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Objective This study aimed to compare the efficacy of using dexmedetomidine with salbutamol and salbutamol nebulization alone in patients with acute exacerbation of asthma presenting to the emergency department. Methods This clinical trial included 60 patients, in the age range of 18 to 55 years, with signs of bronchospasm presenting to the emergency department. In the intervention group, dexmedetomidine 0.5 µg/kg was injected intravenously and three doses of salbutamol nebulization were administered over 60 minutes. In the control group, salbutamol nebulization was administered for 60 minutes three times. The patient's clinical status, based on clinical symptoms, consciousness, speech, breathing rate, heart rate, and blood pressure were recorded before the intervention, and peak expiratory flow rate and forced expiratory volume in 1 second were measured at 20, 40, and 60 minutes after intervention. Patients who did not respond to the intervention were excluded from the study within 60 minutes. Results The increased mean forced expiratory volume in 1 second and mean peak expiratory flow rate were found to be similar in both groups during the treatment (P=0.304). The mean systolic and diastolic blood pressure recorded at 40 and 60 minutes were significantly lower in the intervention group. During this study, no patient was excluded before 60 minutes. Conclusion Administration of dexmedetomidine in addition to standard salbutamol treatment has no beneficial effect in patients with acute asthma attacks and merely causes hypotension in patients.

Introduction and Purpose: The importance of pain control in patients with limb trauma in the emergency department and its complications is the main issue in post-emergency care and plays an important role in accelerating the improvement of patients' general status. Therefore, the present study aimed to evaluate the analgesic and sedative effects of ketamine infusion against intravenous morphine in relieving fracture pain of long or short bones in the upper and lower limbs. Materials and Methods: We examined the effect of ketamine and morphine as ketamine infusion at a dose of 0.4 mg/kg/IV/10min and intravenous morphine at a dose of 0.1 mg/kg/IV in patients aged 18-65 years with limb trauma who visited the hospital emergency department. We also compared the duration of analgesia, the amount of pain relief according to the Visual Analogue Scale (VAS) in each of the drugs and complications of the above methods, including apnea, bradycardia, tachycardia, decreased level of consciousness, nausea, vomiting, hypertension and hypotension, seizures, and disturbed sleep, and mentioned the preferred method. Results: In the study, we studied 120 patients, 60 of whom received ketamine and 60 received morphine. The mean age of patients was 13.02±13.67 years with a minimum age of 19 years and a maximum age of 70 years, and 89(74.2%) patients were male. There was not any difference between ketamine and morphine in the factors at different times. Conclusion: The results indicated that the potency of low-dose ketamine in relieving pain in patients was very similar to morphine. Keywords: Bone fracture; Ketamine; Morphine.

Introduction: Migraine is a common disease in the emergency department (ED), which is capable of imposing limitations on people’s activity and imposing a high cost on the government. There are a lot of common treatments for migraine. In numerous studies, sodium valproate is included, among other treatments. This Study designed for efficacy evaluation of Sodium Valproate versus Dexamethasone in acute migraine headache pain control. Method: A controlled clinical trial has been established for ED patients with compliant of acute migraine headaches. 108 patients were included and categorized into two groups based on a randomized schedule: one with 1200 mg sodium valproate and another with 8 mg dexamethasone in 150 mL normal saline, which was IV infused in 10 minutes. As a primary outcome, pain visual analog scale (VAS) score was determined and compared on arrival and minutes 30, 60 and 120 after intervention, and as a secondary outcome, the percentage of rescue from headache through medication and sustainability of freedom and relief from headache were determined and compared between the two groups. Results: The mean decline of pain VAS score (0–10) in the sodium valproate group was 2.33 SD (1.74) and 3.49 SD (2.56), and in the dexamethasone group, it was 2.20 SD (1.86) and 3.30 SD (2.45) in the first and second hours after intervention, respectively. In each group, they are statistically significant (P < 0.05), even though there was no statistically significant difference between the two groups of study (P > 0.05). In terms of need for rescue medication, in the sodium valproate group, 30/54 (55.6%) people and in the dexamethasone group, 33/54 (61.1%) people used the medication; however, there were no statistically significant differences found between the two groups (P > 0.05). Conclusion: Probably it can be concluded that there is no statistically significant difference between the efficacy of 1200 mg IV sodium valproate compared and 8 mg IV dexamethasone in reducing acute migraine headache Keywords: Sodium valproate, dexamethasone, acute migraine, pain control.

Background The present study was conducted to investigate the relationship between serum levels of enolase and pathological findings obtained from CT scans of the brain in children with mild blunt brain trauma and help with a more accurate diagnosis of brain injuries. Methods The present observational study was conducted on children presenting with head traumas to the emergency department (ED) of Golestan Hospital in Ahvaz, Iran in 2016. A venous blood sample was immediately taken by the ward nurse from all the eligible patients within 6 hrs of the incident after obtaining their information, performing initial examinations and their initial stabilization. Laboratory serum levels and the corresponding interpretations of CT scans of the brain were collected, recorded and then evaluated and analyzed. Results A total of 62 children with mild blunt brain trauma were included in the study. A significant difference was observed between the positive CT scan group (2.7±9.74 µg/L) and the negative group (4.23±1.33 µg/L) in terms of serum levels of enolase (P

Introduction Minor head trauma is due to the transfer of a mechanical energy to the brain caused by a traumatic event. The present study was accomplished aiming to investigate the cleaved tau protein (CTP) as a brain injury biomarker among patients with minor head trauma. Patients and Methods This observational study was performed on patients with minor head trauma in 2017 who referred to emergency department of Imam Khomeini Hospital and Golestan Hospital of Ahvaz, Iran. The patients over the age of 16 years old with minor head trauma, who had computed tomography (CT) scan at most 10 hrs after the incident, and consented to participate in the study, were enrolled. C-tau evaluation was performed by the enzyme-linked immunosorbent assay (ELISA) method with monoclonal antibodies detecting the C-tau marker. Investigation of the injury after 3 months of minor head trauma was conducted using a post-concussion syndrome questionnaire (RPCS). Results In this study, 86 patients were evaluated. CTP was positive in 14% of the patients and the results revealed that there was a significant relationship between traumatic brain injury (TBI) and positive CTP (p < 0.0001). The CTP had a sensitivity and specificity of, respectively, 92% and 100% in detecting intracranial trauma. In addition, positive and negative predictive powers for this marker were 100% and 98%, respectively. Conclusion In general, contrary to previous studies, the findings of this study suggest that evaluation of the CTP levels can be a strong biomarker with high sensitivity and specificity in detecting TBI.

Introduction: Fentanyl is a lipid soluble, highly potent opioid. The lipid solubility of fentanyl makes it an ideal opioid to be administrated by inhalation. The current study compared ketamine infusion and nebulized fentanyl in bone fracture pain relief. Methods: In this double-blind, randomized clinical trial, patients aged 18 to 55 years who were admitted to the emergency department (ED) with limb fracture were recruited. A total of 127 patients were included in the study, 51.1% (65) of whom were male and 48.9% (62) of whom were female. The patients were divided equally into two groups: Group I received 100 cm3 IV infusion of normal saline and 4 μg/kg of 50 μg/ml nebulized fentanyl; Group II received 0.4 mg/kg ketamine in 10 min and 5 cm3 nebulized normal saline. Pain was assessed using a visual analog scale just before treatment and 5, 10, 15, 30, and 60 min post-treatment. Results: Before intervention, the pain scores of both groups showed no significant difference. However, log linear analysis in both groups showed a significantly decrement during the follow up (60 min) (p

Background: Renal colic is one of the most common complaints among refereeing patients to the emergency department (ED). Non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are gold standards to relieve pain. Objectives: The aim of this study was to evaluate the effects of intranasal Ketamine on pain control versus Ketorolac. Methods: In this randomized clinical trial (RCT), the patients were randomly assigned into two groups. Ketorolac 30 mg was given intravenously to all patients in the control group, the patients in intervention group received 1 mg/kg drops of Ketamine intranasally. Pain severity, vital signs, and adverse events (AEs) were recorded after 60 minutes post-dose. Results: A total of 100 patients were enrolled in this study. The mean visual analog scale (VAS) score after the first 5 minutes was lower in the intranasal Ketamine group compared to control (5 ± 2.26 vs. 8.62 ± 0.49, respectively; P < 0.001), which remained significant at the end of 60th minute (P < 0.001). Moreover, additional analgesics administration was higher in intravenous Ketorolac than intranasal Ketamine (22 vs 0%), which was significantly different (P = 0.001). Patients' satisfaction was higher in the intranasal Ketamine group compared to control (3.56 ± 0.35 vs. 1.82 ± 0.98, respectively; P < 0.001). Conclusions: Intranasal Ketamine was beneficial in controlling renal colic-induced pain, which could be prescribed as a treatment instead of normal treatment. It can rapidly improve pain relief in the short term, has lower AEs, and increases the patients' satisfaction.

Introduction Headache is one of the most common neurological conditions among emergency department visits (ED), although the best therapy has not been identified yet. Therefore, in the current study, we aimed to compare the pain-relieving effect of metoclopramide and ketorolac in acute primary headaches patients. Methods This double-blind, randomised clinical trial was conducted at Golestan Hospital, Ahvaz, Iran. This research involved all adult patients with acute primary (migraine or tension-type) headaches presented to the ED. Pain intensity was assessed with 0 to 10 verbal Numeric Rating Scales (NRS). The subjects were randomised into 10 mg intravenous (IV) metoclopramide or 30 mg IV ketorolac groups. Pain score and drug adverse reactions were compared between the two groups at baseline, 15, 30, and 60 min after baseline. Results 108 patients completed this trial and were equally divided into two groups (mean age of 34 ± 8.54 years; 57.4% female). Before treatment, the mean pain score was 6.9 and 6.8 in metoclopramide and ketorolac groups, respectively (p > 0.05). Metoclopramide failed to provide more improvement in pain score at 30 min (p = 0.55) and 60 min (p = 0.15) from baseline. There were no serious adverse events in this study. Only five patients required rescue medication which four of them were in ketorolac group. Conclusion We were unable to reject the null hypothesis that there would be no difference in pain outcomes between metoclopramide and ketorolac.

Introduction: B-type natriuretic peptide (BNP) regulates different physiological processes such as blood pressure, cardiac growth, and neural and skeletal development. Thus, the aim of this study w as to evaluate the effect of BNP in the treatment of acute asthma attacks. Material and methods: In this randomized clinical trial, patients with acute asthma attacks were enrolled. The patients were divided randomly into two groups. Patients in the interventional group received BNP via intravenous infusion. Two µg/kg of BNP was injected as a bolus in 60 seconds. Then, infusion of BNP immediately began and was given in 0.01, 0.02, and 0.03 µg/kg/min doses every 30 minutes for the first 1.5 hours. The patients in the control group received nebulized salbutamol. Afterwards, peak flow meter findings, hemodynamic parameters, and estimation of the clinical severity of asthma in both groups were checked every 30 minutes. Results: In total, 40 patients were included in this study. The values of PEFR in the 60th and 90th minutes in the control group were lower than those in the interventional group. In the 60th minute, the mean of PEFR was 377.3 in the BNP group but 335.95 in the control group (P = 0.049). Moreover, this difference remained significant in the 90th minute (P = 0.021). However, forced expiratory volume in one second (FEV1) did not differ between the groups at any time (p > 0.05). Conclusions: Although a large experimental study is needed to verify our hypothesis, it seems that BNP might be a therapeutic option in asthma exacerbations, particularly in those with b2 agonist receptor polymorphism.

IntroductionImmediate diagnosis of stroke is crucial in reducing its morbidity and mortality rate. There are various pre-hospital assessment tools, such as the Prehospital Ambulance Stroke Test (PreHAST) and the Cincinnati Prehospital Stroke Scale (CPSS) used to identify stroke early in the chain of care. The aim of this study is to compare the accuracy of PreHAST with CPSS in diagnosing stroke.MethodsIn this diagnostic accuracy study patients with suspicion of stroke were included in this study. In CPSS, the criterion used to indicate stroke are facial droop, speech and arm drift. In PreHAST it is eye position, visual field, facial palsy, right and left arms paresis, right and left legs paresis, sensory and speech. After data collection, sensitivity and specificity were calculated using standard formulae. Different cut-off points for the best diagnostic accuracy were examined in both CPSS and PreHAST.ResultsIn this study, 883 patients were investigated. The results demonstrated that in CPSS, the highest specificity and sensitivity was for facial droop (84.9%) and arm drift (82.7%); and in PreHAST it was eye position (99.6%) and facial palsy (49.2%). The best predictor of stroke in CPSS with highest sensitivity (78.5%) and specificity (66%) was a cut-off point of 1.5 (AUC: 0.744) (p

Asthma is the most common chronic disorders of the respiratory tract. This study aimed to evaluate the effect of low-molecular-weight heparins (LMWHs) in the treatment of acute asthma.In this randomized clinical trial, patients with acute asthma attacks were enrolled. The patients were divided randomly into two groups. Patients in the intervention group received nebulized LMWH (1 mg/kg) with albuterol (2.5 mg) every 20 min for 10 min. The patients in the control group received nebulized albuterol with the same dose. Then peak expiratory flow rates (PEFR) and forced expiratory volume in 1 s (FEV1), and hemodynamic parameters in both groups were assessed for every 20 min.In total 70 patients enrolled in this study. We found that the mean PEFR at 40 min was higher in the LMWH group than the control group (202.51 L/min and 180.2 L/min) (p = 0.001). Moreover, this difference remains significant in the 60th minute (p 0.001). Further, FEV1 was significantly higher in the LMWH group after 60 min (1.82 L/min vs 1.48 L/min, p 0.001). Moreover, we found that the hemodynamic parameters were sustainable in the intervention group.The study suggests that LMWH in mild-moderate asthma attacks may be beneficial in the short term and could be prescribed in addition to standard albuterol therapy.

Efficient novel medications can facilitate the acute phase of asthma treatment. The aim of this study was to investigate whether nebulized lidocaine as an additional treatment can improve clinical, forced expiratory volume in 1 s (FEV1), and peak expiratory flow rate (PEFR) indexes during an acute asthma attack. A double-blind randomized clinical trial was conducted in 60 adults with possible acute asthma attack who had been referred to the emergency department of our hospital. Patients were randomized into control and treatment groups. The treatment group received nebulized lidocaine 200 mg at 0, 20, 40, and 60 min after arrival + standard treatment with a single dose of oral prednisolone 50 mg at arrival + nebulized albuterol 2.5 mg and nebulized ipratropium bromide 0.5 mg at 0, 20, 40, and 60 min. The control group received only standard treatment. Clinical severity (Borg Dyspnea Scale), FEV1, and PEFR indexes and hemodynamic parameters were recorded at arrival and at 20-min intervals for 60 min after arrival. Mean PEFR and FEV1 increased significantly from baseline in both treatment groups, with no significant between-group differences (BGDs). The BGDs in respiratory rate and hemodynamic parameters (heart rate, systolic and diastolic blood pressure, and oxygen saturation) at 0, 20, 40, and 60 min after arrival were not significant (p > 0.05). Finally, the severity of dyspnea (Borg Dyspnea Scale) did not differ between the two groups at discharge (0.68 vs. 0.76; p = 0.566). The results of this study found no benefit from adding nebulized lidocaine to the standard treatment of asthma attacks. Our data reject any benefits for the efficacy of nebulized lidocaine, at least for short-term use in the acute phase of an asthma attack. Research on the efficacy of nebulized lidocaine during the course of an acute asthma attack is limited, and more research is required to clarify the detailed clinical effects.

Background:More than half of the patients attending emergency centers need analgesics. Injectable analgesics are currently the most common pain control strategy, but entail complications. Fentanyl is one of the most commonly used pain-relief opiates available in various forms.Objective:The present study aims to compare analgesic effects of nebulized against intravenous fentanyl for controlling pain due to limb fracture.Method:The present double-blind clinical trial recruited 213 patients presenting with fractured limbs to emergency departments. The first group of patients received 1 micg/kg of intravenous fentanyl citrate from a solution of 50 micg/ml and 5 ml of normal saline in nebulized form (group A), and the second group intravenously received 5 ml of normal saline and 4 micg/kg of 50 micg/ml solution of fentanyl citrate in nebulized form, whose volume reached 5 ml with the addition of normal saline (group B). Then, pain level was frequently measured and compared in the two groups for 20 minutes.Results:The results obtained showed reduced pain level in both the groups. However, point-by-point comparison of pain in the two groups revealed significantly greater pain reduction in intravenous fentanyl group (PConclusion:According to the results, although nebulized fentanyl is effective in controlling pain due to limb fracture, it was less effective than intravenous type, and unable to control pain in many cases.

Background: Vertigo is an illusion of rotation that is caused by the asymmetry of neurological function of the right and left vestibular nuclei. The aim of this study was to compare the efficacy and side effects of oral betahistine with injectable promethazine in treatment of acute peripheral vertigo. Methods: In this double-blind clinical trial study, the patients with acute peripheral vertigo were assigned in the two groups: receiving promethazine intramuscularly at a dose of 25 mg (group A) and receiving 8 mg betahistine tablets (group B) and the severity of their vertigo was evaluated on the visual analog scale (VAS) scoring system. In addition, adverse events in both groups of patients were compared and evaluated. Results: A total of 162 patients (82 subjects in group A) participated in this study. The mean age, gender distribution, intensity and symptoms of vertigo were similar in both groups before the intervention. At 2 and 3 h after the intervention, the score of VAS in patients taking betahistine was significantly higher than promethazine. In addition, the clinical symptoms after taking betahistine were significantly less. Side effects seen in patients taking the promethazine include mainly drowsiness. After taking betahistine, the most common complication was abdominal problems (nausea and vomiting). Conclusion: The results of this study show that betahistine is a safe and effective drug in controlling patients with acute vertigo and its impact is more than promethazine. J Clin Med Res. 2017;9(12):994-997 doi: https://doi.org/10.14740/jocmr3093w

Introduction This study was designed to compare the analgesic efficacy of sublingual (SL) buprenorphine and intravenous (IV) ketorolac for renal colic pain relief. Methods The present study was carried out as a double-blind, double-dummy randomized clinical trial in patients diagnosed with acute renal colic attending the emergency department. The study subjects were 63 patients with confirmed renal stones. The subjects were randomly divided into two groups. One group, which included 32 patients, received SL buprenorphine tablets (2 mg) with an IV placebo, and another group, including 31 patients, received ketorolac tromethamine (30 mg) with a SL placebo. After medication, the pain of subjects was measured by a standard visual pain analogous scale (VPAS) in minutes 0, 20, 40, and 60 of study. Also, probable adverse effects were recorded. Results In 28.1% of patients in the buprenorphine group, the mean pain score decreased from 9.2 to 5.9, 2.8, and 1.5 after 20, 40, and 60 min, respectively, as determined by VPAS. Also, in 38.7% of patients in the ketorolac group, the mean pain score decreased from 9.1 to 5.5, 3.0, and 1.6 after 20, 40, and 60 min, respectively, as determined by VPAS. The two groups did not significantly differ for pain reduction at 20, 40, and 60 min (P value = 0.16, 0.34, and 0.3, respectively). No adverse effects were seen in the ketorolac group, but vomiting (18.8%), nausea (18.8%), and dizziness (21.9%) were detected in the buprenorphine group. Conclusions We found no difference between SL buprenorphine and intravenous ketorolac in renal colic pain relief but more adverse effects in the buprenorphine group. Trial Registration Iranian Registry of Clinical trials identifier, IRCT2015041421773N1.

Kidney stones are a fairly common problem that manifests itself as symptoms of acute abdominal and flank pains in patients presenting to emergency departments.The present study was conducted to compare the analgesic effect of intravenous fentanyl with that of intranasal ketamine in renal colic patients.One mg/kg of intranasal ketamine was administered in the first group, and one μg/kg of intravenous fentanyl in the second group. The pain severity was measured in the patients in terms of a visual analogue scale (VAS) score at the beginning of the study and at minutes 5, 15 and 30, and the medication side-effects were evaluated and recorded.A total of 130 patients were ultimately assessed in two groups of 65. In the ketamine group, the mean severity of pain was 8.72 ± 1.52 at the beginning of the study (P 0.001), 5.5 ± 2.97 at minute 5 (P 0.001), 3.38 ± 3.35 at minute 15 (P = 0.004) and 2.53 ± 3.41 at minute 30 (P = 0.449). In the fentanyl group, this severity was 9.66 ± 88.8 in the beginning of the study (P 0.001), 7.27 ± 1.37 at minute 5 (P 0.001), 4.61 ± 1.5 at minute 15 (P = 0.004) and 1.24 ± 1.25 at minute 30 (P = 0.449). The general prevalence of the medication side-effects was 10 (15.4%) in the ketamine group and 1 (1.5%) in the fentanyl group (P = 0.009).Ketamine was found to be less effective than fentanyl in controlling renal colic-induced pain, and to be associated with a higher prevalence of side-effects; nevertheless, ketamine can be effective in controlling this pain in conjunction with other medications.

Background: The effective relief of renal colic patients with low complications is one of the important concerns of emergency physicians. The aim of this study was to investigate the use of injectable ketamine as an alternative to routine drugs in the relief of pain in patients with renal colic. Methods: This double-blind clinical trial was conducted on patients who had suffered kidney pain due to kidney stones in 2017, referred to Ahvaz Imam Khomeini Hospital. Patients were divided into 2 groups: the first group received intravenous ketamine (0.3 mg/kg) and the second group received intravenous morphine (0.1 mg/kg) in a double-blind form. Finally, the mean pain was evaluated before injection, after 10, 20, 30, and 60 minutes as the initial result while the side effects were considered as secondary results. Results: In this study, 135 patients with renal colic participate in this study. The mean pain at the time of referral to the hospital in the group receiving morphine and ketamine was 9.2 and 9.2, respectively, which did not show any significant difference. Based on these findings, there was no significant difference between the factors evaluated during the study of the two groups. Only in the ketamine group, there were 3 cases of nausea and 1 of vomiting. However, there was a significant increase in the need for additional doses of fentanyl in the morphine recipient group (p = 0.02). Conclusion: The findings suggest that the use of ketamine can produce a more rapid relief effect, and decrease the use of opioids which create various complications, including nausea and vomiting in patients, especially patients with renal colic.

Background Ureter muscles contraction movements caused pain in renal colic. Magnesium sulphate could influence the pain by reducing acetylcholine in the nerve terminals. We have aimed to evaluate the analgesic effects of magnesium sulphate on acute renal colic pain. Method In this double-blind clinical trial study, the patients with renal colic pain were randomly divided into 2 groups; Group I received an intravenous infusion of 30 mg of Ketorolac and normal saline as placebo, Group II 50 mg/kg magnesium sulphate 50%/100 ml normal plus 30 mg of Ketorolac. The pain severity of patients was assessed using the visual analog scale (VAS) at baseline, and 15 and 30 min after intervention. Results Baseline pain score and demographic characteristics did not significantly different between the groups. After 30 min the pain score significantly reduced in both groups. While, at 15 and 30 min, mean pain score did not show statistically significant differences. Conclusion Our findings indicated that Magnesium sulphate did not influence renal colic pain relief.

Pain relief, using opiates as a primary choice, is an important part of treating limb fractures. Yet, in order to reduce opiate consumption, other combinations have been introduced. This study aimed to compare pain reduction by a combination of morphine-midazolam with morphine injection in patients with limb fractures.A randomized double-blind study of patients with upper or lower extremity fractures was conducted. Patients' response to treatment with either morphine-midazolam solution or morphine at 15, 30, 45, 60, 120, and 180 minutes were assessed. The Kaplan-Meier curves and generalized estimating equations were examined to evaluate the success of treatment.A total of seventy-two patients aged 18-60 (80.6% male; mean age: 35±17.9 years) were included. At 15, 30, 45, and 60 minutes, successful pain control was seen in 8.83 22.2%, 33.3% and 63.9% of the patients in the morphine group, and 11.1%, 27.7%, 44.4% and 63.8% in the midazolam-morphine group. By the third hour, pain-control was achieved in all patients receiving morphine while pain persisted in one patient receiving morphine-midazolam. Log-rank test showed no significant difference between the two groups (p=0.55).Our findings revealed that adding midazolam to morphine did not improve its pain-relief profile.

Background: Exacerbation of acute asthma attacks is a medical challenging problem that affects health systems all around the world. According to the reports, acute asthma has allocated about 1 to 12% of adults’ referral to the emergency departments by itself. This study aimed to investigate the effect of additional nebulized magnesium sulfate, as an additional complementary treatment, on the management of acute asthma attack. Due to controversies and the fact that previous research has been unable to confirm the benefits of routine use of magnesium in the course of treatment of asthma acute phase, this trial was conducted. Methods: Patients with a possible clinically suggested acute asthma attack, aged 18 to 65, were divided into two groups of intervention and control. An initial peak flow meter evaluation at arrival identified the severity of patients’ asthma attack. 148 patients with moderate to severe attacks were included in the study in two groups. Patients of the control group received standard asthma treatment consisting of nebulized albuterol 2.5 mg and nebulized ipratropium bromide 0.5 mg, both in minutes 0, 20, and 40 after arrival and oral single-dose prednisolone 50 mg at arrival. Patients of the case group received additional doses of nebulized magnesium sulfate 0.3 g in minutes 0, 20, and 40 after arrival in addition to the standard treatment performed on the control group. The clinical setting of dyspnea Borg scale in both the case and control groups, as well as their PEFR and FEV1 values, were recorded during the trial in minutes 0, 20, 40, and 60 after arrival. Chi-square, T-test, and Mann Whitney test were applied for data analysis. Results: The study was conducted on 148 subjects who were divided into two groups of 75 and 73 as case and control groups, respectively. PEFR values in minutes 40 and 60 after arrival were 295.04 and 336.2 in the case group and 249.64 and 282.86 in the control group, and there was a significant difference in the PEFR improvements between the case and control groups (P < 0.001). In addition, FEV1 in minutes 40 and 60 after arrival was respectively 2.26 and 2.66 in the case group and 1.88 and 2.23 in the control group. There were significant differences in FEV1 improvements between the case and control groups (P < 0.001). Conclusions: According to the results of this study, it can be concluded that administration of nebulized magnesium sulfate as an adjunctive medication to the standard treatment is beneficial in the management of moderate to severe acute asthma attacks and significantly leads to better control of acute attack in short term.

Background: Analgesics such as opioids are commonly used for pain control in emergency departments. correlated respiratory side effects and central nervous system depression confine opioids application as analgesic medication. New pain control choices such as Nitric oxide and Ketamine may be alternatives. This study evaluates efficacy of Nitric Oxide versus Ketamine in purpose of pain reduction in limbs fractures. Methods: In a randomized clinical study, 75 patients that were referred to the emergency department with pain, which has been caused by bone fractures, were randomly assigned into 2 groups: receiving ketamine with an intravenous bolus dose of 0.3 mg/kg versus mixture of 50% nitrous oxide/50% Oxygen. The pain score in the groups were measured and compared by the Visual Analog Scale consecutively at arrival and 5, 10, 15 minutes after intervention. Results: Fifteen minutes after the intervention, the score of pain in patients receiving ketamine, reached 2.5 from 8.86 at the baseline. This is while in the second group, 15 minutes after the treatment, reached to 5.02 from 9.52 at the baseline. The amount of pain reduction in both groups was statistically significant. A point-by-point comparison of the amount of the pain did not show significant differences in both groups. Conclusions: The findings of this study showed that both ketamine and Nitrous Oxide/Oxygen mixture are effective in alleviating the pain of patients with limb’s fracture, however, there is no precedence between these medications as a pain killer.

Introduction: Cryptococcosis is an opportunistic fungal infection mostly in immunocompromised patients. Here we present the immunocompetent case with crypotoccosis. Case Presentation: A 60-year-old man without any history of immunodeficiency or major risk factor of fungal infection, referred to the emergency department with systemic symptoms and low back pain. The patient’s condition gradually deteriorated within days by forming the clinical picture of a multi−system disease and eventually leading to a fatal outcome. The results of skin biopsy, BAL, gastrointestinal biopsy samples and post mortem lung and liver necropsies confirmed the disseminated Cryptococcus neoformans infection in smears and cultures. Discussion: This case emphasizes the need for a high index of suspicion for fungal infections in patients with multi−organ involvements who are unresponsive to treatment. Even without any obvious history or sign of immunodeficiency.

Hymenoptera stings are self-limiting events or due to allergic reactions. Sometimes envenomation with Hymenoptera can cause rare complications such as acute encephalopathy, peripheral neuritis, acute renal failure, nephrotic syndrome, silent myocardial infarction, rhabdomyolysis, conjunctivitis, corneal infiltration, lens subluxation, and optic neuropathy. The mechanism of peripheral nervous system damage is not clearly known. In our studied case after bee sting on face between the eyebrows with little erythema and 1 × 1 cm in size, bilateral blindness developed and gradually improved. Lateral movement of eyes was restricted with no pain. Involvement of cranial nerves including II, V, and VI was found. With conservative therapy after a year significant improvement has been achieved.