Objective:To compare the effects of intravenous morphine and a low dose of ketamine on pain intensity of patients with traumatic fractures of the long bones. Methods: This randomized, controlled, double-blinded, clinical trial was conducted in the adult emergency department (ED) of Emam Khomeini hospital, a tertiary general hospital affiliated with Mazandaran University of Medical Sciences, in Northern Iran, during a 6-month period. Patients were randomly assigned to receive intravenous morphine (0.1 mg/kg) or low dose ketamine (0.5 mg/kg) for control of the pain in the emergency room. The pain intensity was checked by a nurse using the visual analogue scale (VAS) at 30, 60, 90, 120, 180 and 240, minutes after the intervention. Results: Overall we included a total number of 156 patients with mean age of 35.87±3.38 years. There were 111 (71.2%) men and 4 (28.8%) women among the patients. Patients were randomly assigned to receive intravenous morphine (n=78) or low dose ketamine (n=78). The pain intensity decreased significantly in both study groups after 240 minutes of intervention. However, there was no significant difference between the two study groups regarding the pain intensity at 30 (p=0.378), 60 (p=0.927), 90 (p=0.434), 120 (p=0.557), 180 (p=0.991) and 240 (p=0.829) minutes. The side effects were comparable while low dose ketamine was associated with higher need for rescue analgesic (p=0.036). Conclusion:The results of the current study demonstrates that the intravenous low dose ketamine leads to successful pain control in patients with long bone fractures and the effects are comparable with intravenous morphine.
Introduction: The relationship between increased levels of cardiac troponins and morbidity and mortality of traumatic patients is not still well recognized. Aim: The aim of this study was to investigate the prognostic value of cardiac troponin I and T on admission in mortality of multiple trauma patients admitted to the emergency department. Methods: In this prospective follow-up study, the cardiac troponin I and T levels were measured in patients with multiple trauma referring to the emergency department (ED) between March 2014 and February 2015 at Imam Khomeini Hospital, Sari, Iran. Patients were followed prospectively until discharge from hospital or death. Results: The levels of cardiac troponins I and T in patients with multiple trauma were significantly associated with their mortality, especially at the level of 0.5 and 1.2 μg/dl (p<0.05). Multivariate regression analysis showed association of level of cardiac troponin I and T with patients’ mortality, after controlling for patients’ age, vital signs and GCS on admission. The sensitivity and specificity of troponin I at levels greater than 0.4 μg/dl in predict mortality in this study were as 65.5% and 55.3%, while the values for troponin T were 65.1% and 54.9%, respectively. Conclusion: Elevated cardiac troponin I and T levels provide excellent prognostic information regarding mortality in patients with multiple-trauma, independent of age, hemodynamic variables and GCS score.
BACKGROUND: Death in multiple trauma (MT) patients is one of the serious concerns of the medical service provider. Any prediction of the likelihood of death on the assessment of the patient's condition is performed using different variables, one of the tools in the triage of patients to determine their condition. AIM: We aimed to investigate the frequency and the predictive value of death in 24 hours triad of death in patients qualified with multiple traumas admitted to Imam Khomeini hospital. METHODS: This was a prospective cross-sectional study to determine the prevalence and predictive value of 24-hour triad of death among patients with MT referred to an emergency department. Three factors including acidosis, hypothermia and coagulopathy and predictive value of 24-hour death were evaluated. Arterial blood gas, oral temperature and blood samples for coagulation factors were analysed. Data were analysed using SPSS version 19. Multivariate analysis (logistic regression) was used to determine the predictive value of the triad of death. RESULTS: A group of 199 MT patients referring to Imam Khomeini hospital during the first 6 months of 2015 were evaluated for the first 24 hours of admission. Logistic regression analysis showed that using the following formula based on the triad of death can predict death in 96% of cases can be based on the triad of a death foretold death upon admission to the emergency room. It should be noted that this prediction tool as 173 people left alive after 24 hours as live predicts (100% correct). CONCLUSION: The triad of death is one of the tools in the triage of patients to determine their condition and care plan to be used, provided valuable information to predict the prognosis of patients with a medical team.
Introduction: Deep vein thrombosis (DVT) is a common cause of admission to the emergency departments (ED). Doppler ultrasonography of the entire lower limb is the first-line imaging modality. But most EDs do not access to full-time radiologists which can lead to delayed diagnosis. Aim: The aim of this study was to evaluate the diagnostic accuracy of three-point compression ultrasonography performed by emergency medicine resident for diagnosis of DVT. Methods: This prospective diagnostic study was carried out at Imam Khomeini Hospital in Sari from March 2018 to November 2018. For all patients with suspected lower extremity DVT, first bedside 3-point compression ultrasound were performed by a third year emergency medicine resident at ED. Then Doppler ultrasonography were performed by a radiologist in the radiology department, as a reference test. Sensitivity, specificity, and positive predictive value of the three-point compression ultrasound performed by emergency medicine resident was calculated. Results: Of the 72 patients enrolled in our study, 50% of the patients were male, with an average age of 36±19 years. The mean of patient admission time to perform ultrasonography by an emergency medicine resident and radiologist were 14.05±19 and 216±140.1 minutes, respectively. The two groups had a statistically significant difference (P<0.0001). In ultrasonography performed by emergency medicine resident and doper ultrasonography by radiologist, 91.67% and 36.1% of patients were diagnosed with DVT, respectively. Although the ultrasonography performed by emergency medicine resident has a relatively low sensitivity (53.8%), it has a good specificity (85.7%). The positive and negative predictive value was 70 and 75%, respectively. Conclusion: Although the results of this study indicate insufficient sensitivity of bedside three-point compression ultrasound performed by emergency medicine resident in diagnosis of lower limb DVT, the specificity, positive and negative predictive values and positive likelihood ratio were almost appropriate.
Introduction: Pain is one of the most common reasons that patients visit emergency departments. Morphine has been used extensively in pain management but there is no consensus about the effectiveness of method of administration. The aim of this study was to compare the divided dose vs bolus medication form of morphine sulfate for management of acute pain in traumatic fracture. Methods: we designed a randomized double-blind clinical trial. On basis of inclusion and exclusion criteria, 160 patients with acute traumatic fracture were enrolled to the study and randomly divided into two groups. The first group (bolus group) received 0.1mg/kg morphine and then 0.1mg/kg normal saline every 5 minutes. The second group (titration group) received 0.1mg/kg of morphine in divided doses every 5 minutes. All injections were intravenously. The primary outcome was pain and before of injection, 15 minutes and 60 minutes after injection were recorded. Data were analyzed using SPSS 19. Results: 77 patients included 49 (63.6%) male with mean age of 47.42 ± 13.15 years were in titration group and 83 patients included 47 males (56.6%) with mean age of 52.40 ± 15.62 years were in bolus group. The complication rate was significantly higher in bolus group (75.9% vs 53.2%, P <0.0001). The need to extra morphine injection in bolus and titration group were 62.7% and 28.6%, respectively (P <0.0001). The mean pain score before and at 15 and 60 minutes after injection were 9.56 ± 1.03, 6.61 ± 1.86 and 1.85 ± 1.13 in titration group and 9.76 ± 0.48, 6.53 ± 1.59 and 0.61 ± 0.46 in bolus group, respectively. The pain score was significantly lower in titration group at 60 minutes after injection (P <0.0001). Discussion: The results of this study showed that titration of morphine are a safe and effective method in compared with bolus administration to reducing acute pain in traumatic fracture.
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