Comparison of the Relationship Between SI and RASI Scores With the Outcome of Sepsis Patients

The aim of this study was to compare the relationship between shock index (SI) and respiratory adjusted shock index (RASI) scores with the final outcome of sepsis patients referred to the emergency department. This was prospective research that examined individuals who had been diagnosed with sepsis, determined by the presence of at least two of the three quick sepsis-related organ failure assessment (qSOFA) criteria and the presence of an infectious disease based on a diagnosis made by a hospital physician of Imam Reza and Ghaemshahr of Mashhad in 2019. Demographic information of patients, SI score, RASI score, and information related to the patient's clinical symptoms were recorded in the checklist. The final outcome of this study was considered mortality. Data analysis was performed using descriptive and inferential tests. In the present study, a total of 178 patients, 46 patients (25.8%) were transferred to the intensive care unit, and 98 patients (55.1%) were admitted to the normal wards. Eighty-five patients (47.75%) died and the mean length of hospital stay of all patients was 11.07 ± 9.23 days. Forty-four patients (24.7%) had referred with a decreased level of consciousness and 44 patients (24.7%) presented with confusion. The rest of the patients reported normal levels of consciousness. Kaplan Mir analysis with log-rank was performed to determine the difference in survival distribution in different SI groups: Survival distribution was not statistically different for the four defined groups (based on statistical quartiles (P = 0.320). Receiver operator curves were considered as the date of death in the case of the deceased and the date of discharge from the hospital in the case of the living as censored. The AUC of the RASI scoring system for predicting mortality was 0.614 (P = 0.009) while this value was not significant for SI (P = 0.152). In logistic regression analysis, it was found that by adjusting for the variables of age, sex, sepsis etiology, blood pressure and heart rate, level of consciousness, and gender, patients with the lower respiratory rate (OR 1.6, z = −0.159 p = 0.007), younger age (OR 1.6, z = −0.029 p = 0.006) and higher RASI score are more in risk of mortality (OR 1.29, z = 1.209, p = 0.031). The results of our study showed that RASI scoring can be a good criterion for predicting the chance of mortality in patients with sepsis and could be used complementary to previous criteria such as SI. Patients with high RASI scores should be given more attention to reducing the chance of death.

Risk Stratification of Pulmonary Thromboembolism using Brain Natriuretic Peptide and Troponin I; a Brief Report

INTRODUCTION

Pulmonary thromboembolism (PTE) is one of the most prevalent medical disorders, with a notable annual fatality rate. This study aimed to evaluated the accuracy of serum pro-BNP and troponin I levels in PTE diagnosis.

METHODS

This cross-sectional study was implemented on 267 patients with suspected PTE (sudden chest pain or sudden dyspnea) in Imam Reza Hospital in Mashhad, Iran. All patients underwent pulmonary computed tomography (CT) angiography (as the gold standard test) and their serum levels of troponin I and pro-BNP were measured. The screening performance characteristics of pro-BNP in detection of PTE cases were measured and reported using receiver operating characteristic (ROC) curve analysis.

RESULTS

Two-hundred-sixty-seven patients with a mean age of 67.7 ±11.5 years were evaluated (60.1% male). PTE was confirmed via CT angiography in 121 patients. The area under the ROC curve of troponin I and pro-BNP in detection of PTE was 0.501 ng/mL and 0.972 pg/mL, respectively. The sensitivity and specificity of proBNP at the best cut-off point (100 pg/ml) were 85.4% and 80.2%, respectively. The sensitivity and specificity of troponin I at the best cut-off point (0.005 ng/ml) were 65.5% and 42%, respectively.

CONCLUSION

Due to the comparatively good sensitivity and specificity of proBNP in diagnosis of pulmonary thromboembolism, it can be employed as a diagnostic determinant in patients with suspected pulmonary thromboembolism along with other laboratory tests.

Evaluating the diagnostic value of nitrite test in comparison with U/S results in patients with urinary tract infection symptoms: A cross-sectional study

Objective: The purpose of this study is to evaluate the diagnostic value of nitrite test in comparison with urine culture (U/C) results in patients with Urinary tract infection (UTI) symptoms. Methods: This cross-sectional study was performed on 203 patients with UTI symptoms. Middle urine sample was taken into sterile plastic containers, and simultaneously the urine sample and the nitrite test were done by the use of urine dipstick test. Data were analyzed using SPSS software version 23. Results: The results of the urine culture test indicated that the highest excreted organisms in both sexes were E. coli (58.8%), Candida (17.6%), Klebsiella (8.8%), E. coli (MDR) (5.9%), Pseudomonas (2.9%), Enterococcus (2.9%) and Acinetobacter (2.9%). The results showed that there was a significant correlation between U/C and urine analysis (U/A) test results (P = 0.01), and in U/C positive results, U/A results were significantly positive for UTI. Other findings showed a significant relationship between the results of nitrite one and nitrite two tests (P = 0.001). There was a significant correlation between urinary, and nitrite1 levels (P = 0.04). Also, in this study, the sensitivity and specificity of diagnostic tests for U/A and nitrite 1 and 2 with U/C were calculated as the Golden Standard method. Conclusion: Overall, the results of this study showed that the negative nitrite test and urine dipstick test could be performed in emergency cases to prevent ectopic dysfunction and inadequate diagnosis. Also, it can reduce the unreasonable expenses for U/A.

Emergency Medicine Resident versus Radiologist in Detecting the Ultrasonographic Signs of Acute Cholecystitis; a Diagnostic Accuracy Study

INTRODUCTION

Dependence of ultrasonography on the operator's skill plays a major role in the differences between various studies in reporting its diagnostic accuracy. Therefore, the present study was done with the aim of comparing the ultrasonography findings performed by emergency medicine resident and radiologist in evaluation of acute cholecystitis.

METHODS

The present diagnostic accuracy study has been carried out on patients presenting to the emergency department with complaint of pain in the right upper quadrant of abdomen suspected with acute cholecystitis. All the patients underwent gallbladder ultrasonography by a trained emergency medicine resident and a radiologist and their findings were compared with surgical and pathology findings regarding gallstone and increased gallbladder wall thickness.

RESULTS

51 patients with the mean age of 42.3±15.8 (17-81) years were analyzed (82.4% female). The overall agreement between emergency medicine resident and radiologist in ultrasonographic diagnosis of cholecystitis was 0.421 (95% CI: 0.118-0.724). Based on the pathology and surgical findings, acute cholecystitis was confirmed for all 51 (100%) patients. Meanwhile, based on the ultrasonographic report of radiologist and emergency medicine resident only 45 (88.2%) and 34 (66.7%) patients, respectively, were diagnosed with cholecystitis. Screening performance characteristics of ultrasonography by radiologist for detection of gallbladder stone (p = 0.010) and gallbladder wall thickness (p < 0.0001) were significantly better than emergency medicine resident.

CONCLUSION

The screening performance characteristics of ultrasonography by radiologist in detection of gallstones and increased wall thickness of gallbladder were significantly better.

Screening Characteristics of Bedside Ultrasonography in Confirming Endotracheal Tube Placement; a Diagnostic Accuracy Study

INTRODUCTION

Confirmation of proper endotracheal tube placement is one of the most important and lifesaving issues of tracheal intubation. The present study was aimed to evaluate the accuracy of tracheal ultrasonography by emergency residents in this regard.

METHOD

This was a prospective, cross sectional study for evaluating the diagnostic accuracy of ultrasonography in endotracheal tube placement confirmation compared to a combination of 4 clinical confirmation methods of chest and epigastric auscultation, direct laryngoscopy, aspiration of the tube, and pulse oximetry (as reference test).

RESULTS

150 patients with the mean age of 58.52 ± 1.73 years were included (56.6% male). Sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio of tracheal ultrasonography in endotracheal tube confirmation were 96 (95% CI: 92-99), 88 (95% CI: 62-97), 98 (95% CI: 94-99), 78 (95% CI: 53-93), 64 (95% CI: 16-255), and 0.2 (95% CI: 0.1-0.6), respectively.

CONCLUSION

The present study showed that tracheal ultrasonography by trained emergency medicine residents had excellent sensitivity (>90%) and good specificity (80-90) for confirming endotracheal tube placement. Therefore, it seems that ultrasonography is a proper screening tool in determining endotracheal tube placement.

The Relation of Q Angle and Anthropometric Measures with Ankle Sprain; a Case-control study

INTRODUCTION

Since most studies on ankle sprain are medical and sports-related and not much epidemiologic and etiologic data from the general population exist in this field, the present study evaluates the relationship between Q angle and anthropometric measures with ankle sprain in the general population.

METHODS

In the present case-control study, all of the patients over 18 years age presenting to emergency departments (ED) of two educational Hospitals, complaining from ankle sprain, were evaluated during more than 1 year. A checklist consisting of demographic data, height, weight, body mass index (BMI), and history of ankle sprain, as well as degree of Q angle was filled for all participants. The correlation of mentioned variables with incidence of ankle sprain was calculated using SPSS 22.

RESULTS

300 patients with ankle sprain were evaluated (53.5% male). Mean age of the patients was 37.03 ± 14.20 years. Mean weight, height, and BMI were 71.71 ± 11.26 (43 - 114), 168.74 ± 8.63 (143 - 190) and 25.14 ± 3.19 (18.41 - 38.95), respectively. Mean Q angle of the patients was 12.78 ± 3.19 degrees (5 - 23). There was a significant correlation between weight (p < 0.001), BMI (p = 0.001), history of sprain (r: 0.26, p < 0.001) and Q angle (p = 0.002) with incidence of ankle sprain. In addition, there was a significant statistical correlation between weight (p = 0.031), BMI (p = 0.020) and Q angle (p = 0.004) with history of ankle sprain. In patients with a history of ankle sprain, Q angle was wider by about 2 degrees.

CONCLUSION

It seems that the prevalence of ankle sprain directly correlates with high weight, BMI, and Q angle and is more prevalent in those with a history of sprain. Although the findings of the present study show a statistically significant correlation between these factors and ankle sprain, the correlation is not clinically significant.

Remifentanil versus Fentanyl/Midazolam in Painless Reduction of Anterior Shoulder Dislocation; a Randomized Clinical Trial

INTRODUCTION

Performance of painful diagnostic and therapeutic procedures is common in emergency department (ED), and procedural sedation and analgesia (PSA) is a fundamental skill for every emergency physician. This study was aim to compare the efficacy of remifentanil with fentanyl/midazolam in painless reduction of anterior shoulder dislocation.

METHOD

In this randomized, double blind, clinical trial the procedural characteristics, patients' satisfaction as well as adverse events were compared between fentanyl/midazolam and remifentanil for PSA of 18-64 years old patients, which were presented to ED following anterior shoulder dislocation.

RESULTS

96 cases were randomly allocated to two groups (86.5% male). There were no significant difference between groups regarding baseline characteristics. Remifentanil group had lower duration of procedure (2.5 ± 1.6 versus 4.6 ± 1.8 minutes, p < 0.001), higher pain reduction (53.7 ± 13.3 versus 33.5 ± 19.6, p < 0.001), lower failure rate (1 (2.1%) versus 15 (31.3%), p < 0.001), higher satisfaction (p = 0.005). Adverse events were seen in 12 (25%) patients in midazolam/fentanyl and 8 (16.7%) cases in remifentanil group (p = 0.122).

CONCLUSION

It seems that use of remifentanil resulted in lower procedural time, lower failure rate, and lower pain during procedure as well as higher patient satisfaction in comparison with midazolam/fentanyl combination in anterior shoulder dislocation.

A Randomized Clinical Trial of Intravenous and Intramuscular Ketamine for Pediatric Procedural Sedation and Analgesia

INTRODUCTION

Ketamine is an agent broadly used for pediatric procedural sedation and analgesia in emergency departments. It has been found to be safe and with a low risk of complications. Choosing between intravenous (IV) and intramuscular (IM) injections is a matter of concern, so we did a comparison between the two methods in terms of their efficacy and rate of complications.

METHODS

This single-blind clinical trial recruited 240 children (age: three months to 15 years, weight > 5 kg), who underwent short and painful procedures at the emergency departments. They were randomly allocated to two groups of 120 patients to receive either IV or IM ketamine with of 1.5 and 4 mg/kg doses, respectively. Indications for use, dose, side effects, and efficacy of the medications as well as duration of the procedure and time to recovery were compared between the two groups.

RESULTS

The mean age of the IV and IM groups were 6.5 ± 3.6 and 3.05 ± 2.6 years, respectively (p < 0.001). The onset of action of ketamine was 1.7 ± 1.1 minutes in the IV group and 8.6 ± 3.1 in the IM ones (p < 0.001). Patients of the IV and IM groups remained in optimal sedation for 20.6±12.0 and 37.2±11.8 minutes, respectively (P < 0.001). Time until emergency department discharge was 65.3 ± 36.9 minutes in the IV group and 72.2 ± 14.5 in the IM group (P = 0.40). Ketamine had excellent and moderate efficacy in 66.7% and 32.5% of the IV group and 70.0% and 25.0% in the IM group, respectively (p = 0.02). Totally, 60.0% of IV group patients and 40.0% of IM group experienced drug side effects (p = 0.21). Need for rescue dose was significantly higher in IV group (26.7% vs. 10.0%; p < 0.001). Finally, recovery was tranquil and comfortable in 88 patients (73.3%) of the IV group and 108 patients (90.0%) of the IM group (p = 0.06).

CONCLUSION

We found that although the sedative and analgesic effects of IM and IV ketamine are not significantly different, duration of effect and onset of action are more desirable in the IV group for suturing, fracture reduction, and foreign body removal. Meanwhile, the IM method can lead to lesser need of rescue doses.