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Background: Distal radius fractures are one of the most common upper extremity fractures, and their incidence continues to increase due to an aging population and an increase in osteoporosis. Various methods of analgesia for distal radius fractures have been described-including hematoma blocks and nerve blocks. Hematoma blocks are a simple and effective method of providing analgesia; nonetheless, their efficacy may be limited in some cases. On the other hand, nerve blocks provide more targeted analgesia and may be more effective in reducing pain during fracture reduction. This study aimed to compare the analgesic effectiveness of radial and median nerve blocks with hematoma blocks under ultrasound guidance in treating distal radius fractures. Also, this study aimed to compare the analgesia of radial and median nerve blocks with hematoma blocks under ultrasound guidance to reduce distal radius fractures., Methods: In this prospective trial, patients with distal radius fractures referring to 2 academic centers were placed into 2 randomized groups, including hematoma block, and radial median block, both of which were ultrasound-guided. The patient's pain levels were measured and recorded based on the visual analog scale before the block, 5, 10, and 15 minutes after the block, at the start of reduction, during reduction, and 5, 10, and 15 minutes after reduction. Patient satisfaction and physician satisfaction rates were assessed, and side effects were also observed for 1 week. Quantitative variables were reported as mean ± standard deviation, and number and frequency percentages were reported for qualitative variables. The Student t test and the chi-square test were used on a case-by-case basis. The significance level was set at P ˂ 0.05., Results: In this study, 120 patients were included. The groups had no significant differences in pain reduction during the procedure. Analgesic medication was needed during the procedure for 17 patients; nerve blocks were applied for 6 patients, and hematoma blocks for 11 patients, which was statistically significant ( P = 0.041). Satisfaction rates for patients and physicians performing the procedure were significantly higher in the nerve block group than in the hematoma block group ( P = 0.001; P ˂ 0.001, respectively)., Conclusion: The results of this study suggest that ultrasound-guided radial and median nerve blocks can be used as alternative methods of analgesia with other techniques in the reduction of distal radius fractures in emergency departments., Competing Interests: The authors declare that they have no competing interests., (© 2023 Iran University of Medical Sciences.)

Introduction: Although pain management in EDs has been fully addressed in clinical trials, prehospital settings have rarely been investigated., Objective: The present study was conducted to compare the effectiveness of intravenous acetaminophen with that of ketorolac in pre-hospital pain control., Method: This randomized clinical trial (RCT) was performed at a prehospital setting during EMS missions in Tehran, Iran. The eligible candidates comprised all patients over the age of 7 years with a complaint of moderate to severe pain. The patients were randomly assigned to two groups, one receiving 30 mg of intravenous (IV) ketorolac and the other 1 g of IV acetaminophen. The pain intensity was measured using a visual analog scale (VAS) before administering the analgesic and upon admission to the ED., Results: The present study was conducted on 150 patients aged 8-81 years with a mean age of 40.4 ± 17.7, including 84 (56%) males. The mean reduction in the pain score was 14.9±8.6 in the acetaminophen group and 16.0±8.8 in the ketorolac group. Univariate analyses suggested no statistically significant differences between the two groups in terms of delta pain score (pain reduction) (P=0.429)., Conclusion: Based on the obtained findings, both ketorolac and acetaminophen could be administered for pain management in prehospital settings in both traumatic and non-traumatic patients in case their contraindications are considered., Competing Interests: Conflict of interest None declared., (Copyright© 2019 Tehran University of Medical Sciences.)

Iran is among the countries which change official time, every year according to their constitutions. Studies have shown an increase of incidence ratio (IR) of acute myocardial infarction by these time transitions. Despite annual time changes in Iran, there is no published data to prove this among the Iranian. This retrospective study examined the IR of patients with AMI, who were admitted to the Emergency Department (ED) of 5 teaching hospitals during the week just after the time transitions (observed period), with two weeks before and after the time transitions (expected period), both in spring and fall. In total, 11051 patients were admitted during the ten weeks (observed and expected), in both spring and fall time transitions. The IR of AMI during both observed and expected period did not show any significant difference (p > 0.05); however, the incidence of AMI was increased during the first week after the transition in spring (p > 0.05). Although the results of the present study did not prove the relation between time transitions and incidence of AMI, a slight increase existed for IR of AMI during three days after spring shift. This increase in IR of AMI can be due to Nowrooz, the national holidays which lasts four days after turning clocks forward in Iran.

Introduction: Painful surgical procedures require adequate sedation and analgesia. A vast array of medications can be used for Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs)., Objective: The present study was conducted to compare Propofol-Ketamine (PK) and Propofol-Fentanyl (PF) compounds in patients undergoing closed reduction in EDs., Methods: This randomized, double-blind, clinical trial was conducted on 110 consecutive patients who required sedation for closed reduction. The patients were randomly divided into two groups of equal sizes. The PK group received an intravenous bolus of 1 mg/kg of propofol plus 0.5 mg/kg of ketamine, and the PF group received an intravenous bolus of 1 mg/kg of propofol plus 1 µg/kg of fentanyl. The analgesic effect and success rate were the primary outcomes under study., Results: The PK group achieved more effective analgesia at the end of the experiment. The success rate was almost the same in both groups Shivering (p=0.005) and a drop in oxygen saturation to below 92% (p=0.048) were two side effects that were more prevalent in the FK group. The mean recovery time was significantly shorter in the PK group (p<0.001). The patients in the PK group were more satisfied., Conclusion: In comparison with the PF compound, the use of KP leads to better pain relief and greater patient satisfaction and shorter sedation time in PSA.

Background: The combination of morphine with low doses of ketamine (MK) has been utilized in the Emergency Department (ED) compared with morphine and placebo (MP) for the treatment of acute pain in few studies. The purpose of this study was to compare the effect of MP with MK for the treatment of severe pain with renal colic of patients who had been referred to the ED., Methods: This study is a double blind randomized clinical trial on patients with severe renal colic pain who were referred to the ED. Patients were enrolled with pain severity of at least 6 of the 10 visual analogue scales (VAS). Patients were divided into two groups: Morphine 0.1mg/kg and placebo (MP group) and morphine 0.1mg/kg and ketamine 0.15mg/kg (MK group). Pain of patients was studied in 10, 30, 60, 90, and 120min after injection., Results: Totally, 106 patients were enrolled in study groups. Assessment of the average pain during 120min at 10 and 30min after the start in the drug, MK group was significantly lower than the MP group (p=0.019 and p=0.003 respectively)., Conclusion: Given that combinations of morphine with low doses of ketamine in patients with renal colic pain causes more pain and morphine consumption reduction then this combination is suggested as an alternative treatment that could be utilized in patients with renal colic., (Copyright © 2017. Published by Elsevier Inc.)

Introduction: Chest ultrasonography is routinely used in evaluation of chest trauma for diagnosis of pulmonary injury. This study aimed to evaluate the accuracy of B-Lines for diagnosing lung contusion in patients with blunt trauma of the chest., Methods: Trauma patients who met the inclusion criteria were enrolled in the study and underwent ultrasonography by trained emergency medicine residents. Ultrasound results were recorded in terms of number of B-lines and the existence of peripheral parenchymal lesion (PPL). After ultrasound, the patient underwent chest x-ray and chest CT scan (as reference test) and screening performance of B-lines and PPL were evaluated., Results: 147 patients underwent chest ultrasound. The mean age of the patients was 40.74 ± 18.6 (78.9% male). B-lines˃3 had 94.0% (95% CI: 83.45-98.75) sensitivity and 57.7% (95% CI: 47.3-67.7) specificity, B-lines˃6 had 90.0% (95% CI: 78.2-96.7) sensitivity and 93.81% (95% CI: 87.0-97.7) specificity, and PPL had 34.0% (95% CI: 21.2-48.8) sensitivity and 100% (95% CI: 96.3-100.0) specificity. Composite findings of B-lines˃6 + PPL had 92.0% (95% CI: 80.8-97. 8) sensitivity and 93.8% (95% CI: 87.0-97.7) specificity in the diagnosis of lung contusion., Conclusion: PPL and B-Lines˃6 had the highest accuracy in detecting lung contusion. B-Line˃6 had high sensitivity and specificity and was easy to perform; thus, it seems that B-Line˃6 could be considered as an alternative screening tool in detection of lung contusion., Competing Interests: There are no conflicts of interest to declare.

Background: Ketamine, as an opium alternative, has been proposed for pain relief in the emergency department (ED)., Objectives: This study was carried out to compare low dose ketamine (LDK) with morphine for pain relief in trauma patients., Methods: In this randomized double-blinded clinical trial, 300 trauma patients from the ED of 2 teaching hospitals in Tehran, Iran were enrolled and randomly divided into 2 equal groups. The 1st group received 0.2 mg/kg of ketamine while the 2nd group received 0.1 mg/kg of intravenous morphine. The pain intensity and complications were measured and compared every 15 minutes to 1 hour., Results: Fifteen minutes after drug injection in both groups, a significant reduction was found in average pain intensity compared to the initial pain (P = 0.01). At 15 minutes, no significant difference was found in both groups in regards to average pain intensity (P = 0.23). The average pain intensity at 30, 45, and 60 minutes in the group receiving morphine was lower than the ketamine group (P = 0.01, P < 0.001, P < 0.001 respectively). Two complications (drop in O 2 saturation below 90% and flushing) were significantly greater in the morphine group., Conclusions: The results of this study suggest that LDK, at a dose of 0.2 mg/kg, in the earlier minutes leads to significant reduction of pain when compared to that of intravenous morphine. It also created fewer complications than morphine.

Introduction: Few studies have assessed the value and accuracy of focused cardiac ultrasound (FOCUS) performed by emergency physicians. The aim of the present study was to evaluate the diagnostic accuracy of FOCUS performed by emergency medicine residents compared to echocardiography performed by a cardiologist in emergency department (ED) patients suspected of cardiovascular disease., Methods: The research involved a prospective observational cross-sectional study enrolling patients over 18-years old suspected of having cardiovascular disease who required an echocardiograph. For each patient, a FOCUS test was conducted by a trained emergency medicine resident. The diagnostic accuracy of ED performed FOCUS was compared to echocardiography performed by a cardiologist (gold standard) in the ED. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios were calculated for FOCUS. The agreement of EM residents and cardiologists on each finding was evaluated using Cohen's kappa coefficient with 95% CI., Results: Two hundred and five patients, with a mean age of 61.0 ± 17 years (50% male), were included in this study. Agreement between FOCUS performed by an emergency medicine resident and echocardiography performed by a cardiologist in measuring ejection fraction of the left ventricle was 91% ( κ  = 0.85; 95% CI = 0.79-0.91). Reports of the two groups for identifying right ventricular enlargement showed 96% agreement ( κ  = 0.86; 95% CI = 0.82-0.90). The agreements for right ventricular pressure overload, wall motion abnormality and pericardial effusion were 100% ( κ  = 0.83; 95% CI = 0.77-0.89), 92% ( κ  = 0.83; 95% CI = 0.76-0.90), and 96% ( κ  = 0.83; 95% CI = 0.77-0.89), respectively., Conclusion: FOCUS performed by emergency medicine residents is comparable to echocardiography performed by cardiologists. Therefore, it could be a reliable tool and screening test for initial testing of patients suspected of cardiac abnormalities.

Objective: To determine the effects of pre-injury consumption of anti-platelet agents on the 30-day outcomes of patients with mild traumatic brain injury (TBI)., Methods: This prospective cohort study was conducted at three general hospitals in Tehran, Iran between July 2013 and July 2014. The study population included all patients with mild TBI aged over 18 years that medicated with aspirin or clopidogrel before occurring trauma. Within hospitalization, all patients were assessed with respect to in-hospital conditions especially complications and adverse events. After discharge, the individuals were followed for 30 days by telephone to assess mortality and disability using the Glasgow outcome scale (GOS)., Results: Of 1140 patients with mild TBI, only 135 had previously received aspirin and/or clopidogrel. The mean age was dramatically higher in those who were taking aspirin or clopidogrel (p<0.001). The patients with previously use of anti-platelets were more transferred by ambulance when compared to another group (p=0.006). The patients on anti-platelets had significantly lower GCS on admission when compared to others (p<0.001). Length of hospitalization was significantly longer in those receiving anti-platelets (p=0.003). In follow-up, 30-day mortality and disability was revealed in 2.8% of patients that received only aspirin and 7.5% in aspirin with clopidogrel and in 1.6 % of those who did not receive drugs without any significant difference between aspirin and control group (p=0.208) and significant difference in aspirin with clopidogrel group (p<0.001)., Conclusion: The premedication by anti-platelets (aspirin and/or clopidogrel) in patients with mild TBI leads to prolonged hospital stay, and increase rate of disability. Age and on admission GCS are the independent risk factors for predicting the outcome in patients with mild TBI receiving anti-platelet agents.

Introduction: Although many protocols are available in the field of the prehospital medical care (PMC), there is still a notable gap between protocol based directions and applied clinical practice. This study measures the rate of protocol adherence in PMC provided for patients with chest pain and loss of consciousness (LOC)., Method: In this cross-sectional study, 10 educated research assistants audited the situation of provided PMC for non-traumatic chest pain and LOC patients, presenting to the emergency department of a tertiary level teaching hospital, compare to national recommendations in these regards., Results: 101 cases with the mean age of 56.7 ± 12.3 years (30-78) were audited (55.4% male). 61 (60.3%) patients had chest pain and 40 (39.7%) cases had LOC. Protocol adherence rates for cardiac monitoring (62.3%), O2 therapy (32.8%), nitroglycerin administration (60.7%), and aspirin administration (52.5%) in prehospital care of patients with chest pain were fair to poor. Protocol adherence rates for correct patient positioning (25%), O2 therapy (75%), cardiac monitoring (25%), pupils examination (25%), bedside glucometery (50%), and assessing for naloxone administration (55%) in prehospital care of patients with LOC were fair to poor., Conclusion: There were more than 20% protocol violation regarding prehospital care of chest pain patients regarding cardiac monitoring, O2 therapy, and nitroglycerin and aspirin administration. There were same situation regarding O2 therapy, positioning, cardiac monitoring, pupils examination, bedside glucometery, and assessing for naloxone administration of LOC patients in prehospital setting., Competing Interests: There is no conflict of interest between authors.

Introduction: Scorpion sting is an important public health problem in some countries, including Iran. This study aimed to describe the demographics of a large number of these victims in some endemic areas of Iran., Methods: This cross-sectional study evaluated baseline characteristics, clinical findings, management, and disposition of scorpion stung cases in 26 cities of 4 provinces in the southwest quarter of Iran, during one year., Results: 3008 cases of scorpion sting with mean age of 27.07 ± 16.58 years were studied (51.3% female). The mean time from sting to hospital was 1.89 ± 1.04 hours. No first aid measures had been taken in 96.6% of cases. Lower (39.5%) and upper (35.7%) extremities were stung most frequently. Midnight to 6:00 am was the period of time most of stings occurred (34.2%). Local pain (77.2%) and erythema (63.5) were among the most common signs and symptoms. 2026 (67.3%) victims had been discharged; 326 (10.8%) were admitted or referred to other hospitals and 5 (0.2%) cases died., Conclusion: It seems that demographic characteristics of scorpion sting in Iran are not so different from those reported from other sites of the world, as signs and symptoms of local and systemic envenomations. Victims, companions, and healthcare providers perform many futile and maybe harmful measures and there is a need to educate all about all of these details.

Objectives: Meningitis is an important disease among the patients being visited in Emergency Departments (EDs). There are many signs to diagnose it with different sensitivity and specificity reported in previously done studies. Current study tries to evaluate diagnostic accuracy of "Jolt accentuation" in the diagnosis (Dx.) of meningitis in patients with fever and headache., Materials and Methods: 48 adult patients, who were referred to two teaching EDs for fever and headache and were diagnosed as suspected meningitis, were included in this prospective observational study. Demographic characteristics of patients were recorded in data sheets, as well as the results of exams including nuchal rigidity, Kernig and Brudzinski signs, and Jolt accentuation. Then, lumbar puncture (LP) was done and cerebrospinal fluid (CSF) was analyzed for each patient; pleocytosis (more than five white blood cells in high power field) were considered as meningitis. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (LR + and LR - ) of the above mentioned signs were compared to each other., Results: Meningitis was proved in 33 patients (68.8% of them), according to CSF analysis. Jolt accentuation had sensitivity, specificity, PPV, NPV, LR + , and LR - of 69.6%, 33.3%, 69.6%, 33.3%, 1.02, and 0.91, respectively. Jolt accentuation had the highest sensitivity rate all of the signs mentioned above; although, it was not significant., Conclusion: Jolt accentuation alone cannot rule in or out the Dx. of meningitis in patients with fever and headache; LP is still recommended for these patients.

Objectives: To assess ECG changes in patients with tramadol-induced seizure(s) and compare these changes in lower and higher than 500 mg tramadol doses as a main goal., Material and Methods: In an analytical-cross sectional manner over 1 year, 170 patients with idiosyncratic seizure(s) after using tramadol, were studied. Full data were recorded for each patient. ECGs were taken from all the patients on admission and 1 h later and were assessed for findings., Results: 70 of 170 patients (41.2%) had used lower than 500 mg doses of tramadol while 90 patients (52.9%) were included in the high dose group. Rate of female patients in the high dose group was significantly higher. The average age of patients in the high dose group was significantly lower (22.04 vs 25.76). The high dose group had significantly higher heart rates. There was no history of cardiovascular diseases; two patients had previous history of seizure. No significant difference was shown between low dose and high dose groups from the point of ECG changes., Discussion and Conclusion: Using doses higher than 500 mg is more frequently seen in women, young people and those who have not experienced previous use of tramadol. Terminal S wave, sinus tachycardia, and terminal R wave in the lead aVR are among the most common ECG changes in tramadol users.

Aims: To evaluate the effect of intravenous (IV) acetaminophen on reducing the need for morphine sulfate in intubated patients admitted to the Intensive Care Unit (ICU)., Settings and Design: Current study was done as a clinical trial on the patients supported by mechanical ventilator., Subjects and Methods: Behavioral pain scale (BPS) scoring system was used to measure pain in the patients. All of the patients received 1 g, IV acetaminophen, every 6 h during the 1(st) and 3(rd) days of admission and placebo during the 2(nd) and 4(th) days. Total dose of morphine sulfate needed, its complications, and the BPS scores at the end of every 6 h interval were compared., Results: Totally forty patients were enrolled. The mean pain scores were significantly lower in the 2(nd) and 4(th) days (4.33 and 3.66, respectively; mean: 4.0) in which the patients had received just morphine sulfate compared to the 1(st) and 3(rd) days (7.36 and 3.93, respectively; mean: 5.65) in which the patients had received acetaminophen in addition to morphine sulfate too (P < 0.001). Cumulative dose of morphine sulfate used, was significantly higher in the 1(st) and 3(rd) days (8.92 and 3.15 mg, respectively; 12.07 mg in total) compared to the 2(nd) and 4(th) days (6.47 mg and 3.22 mg, respectively; 9.7 mg in total) (P = 0.035)., Conclusion: In our study, IV acetaminophen had no effect on decreasing the BPSs and need of morphine sulfate in intubated patients admitted to ICU.

Background: Local anesthetic injections are widely used in the emergency department for different purposes. Pain management for such injections is of great importance to both patients and the healthcare system., Objectives: Our study aimed to determine the effectiveness and safety of cryotherapy in patients receiving local anesthetic injections., Methods: Subjects who presented with superficial lacerations were randomly assigned to 2 groups, the first group received ice packing prior to injection and the second did not. The pain severity, length and depth of the laceration, and the other necessary information before and after the pain-reducing intervention were measured, documented, and compared at the end of the study. Pain scores were measured using a numerical rating scale before and after the procedure, and the differences were compared using a t-test., Results: Ninety subjects were enrolled in the study, 45 in each group. There were no statistical differences between the 2 groups in terms of baseline preoperative and operative characteristics (P > 0.05). The pain scores in the cryotherapy group were significantly lower before and after the procedure (P < 0.001). There was no statistically significant difference between the 2 groups for wound infection (P = 0.783)., Conclusions: Cooling the injection site prior to local anesthetic injection is an effective and inexpensive method to reduce the pain and discomfort caused by the injection.

Introduction: It is thought that pituitary-adrenal axis has a fundamental role in outcome of cardiopulmonary arrest (CPA). This study designed to evaluate the correlation between adrenal reserve and post-resuscitation outcome., Methods: In this clinical trial study, 52 consecutive patients with CPA were enrolled in two emergency departments (EDs) over a 3-month period. Plasma cortisol level was measured at the beginning of CPR. Intravenous adrenocorticotropic hormone (ACTH) stimulation test was carried out after successful CPR, and blood samples were taken at 30 and 60 minutes, and 24 hours thereafter. Patients were divided into two groups: in-hospital death or hospital discharge., Results: In patients who died, baseline and post-ACTH serum cortisol after 30 and 60 minutes and 24 hours were higher than patients who discharged from the hospital, but it was not statistically significant except to that of minute 60 (P=0.49). A model of multivariate logistic regression analysis showed that age and need for vasopressor infusion correlated with mortality., Conclusion: Current study could not show the statistically significant difference in initial and post-ACTH serum cortisol levels between survivor and non-survivor patients with cardiac arrest who had initial successful CPR, except to that of minute 60.

Introduction: Patients with possible spinal injury must be immobilized properly during transport to medical facilities. The aim of this research was comparing spinal immobilization using a long backboard (LBB) with using a vacuum mattress splint (VMS) in trauma victims transported by an Emergency Medical Services (EMS) system., Methods: In this randomized clinical trial, 60 trauma victims with possible spinal trauma were divided to two groups, each group immobilized with one of the two instruments. Speed and ease of application, immobilization rate, and the patients' comfort were recorded., Results: In this survey, LBB was faster to apply: 211.66 (SD = 28.53) seconds vs 654.00 (SD = 16.61) seconds. Various measures of immobilization were better by LBB. Also, LBB offered a significant improvement in comfort over a VMS for the patient with possible spinal injury. All of the results were statistically significant., Conclusion: The results of this study showed that immobilization using LBB was easier, faster, and more comfortable for the patient, and provided additional decrease in spinal movement when compared with a VMS.

Introduction: An appropriate procedural sedation and analgesia (PSA) is crucial to reduce a dislocated shoulder successfully in emergency department. This study compares sedative effect of inhalational Entonox(®) (En) to intra-venous (IV) Midazolam plus Fentanyl (F+M)., Methods: 120 patients with recurrent anterior shoulder dislocation were randomly assigned into two groups. 60 patients (group F+M) received 0.1 mg/kg IV Midazolam plus 3µg/kg IV Fentanyl and 60 patients (group En) received Entonox(®) with self administration face mask on an on-demand basis. Traction/counter-traction method was used to reduce the dislocated shoulder joint in both groups., Results: 48 out of 60 (80%) patients in group F+M and 6 out of 60 (10%) patients in group En had successful reduction (p < 0.0001). The mean pain score reduction was 6.3 ± 1.2 for group F+M and 3 ± 0.9 for group En (p < 0.0001). There was a statistically significant difference in mean patient satisfaction (assessed with Likert score) between two groups (4.45 ± 0.6 for group F+M and 2.3 ± 1 for group En; p < 0.0001). Duration of entire procedure (since the beginning of PSA up to the end of successful or unsuccessful reduction) was shorter in Group F+M, but successful reductions occurred earlier in group En. No major side effect such as airway compromise, retracted respiratory depression, or circulatory failure was occurred in any group., Conclusion: Entonox(®) may not be an appropriate agent to help reducing a dislocated shoulder.