Accepted Manuscript

Procalcitonin and D-dimer in predicting 28-day-mortality rate and

severity of sepsis based on SOFA score

Mehdi Momeni, Elnaz Vahidi, Javad Safavi, Morteza Saeedi

PII: S0735-6757(17)30555-7
DOI: doi: 10.1016/j.ajem.2017.07.025
Reference: YAJEM 56811
To appear in:
Received date: 18 June 2017
Revised date: 4 July 2017
Accepted date: 6 July 2017

Please cite this article as: Mehdi Momeni, Elnaz Vahidi, Javad Safavi, Morteza Saeedi ,
Procalcitonin and D-dimer in predicting 28-day-mortality rate and severity of sepsis based
on SOFA score, (2017), doi: 10.1016/j.ajem.2017.07.025

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 ACCEPTED MANUSCRIPT

Procalcitonin and D-dimer in predicting 28-day-mortality rate and severity of sepsis based on SOFA
score

Mehdi Momeni , MD ; Assistant Professor of Emergency Medicine, Emergency Medicine Research

Center, Shariati Hospital; Emergency Medicine Department, Tehran University of Medical Sciences,
Tehran, Iran

Elnaz Vahidi, MD ; Assistant Professor of Emergency Medicine, Emergency Medicine Research Center,
Shariati Hospital, Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran

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Javad Safavi, MD ; Emergency Medicine Department, Shariati Hospital, Tehran University of Medical

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Sciences, Tehran, Iran

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Morteza Saeedi, MD; Associate Professor of Emergency Medicine, Emergency Medicine Research
Center, Shariati Hospital; Emergency Medicine Department, Tehran University of Medical Sciences,
Tehran, Iran
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Corresponding author: Morteza Saeedi, MD ; Tehran University of Medical Sceinces, Prehospital
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Emergency Research Center, Shariati Hospital.

North Amirabad street Tehran Iran Tel: 982184902719; Fax: 982188633039

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m_saeedi@tums.ac.ir
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Short running title: Procalcitonin and D-dimer in predicting mortality rate

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We have not funding source

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Word count: 2744

Trail was registered in www.irct.ir and trail number is IRCT201408068872N5

Author’s contributions:

Momeni M; study design and supervision, Safavi J; data gathering and analysis, Vahidi E; data analysis
and drafting, Saeedi M; critical revision

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 ACCEPTED MANUSCRIPT

Epistaxis is a common complaint in patients presenting to Emergency Department

with the annual prevalence of about 11 % [1, 2]. Sixty percent of population
experience epistaxis at least once during life [3, 4]. Annually, 14.9 out of 10000
persons need medical care for epistaxis and among these, 1.6 are admitted [5].
Eighty to ninety percent of epistaxis is originated from anterior nasal cavity [6],
Direct compression of the cartilaginous part of the nose for 10 – 15 minutes is a

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simple and effective way to control epistaxis with success rate up to 65% [7],

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however; it is often missed in epistaxis management and the needed time is not

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considered by the patient [8].

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The application of direct pressure with a correct method and enough time can
easily obviate the need for further aggressive and expensive interventions and it
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may prevent their adverse events [9].

It is supposed that patients do not apply manual compression constantly for enough
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time, therefore nose clips may have better success rate because they are not in need
of patients’ cooperation.
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This study is a randomized clinical trial conducted in Shahid Rahnemoon Hospital

Emergency Department from January 2016 to July 2016. The study was approved
by Ethics Committee of Shahid Sadoughi University of Medical Sciences.

Patients triaged with chief complaint of epistaxis were visited by the physicians in
charge of the study and eligible patients were selected. All the assistants involved

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in the study were trained to glean the required data.

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Patients older than 16 years presented to the Emergency Department with active

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epistaxis of anterior origin were included in the study.

Patients were excluded from the study if there were traumatic or post-surgery

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epistaxis, bleeding disorders or anticoagulant use, intervention for controlling
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epistaxis in recent six months, posterior epistaxis, hemodynamic instability, upper
respiratory tract infection, association with a significant complaint (e.g. chest
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pain), and septal deviation.

After written informed consent, patients eligible for the study was randomized into
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intervention group (nose clips) and control group (manual compression After
allocation, demographic information of the patients was recorded in a prepared
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form. Severity of epistaxis was defined as, no bleeding (1), spotting (2), oozing (3)
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and severe blood flow (4).

After clearing the clots by blowing the nose, patients were asked to sit on a chair
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and have sniffing position. In intervention group, nose clip by the nurse, and in
control group manual compression by the patient were applied to the cartilaginous
part of the nose for 15 minutes. Then the compression was relieved and bleeding
severity was assessed and recorded.

If bleeding did not stop, the next step was cauterization of bleeding site, if visible,
or anterior nasal tampon. If these measures were not successful, the next step was

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ENT consultation. Finally, patients satisfaction from the treatment was measured
via Likert scale (strongly satisfied, satisfied, no idea, dissatisfied, strongly
dissatisfied)

Length of stay in the emergency department was measured from the admittion and
disposition time and recorded.

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Twenty six of 92 patients were excluded from the study and the remaining 66 were

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randomly allocated to two groups of 33 patients. Finally, 30 patients in group A
(nose clip) and 31 patients in group B (manual compression) were treated and

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analyzed (figure 1). Age, sex, and epistaxis severity before intervention were the
same in both groups (table 1).

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Both interventions seemed successful in controlling epistaxis (p value: 0.000) and
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epistaxis was controlled to full stop (50.8) or spotting (19.7) in 70.5 % of patients.
Nose clip was better in controlling epistaxis especially in severe epistaxis (p value:
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0.008). ENT consultations were ordered more in manual compression group, but it
was not statistically significant (p value: 0.8). Emergency Department stays in nose
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clip group was less than manual compression (p value: 0.000). Satisfaction was
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higher in nose clip group (p value: 0.000).

As the study interventions were nose clip and manual compression, blinding of the
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patients was impossible. Nose clip used in this study applies constant bilateral
compression to the cartilaginous part of the nose. It had better success rate than
manual compression to fully stop the bleeding (66.7 % versus 35.5 %). Only 1
patient (3.3%) had severe blood flow after applying nose clip much less than
control (11 patients [35.5%]). It is supposed that this difference in controlling
epistaxis is due to dependency of manual compression to patient’s cooperation.

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In control group, further invasive and more time consuming treatment methods
increased the length of stay in the Emergency Department.
It seems that owing to better controlling of epistaxis, shorter length of stay, and
less ENT consultation and intervention, patient's satisfaction from treatment was
significantly higher in nose clip group.
This study revealed that applying nose clips is a simple, but effective way in

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controlling epistaxis leading to time saving and reducing more invasive treatments.

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References
1. Melia L, McGarry GW. Epistaxis: update on management. Curr Opin
Otolaryngol Head Neck Surg 2011;19:30–5.
2. Kilty, S.J., et al., Prospective clinical trial of gelatin-thrombin matrix as
first line treatment of posterior epistaxis. Laryngoscope, 2014. 124(1): p.
38-42.

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3. Tomkinson A, Roblin DG, Flanagan P, et al. Patterns of hospital

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attendance with epistaxis. Rhinology 1997;35(3):129–31.

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4. Viehweg, T.L., J.B. Roberson, and J.W. Hudson, Epistaxis: diagnosis and
treatment. J Oral Maxillofac Surg, 2006. 64(3): p. 511-8.

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5. Douglas, R. and P.J. Wormald, Update on epistaxis. Curr Opin
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Otolaryngol Head Neck Surg, 2007. 15(3): p. 180-3.
6. Fukutsuji, K., et al., Superselective angiographic embolization for
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intractable epistaxis. Acta oto-laryngologica, 2008. 128(5): p. 556-560.

7. Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and
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treatment. J Oral Maxillofac Surg 2006;64(3):511–8.

Zahed R, Moharamzadeh P, AlizadehArasi S, Ghasemi A, Saeedi M. A
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8.

new and rapid method for epistaxis treatment using injectable form of
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tranexamic acid topically: a randomized controlled trial. The American

journal of emergency medicine. 2013 Sep 30;31(9):1389-92.
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9. Bertrand B, Eloy P, Rombaux P, Lamarque C, Watelet JB, Collet S.

Guidelines to the managment of epistaxis. B ENT. 2005 Jan 1:27.

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Assessed for eligibility

Excluded from the study, n=26 n=91
Due to
Trauma, n=13
Anti coagulant usage, n=2
Posterior epistaxis, n=2
Unstable hemodynamic, n=5
Unwillingness, n=2
History of treatment in past 6 month, n=2 Randomized
n=65

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Allocated to manual compression, n=33 Allocated to nose clip, n=32

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Received intervention, n=31 Received intervention, n=30

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Lost to follow-up, n=0
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Analyzed, n=31 Analyzed, n=30

Figure 1: Flow diagram
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Table 1
Baseline characteristics of enrolled patients
Variables Nose clip Manual
Patients N 30 31
Age mean (range) 41 (19-77) 44 (17-68)
Male: Female 14:16 16:15
Epistaxis severity before intervention N (%)
Spotting 7 (23) 6 (19)

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Oozing 8 (26) 9 (29)

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Stream 15 (50) 16 (51)

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