedation (AMSS ≤ +1). Secondary outcomes included the need for additional sedatives, required intubation, duration of hospitalization, and side effects.

Results: The 90 agitated patients were enrolled. The mean age was 30.37±7.36 years (range 18-56); 74% (67/90) were men. The mean time to adequate sedation in ketamine group (7.73 ± 4.71 minutes) was significantly lower than haloperidol group (11.42 ± 7.20 minutes) (= 0.005). 15 minutes after intervention, the sedation score did not differ significantly in both groups (Ketamine:0.14 ± 0.59 vs. Haloperidol: 0.30 ± 0.60; =0.167). The incidence of complications was not significantly different between groups. The physician's satisfaction from the patients' aggression control was significantly higher in ketamine group.

Conclusion: These data suggest ketamine may be used for short-term control of agitated patients, additional studies are needed to confirm if ketamine is safe in this patient population. Given rapid effective sedation and the higher physician satisfaction of ketamine in comparison to haloperidol, it may be considered as a safe and appropriate alternative to haloperidol.IRCT Code: IRCT20180129038549N5.
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http://dx.doi.org/10.29252/beat-060404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6215072PMC
October 2018

Accuracy of Real-time Intratracheal Bedside Ultrasonography and Waveform Capnography for Confirmation of Intubation in Multiple Trauma Patients.

Adv Biomed Res 2018 25;7:95. Epub 2018 Jun 25.

Department of Emergency Medicine, Emergency Medicine Research Center, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.

Background: A secure airway and effective ventilation are key components of advanced life support, and misplacement of endotracheal tube (ETT) can lead to morbidity in multiple trauma patients. The purpose of this study was to investigate the accuracy of ultrasound in diagnosis of direction for tracheal intubation.

Materials And Methods: This descriptive-analytical study was conducted on 100 traumatic patients requiring intubation in 2016 in the Emergency Department of Al-Zahra and Kashani Medical Education Centers in Isfahan. Surface probe was placed transversally in the front of the neck at the top of the suprasternal notch, and the position of trachea was specified by front of comet-tail artifact which is the contour between hyperechoic air-mucosa (A-M) and a posterior reverberation artifact. Intubation accuracy by capnography was investigated, and the results were recorded in each patient's profile. Tracheal sonography was done during placement, or as soon as, the ETT has been embedded. The scanning time was minimized and it was carried out in total time of 10 s.

Results: The diagnosis of intubation accuracy indicated that it was successful in 94 individuals (94%) and unsuccessful in 6 ones (6%). Intubation accuracy in 93 people (93%) was confirmed, and inaccuracy of intubation in 7 people (7%) was diagnosed. Ultrasound sensitivity in diagnosis of intubation accuracy was 97.9% (92.94) with 83.3% (5.6%) specificity. The positive and negative predictive values were 98.9% (92.93) and 71.4% (5.7%) respectively.

Conclusion: Ultrasound method has high sensitivity and specificity to determine the correct placement of the tracheal tube, and it can be implemented as a reliable method given the acceptable positive and negative predictive values.
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http://dx.doi.org/10.4103/abr.abr_179_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036770PMC
June 2018

The Effect of Low-Dose Ketamine in Treating Acute Asthma Attack; a Randomized Clinical Trial.

Emerg (Tehran) 2018 10;6(1):e21. Epub 2018 Apr 10.

Emergency Medicine Research Center, Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: Efficient treatment of asthma can play an important role in controlling asthma attacks, rapid recovery and decrease of patient mortality. Therefore, in the present study the therapeutic effect of low-dose ketamine is evaluated in patients with acute asthma attack.

Methods: In the present single-blind, randomized clinical trial with placebo control, the effect of low-dose intravenous ketamine in treating 18 to 85 year-old asthmatic patients who presented to the emergency department was evaluated. Peak expiratory flow rate (PEFR) and the patients' response to treatment were measured before and 1 hour after treatment. Additionally, using SPSS 22.0, effectiveness of ketamine with 0.3, 0.4, and 0.5 mg/kg doses followed by infusion of the same dose during 30 minutes were compared with placebo.

Results: 92 patients were enrolled (59.8% female, mean age 48.5 ± 13.9 years). 15 (16.3%) patients were treated with 0.3 mg/kg ketamine, 14 (15.2%) with 0.4 mg/kg, and 16 (17.4%) with 0.5 mg/kg doses. Mean PEFR was 336.2 ± 101.5 liters in the placebo group and 345.8 ± 84.7 liters in the ketamine group before intervention (p = 0.6), while after intervention, they were 352.1 ± 101.2 and 415.8 ± 76.2 liters, respectively (p = 0.001). Ketamine treatment with 0.4 and 0.5 mg/kg doses led to a higher increase in PEFR compared to 0.3mg/kg dose (df: 3, 88; F = 23.8; p < 0.001).

Conclusion: It seems that administration of 0.4 - 0.5 mg/kg doses of intravenous ketamine followed by infusion of the same dose during 30 minutes can be effective for rapid recovery of PEFR in patients with mild to moderate asthma.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036522PMC
April 2018

The effect of nitrous oxide in comparison to oxygen combined with fentanyl on the hospitalization time and pain reduction in renal colic patients at emergency department.

J Res Med Sci 2018 20;23:18. Epub 2018 Feb 20.

Department of Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran.

Background: Renal colic is a painful medical emergency, needs urgent intervention to reduce pain. Nonsteroidal anti-inflammatory drugs, opioids, and entonox are pain-relieving agents. This study was aimed to compare fentanyl + entonox (nitrous oxide + O) versus fentanyl + oxygen.

Materials And Methods: One hundred and twenty patients with acute renal colic presenting to the emergency department were enrolled. First, 50 μg fentanyl was infused for all patients. Then, patients divided into two groups receiving masks of entonox and oxygen, respectively. Quantitative measurement of pain was performed by visual analog scale, before the intervention, after 3, 5, 10, and 30 min of that. If the pain was not relieved after 30 min, 50 μg fentanyl was infused. If the pain was still continued, ketorolac and ketamine were used. Hospitalization duration and severity of pain at specified times were compared between patients in two groups.

Results: The mean (standard deviation) time of hospitalization was 211 (59) and 236 (61) min in fentanyl + entonox and fentanyl + O groups, respectively ( = 0.024). The decrease in pain severity after 10 and 30 min in fentanyl + entonox group were significantly greater than fentanyl + O group ( = 0.002 and 0.001, respectively). Mean (standard error) of needed time for renal colic pain to get better was 11.27 (1.23) and 20.47 (1.71) min in fentanyl + entonox and fentanyl + O groups, respectively ( < 0.001). Proportion of patients relief from pain in fentanyl + entonox in the second, third, and fourth measurements were significantly more than fentanyl + O group ( = 0.036, < 0.001, and < 0.001, respectively).

Conclusion: Entonox is more effective to decrease the duration of hospitalization and reduction of pain than O in renal colic patients.
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http://dx.doi.org/10.4103/jrms.JRMS_473_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842448PMC
February 2018

Reverse Triage to Increase the Hospital Surge Capacity in Disaster Response.

Adv J Emerg Med 2018 16;2(2):e17. Epub 2018 Jan 16.

Emergency Medicine Research Center, Department of Emergency Medicine, Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: Successful and effective management of large-scale disasters and epidemics requires pre-established systematic plans to minimize the damage and control the situation. With an increasing number of people in need of urgent medical care, hospitals must improve their response capacity, being at the forefront of responding to disasters and incidents. One way to develop the hospital capacity in disaster response is by reverse triage (RT).

Objective: The current study was conducted to investigate the role of RT to create additional hospital surge capacity in one of the major referral academic hospitals of Isfahan, Iran.

Method: This cross-sectional study was conducted in 2015 at Al-Zahra Subspecialty Hospital, Isfahan, Iran. The ten most common diseases leading to hospitalization in each ward of the hospital in 2014 were reviewed and, based on the prevalence, sorted and listed. Academic instructions for making a decision and possibility of early discharge was written and approved by an expert panel. On a day that was not set previously, the pre-selected in-charge person of each department was asked to run the RT following the instructions, and the number and percentage of those who were eligible for discharge via RT were determined.

Results: The total BOR in Al-Zahra Hospital in 2014 was about 80%, so it was estimated that almost 140 out of 700 beds are vacant. The results showed that by using RT, 108 (20%) hospitalized cases could be discharged, and considering the bed occupancy rate of about 80% and 140 vacant beds, a total of 248 beds could be provided following RT.

Conclusion: Running RT in 41 wards and units of Isfahan Al-Zahra Hospital, on average, added 108 beds to the hospital capacity. This increment is not the same in all wards, as the role of intensive care units in RT for surge capacity is insignificant.
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http://dx.doi.org/10.22114/AJEM.v0i0.48DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549049PMC
January 2018

Radial Head Subluxation: Possible Effective Factors on Time to Re-use the Affected Limb.

Adv J Emerg Med 2018 5;2(2):e19. Epub 2018 Jan 5.

Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: Radial head subluxation (RHS) is a common disorder in children. Although it is not accompanied by any important short- or long-term sequel, it could make the parents worried about.

Objective: The purpose of this study was to determine the possible effective factors that may influence time to use the affected limb.

Methods: This cross-sectional study was conducted prospectively during the years 2014 to 2016. All children under the age of 6 years who visited the emergency department (ED) and were diagnosed as having RHS were eligible. The patients' baseline information was recorded. After the reduction, the time until the affected arm use returned was recorded. The possible relationship between the baseline data and time to re-use the affected limb was assessed.

Results: During the study period, 112 children with a mean age of 30.18 ± 18.18 months were evaluated (53% male). Among the children who visited the ED during the first 4 hours and thereafter, 84% and 60%, respectively, re-used their limb in less than 10 minutes after reduction (p = 0.004). Also, 55% of children less than or equal to 24 months and 89% over the age of 24 months re-used the arm in 10 minutes (p < 0.001). The success rate of the first reduction maneuver was significantly lower in children with a recurrent dislocation (p = 0.001).

Conclusion: It is likely that age less than or equal to 24 months and ED visit after 4 hours of the event lead to a longer duration for re-using the affected arm following reduction.
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http://dx.doi.org/10.22114/AJEM.v0i0.70DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549051PMC
January 2018

The Effect of Implementation of the Standard Clinical Practice Guideline (CPG) for Management of Multiple Trauma Patients Admitted to an Emergency Department.

Adv J Emerg Med 2018 11;2(1):e5. Epub 2017 Dec 11.

Department of Emergency Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: The purpose of triage in the standard Clinical Practice Guide (CPG) for multiple trauma patients is to perform the primary and secondary evaluations in the quickest and shortest possible time with minimal errors and the best quality in the emergency department (ED).

Objective: In this study, a practical program for a coordinated management of multiple trauma patients in the ED has been provided by using the CPG guide. The impact of its implementation on the multiple trauma patients' management was evaluated.

Methods: This is a cross-sectional study conducted in 2014 and 2015 in Isfahan's Al-Zahra hospital ED. Administration and management of multiple trauma patients had been prepared before the implementation of the plan based on standard clinical methods of implementation in a way that used a 12-step protocol for the practical guide. This protocol was designed as a flowchart and the results before and after its implementation were evaluated.

Results: In this study, 100 multiple trauma patients before and after the implementation of the protocol were studied. The mean age of the patients and other baseline characteristics of studied patients in the two periods before and after implantation of the CPG were not significantly different (p > 0.05). The frequency of intubation (p = 0.016) and sent to the operating room (p < 0.001) were different in the two study periods. However, hospitalization in the ICU (p = 0.35) and death (p = 0.73) before and after implementation of the protocol were not statistically different. The time before examination by the EM physicians was significantly lower in all triage levels after CPG implementation. Meanwhile, no change in time elapsed occurred for the surgeons except for the patients in level 2 of triage.

Conclusion: Implementation of the strategic plan of CPG lead to a significant reduction in waiting time for visits by emergency medicine services and other specialized services, increased the deployment of patients needing surgery, and reducing the time spent in the ED.
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http://dx.doi.org/10.22114/AJEM.v0i0.37DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548104PMC
December 2017

Comparing the Effects of Hydroxyethyl Starch and Albumin in Cirrhotic Patients with Tense Ascites; a Randomized Clinical Trial.

Adv J Emerg Med 2017 12;1(1):e7. Epub 2017 Oct 12.

Emergency Medicine Research Center, Department of Emergency Medicine, Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: Large-volume paracentesis is one of the usual treatments for cirrhotic patients with tense ascites, which may cause different complications including decreased cardiac preload, suppressed renin angiotensin system, inactivation of sympathetic nervous system, electrolyte imbalances, etc.

Objective: The aim of this study was to compare the effects of administrating hydroxyethyl starch (HES) and albumin in cirrhotic patients with tense ascites in order to reduce the paracentesis complications.

Methods: In the present randomized clinical trial, 108 cirrhotic patients with tense ascites were enrolled. The patients were randomly divided into 3 groups. In group A, albumin 20% with 5 g/L dose of paracentesis fluid, in group B, HES 6% dissolved in saline were administered, and in group C, a combination of albumin 20% and HES 6% with half the dosage administrated to two other groups were prescribed. Then biochemical panel, and liver function tests and renal and electrolyte complications were compared between the groups.

Results: The results obtained after intervention did not show significant differences between the groups regarding weight (p=0.102), heart rate and platelet count (both p=0.094), hematocrit (p=0.09), creatinine (p=0.421), serum sodium (p=0.743) and potassium (p=0.147), total bilirubin (p=0.375) and urine volume (p=0.421). Additionally, we concluded that mean arterial pressure of patients who had received albumin was higher than the other 2 groups (p < 0.001).

Conclusion: The results of the present study showed the similar effects of HES and albumin in cirrhotic patients with tense ascites undergoing large-volume paracentesis.
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http://dx.doi.org/10.22114/AJEM.v1i1.17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548095PMC
October 2017

The Relationship between Risk Factors of Head Trauma with CT Scan Findings in Children with Minor Head Trauma Admitted to Hospital.

Open Access Maced J Med Sci 2017 Jun 3;5(3):319-323. Epub 2017 Jun 3.

Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Background: In emergency medicine for determining the intracranial injury (ICI) in children with head trauma, usually brain CT scan is performed. Since brain CT scan, especially in children, has some disadvantages, it is better to find a procedure which could help to choose only the children with real head trauma injury for brain CT scan.

Aims: The aim of this study is to find such procedure. This study was descriptive, analytic and non-interventional.

Methods: We reviewed the archived files of children with head trauma injuries referred to the emergency department of Imam Hossein Hospital within two years. Patient's CT scan findings and head trauma risk factors were evaluated in this study.

Results: Out of 368 patients, 326 patients had normal brain CT scan. 28 of them showed symptoms of ICI consisting intraventricular haemorrhage (IVH), contusion, subarachnoid haemorrhage (SAH), subdural haemorrhage (SDH), epidural hematoma (EDH), and pneumocephalus. Twenty-seven patients showed skull FX, which 14 of them had an Isolated fracture, and 13 of them also showed symptoms of ICI. Since patients with isolated FX usually discharge quickly from Emergency Department; their data did not include in results of the study. The patients have been divided into two groups: 1- ICI, 2- without ICI. RR (relative risk), CI (Confidence interval) and sensitivity, positive predictive value (PPV), negative predictive value (NPV) and association of these risk factors with ICI were assessed with the Chi-2 test. In the end to determine the indications of CT scan, the presence of one of these five risk factors is important including abnormal mental status, clinical symptoms of skull FX, history of vomiting, craniofacial soft tissue injury (including subgaleal hematomas or laceration) and headache.

Conclusions: For all other patients without these risk factors, observation and Follow Up can be used which has more advantages and less cost.
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http://dx.doi.org/10.3889/oamjms.2017.071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5503730PMC
June 2017

Brachial Artery Aneurysm as a Limb Threatening Condition: a Case Report.

Emerg (Tehran) 2015 ;3(2):75-7

Department of Emergency Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.

Brachial artery aneurysms are rare but potentially limb threatening condition. The presented case here is a 52-year old male referred to the emergency department complaining a sudden onset and progressive pain with coldness of his right upper extremity during brushing. The right upper extremity was pulseless and three-dimensional computed tomography showed an aneurysm of the proximal right brachial artery associated with arterial occlusion in its distal branch. Embolectomy was done, the aneurysm resected, and the artery successfully re-vascularised by interposing a saphenous vein graft.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4614600PMC
October 2015

Diagnostic Accuracy of Ultrasonography in the Initial Evaluation of Patients with Penetrating Chest Trauma.

Emerg (Tehran) 2014 ;2(2):81-4

Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction: Traumatic chest injuries (TCI) are one of the most common causes of referring to the emergency departments, with high mortality and disability. This study was designed to evaluate the diagnostic accuracy of ultrasonography versus chest X ray (CXR) in detection of hemo-pneumothorax for patients suffering penetrating TCI.

Methods: The present cross-sectional study was performed to evaluate the diagnostic accuracy of ultrasonography in penetrating TCI victims referred to the emergency department of Shahid Kashani and Alzahra Hospitals of Isfahan, Iran, from July 2012 to June 2013. Bedside ultrasonography and plain CXR was done on arrival and three hours after admission. The results of ultrasonography and radiography were separately evaluated by an emergency medicine specialist and a radiologist, who were blind to the aims of the study. Then, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and kappa coefficient was considered to evaluate the accuracy of ultrasonography.

Results: In this research, 64 patients with penetrating chest trauma were assessed (98.4% male). The mean age of them was 25.6±8.5 years (rang: 13-65). The plain radiography revealed the eight (12.5%) cases of pneumothorax and one (1.6%) hemothorax. The findings of primary ultrasonography also showed the same number of hemo-pneumothorax. Sensitivity and specificity of primary ultrasound in diagnosis of pneumothorax were 100% (95% Cl: 60.7- 100) and 100.0% (95% Cl, 92.0% to 100.0%) and in detection of hemothorax were 100% (95% Cl: 50.5-100) and 100% (95% Cl: 92.8-100), respectively. Sensitivity and specificity of ultrasound in the third hour were 100% (95% Cl: 31.3-100) and 100% (95% Cl: 91.4-100), respectively.

Conclusion: Findings of the present study have shown that ultrasonography has an acceptable diagnostic accuracy in the initial assessment of patients with penetrating chest trauma. However, because of its dependency on operator proficiency and other limitations more studies are needed in this area.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4614593PMC
October 2015