مجله طب اورژانس ایران
سال سوم شماره 4 (پاییز 1395)

With the increasing number of patients admitted to emerge ncy department (ED) there is a raise in ratio of patients with severe conditions, who have not yet been admitted to other specialist services or their disposition to other departments has not been done due to overcrowding; therefore, the need for providing intensive care in ED is felt more than ever. Patient overcrowding in ED is one of the most common international concerns. Delays in admission and disposition of patients to intensive care unit (ICU) happen in most crowded hospitals that lack free ICU beds . This problem is not restricted to our country and can even be seen in many developed countries. ICU beds only make up an average of 1.2 – 6.3% of all beds in a hospital, while more than 15 - 20% of the hospital budget is dedicated to them. Studies have sho wn that patients with severe conditions in need of intensive care stay longer in ED and insufficient monitoring and non - standard care in this department can jeopardize the safety of these patients and result in side effects and undesirable outcomes for the m. Long ED stay of patients in need of intensive care leads to increase in ventilator - induced pneumonia and mortality. Most EDs lack the required human resources for providing the care patients with severe conditions need. Therefore, providing cares such a s changing the position of patients for reducing the chance of developing bedsore or keeping mouth hygiene in those under mechanical ventilation in a crowded ED is very difficult if not impossible. Patients with potentially reversible severe diseases reap the most benefit from intensive care. Based on type and quality of care provided, 2 to 80% of patients in ICU are only under cardiopulmonary monitoring and not receiving a vital and effective treatment. Currently, considering the increased number of severe ly ill patients in need of intensive care and their long ED stay, providing equipment and resources needed such as cardiac monitoring, ventilator, and trained staff for providing intensive care for severely ill patients is necessary in ED. This has been te sted and proved successful in many countries, which have a longer history in providing intensive care in ED. Nowadays there is a critical care unit in many developed EDs. In addition, emergency physicians that have been trained in the field of critical car e are working in these units as emergency critical care specialists. It seems that establishing critical care training courses for emergency physicians and initiating an intensive care fellowship course with high capacity for providing intensive care is ne cessary in our country. Existence of these specialists not only provides compensation for scarcity of intensive care specialists, but also increases the quality of critical care in ED and facilitates coordination between ED and ICU.

Increased environmental demand and decreased ability of an individual for responding to them raises mental pressures and leads to job burnout. Since job burnout has never been evaluated in nurses working in hospitals affiliated to Mazandaran University of Medical Sciences, the present study was carried out with the aim of evaluating job burnout rate in nurses working in emergency departments (EDs) of hospitals affiliated to Mazandaran University of Medical Sciences.
The present cross-sectional study included all of the nurses working in EDs of 3 teaching hospitals affiliated to Mazandaran University of Medical Sciences using consecutive sampling. The standard Maslach and Jackson questionnaire was used for assessment of job burnout. SPSS version 20 was used for analyzing data.
A total of 93 nurses with the mean age of 32.48 ± 8.1 were evaluated (72% female). The highest frequency belonged to 20-30 years age range (48.9%) and 5-9 years job experience (39.3%). Based on the results of rotated factor matrix, the load of emotional exhaustion, lack of personal success, and depersonalization in prevalence of job burnout was 7.42, 4.89 and 2.45 respectively. Mean intensity of emotional exhaustion was 33.19 ± 14.35 (0 –54), depersonalization was 4.91 ± 5.27 (0 –20) and lack of personal success was 29.58 ± 8.57 (8–45).
Based on the findings of this study, all the nurses working in the evaluated EDs showed degrees of job burnout. The highest load in prevalence of job burnout belonged to em otional exhaustion, lack of personal success, and depersonalization, respectively. The hospital in which they worked, age, sex, and job experience did not significantly affect the intensity of job burnout.

Although using clinical scales to predict shock severity is interesting for physicians as they provide rapid evaluation without need for special equipment, they are not highly reliable. Therefore, the present study was designed with the aim of assessing the agreement between shock index and base defects as scales of determining shock severity in multiple trauma patients.
In the present prospective cross - sectional study, the agreement of shock index and base defects in determining shock severity in multiple trauma patients presenting to emergency department (ED) was assessed. Patients with blunt multiple trauma aged between 15 to 6 years with 8-15 consciousness level and without any underlying illness were enrolled and finally the data were analyzed using SPSS 20.
In total, 387 patients with the mean age of 36.31 ± 15.03 years (15 – 90) were studied (80.6% male). M ost patients were in the 21 - 30 years age group (37.7%) and the most common trauma mechanisms were car accident (50.1%) and falling from height (24.8%). In addition, 15 (3.9%) patients had systolic blood pressure 10 0/min. According to kappa coefficient, a 0.824 agreement was seen between these scales in rapid prediction of shock index. With the shock index increasing, the number of blood units received in the initial 6 hours of admission to ED for patient resuscitati on rose from 0.02 to 1.72 units.
Considering the results of the present study, it seems that shock index and base defect scales have acceptable agreement in prediction of shock severity in multiple trauma patients. This agreement increases in the 2 extremes namely normal and severe cases (level 1 and 4).

Health care planning for management of patients visiting emergency department (ED) requires accurate statistics and data more than anything. Since chest pain is one of the most common complaints of patients in this department, the present study was done aiming to epidemiologically assess the patients presenting to ED following chest pain with the final diagnosis of myocardial infarction (MI).
In this retrospective cross - sectional study, to evaluate the characteristics of MI patients, medical profiles of all the patients presenting to ED of Shahid Mofatte h Hospital, Varamin, Iran, during 2011 to 2015, with complaint of chest pain and final diagnosis of acute MI were assessed. A pre - designed checklist was used that included demographic data, pain characteristics, history of cardiac diseases and risk factors of cardiovascular diseases, treatments received, time interval between symptom manifestation and presentation to ED, history of similar complaint, duration of hospitalization in ED, site of MI, troponin level on arrival, and final outcome.
168 pa tients with the mean age of 58.05 ± 12.46 years (range: 28 – 85) with complaint of chest pain and final diagnosis of acute MI visited the center during the study period (76.8% male). Before hospitalization in the cardiac care unit, these patients stayed in ED for an average of 12.6 ± 6.5 hours (range: 0.2 – 23.5). Most patients were in the > 50 years age group (74.3%) and had an education level less than high school diploma (91.7%). Mean duration of being affected with hypertension, diabetes, cardiac diseas es, hypercholesterolemia, and smoking for the studied patients were 6.1 ± 4.7 (1 - 20), 6.34 ± 5.9 (1 - 30), 7.1 ± 5.2 (1 - 21), 4.1 ± 3.3 (1 - 14), and 21.5 ± 11 (2 - 50) years, respectively. Mean time interval between symptom manifestation and ED visit was 12.9 ± 6.3 (1 - 24) hours. Patients reported their history of similar pains to go back to about 6.9 ± 3.4 ( - 12) months prior. In most patients, pain site was in anterior chest (88.7%), with sweating 61.01%) and without radiating to arms or jaws (86.3%). Most comm on dysrhythmia observed in this group of patients was ventricular tachycardia (24.4%). Since angiography and surgical intervention equipment were not available, all patients underwent thrombolytic therapy. Only 16 (9.5%) patients had positive troponin on a rrival. Finally, 9 (5.4%) patients died.
Based on the findings of the present study, most cases of MI in the studied center were male, over the age of 50 years, smokers, and had an education level less than high school diploma. The most common site of MI was in the anterior heart wall with anterior chest pain and ventricular tachycardia. In this evaluation, mortality rate of patients with MI was calculated to be 5.4% in the studied center.

At times of disaster, considering the large number of injured patients and limited availability of equipment and service, the injured need to be classified accurately in order to receive the best treatment. The present study was designed aiming to evaluate the knowledge and skill of a hospital’s disaster management team regarding triage at times of disaster.
The present cross - sectional study carried out in 2016 aimed to evaluate the knowledge and skill of the disaster management team in Shahid Rajaei Hospital, Gachsaran, Iran, regarding triage at times of disaster. An anonymous questionnaire designed by researchers was used for gathering data. The questionnaire was filled by a researcher after meeting the disaster team in person and explaining the aim s of the study to them. Data were analyzed using SPSS version 22 and descriptive statsistic tests (central tendency and distribution such as frequency, mean, and standard deviation) as well as inferential ones.
In total, 140 questionnaires were fi lled and gathered. Mean age of participants was 36.42 ± 7.9 (50.7% female). Their mean job experience was 9 ± 6.36 years and their mean experience in emergency department or intensive care unit was 3.03 ± 4.54 years. Mean score for knowledge regarding tria ge was 5.87 ± 2.35 (0 - 11) and mean score for skill was 3.67 ± 2.56 (0 - 9). Mean difference of knowledge score for physicians 6.54 ± 2.22, nurses 6.45 ± 2.09, office workers 4.53 ± 2.71, maintenance 4.60 ± 1.59, and staff of paraclinical units (laboratory, rad iology,...) 6 ± 2.12 did not vary significantly (p = 0.08). There was no significant correlation between job experience and knowledge of triage (p = 0.46, r = 0.01) or triage skill (p = 0.91, r = 0.01).
Findings of the present study showed that knowledge and skill of the disaster management team in Shahid Rajaei Hospital, Gachsaran, Iran, regarding triage at times of disaster is poor. No significant relationship was found between these factors and demographic factors such as age, sex, job experien ce, history of doing triage, level of education, and organizational position.

Biochemical markers of myocardial injuries have radical importance in diagnosis or dismissing cardiac events, especially in cases that electrocardiographic findings are not present. Therefore, this study was designed aiming to appraise 1-month outcome of patients presenting to emergency department (ED) following acute coronary syndrome (ACS) with positive creatine kinase-MB (CK-MB) and negative troponin.
This prospective cross - sectional study was done on patients presenting to ED with complaint of acute chest pain and diagnosis of ACS. Patients who did not have a clear electrocardiographic finding indicating acute myocardial infarction (MI) (ST segment elevation) and had positive CK - MB and negative troponin in laboratory tests of serum were included. Demographic data and baseline characteristics, CK serum level, CK-MB, troponin, and 30-day outcome of the patients were analyzed using SPSS version 19.
13759 patients had visited the ED with complaint of chest pain during the study period (57% f emale). 1003 (7.3%) patients had positive troponin test and 12704 (92.3%) had negative CK - MB index and were therefore eliminated from the study. Finally, 52 (0.4%) had both positive CK - MB and negative troponin indices. 35 (67.3%) of them were discharged fr om ED after serial electrocardiography and negative troponin test. 11 (21.2%) were admitted to critical care unit but were discharged due to having 2 negative troponin tests in 12 hours and normal serial electrocardiogram. 6 (11.5%) were referred for surgi cal interventions. No mortality was seen in 1-month follow-up.
Based on the results of the present study, only 0.4% of ACS patients presenting to the studied ED had positive CK - MB and negative troponin indices. During 1 - month follow - up, no case of mortality or MI was observed among them. Only 2 (3.8%) cases needed surgical intervention.

The present study was done aiming to assess and identify methods of increasing the capacity of emergency department (ED) and therefore, enhancing the efficiency of Alzahra Hospital, Isfahan, Iran, as a whole in facing a disaster with high mortality rate.
This descriptive study was carried out in 2014 in Alzahra teaching hospital, Isfahan, Iran. Indices such as mean percentage of occupied beds in ED, patients’ ED length of stay, triage status, bed turnover interval, and available space, as well as the number of patients that can be discharged from emergency or dispositioned to other wards in 4 - 6 hours were determined. Then according to the number of beds in hospital, radiology ward, and operation rooms, the number of outpatients, critically ill pati ents, and those in need of critical care were determined. Then the possibility of reverse triage was evaluated and the number of patients who could be discharged was calculated.
The total number of admitted patients in 2013 was 50836, 6444 of whic h were outpatients and 44392 needed emergency services. ED admissions in 201 included 20125 (45.3%) cases of acute surgery, 8890 (20%) cases of acute internal patients, and 6215 (14%) cases of sub - acute patients. The longest stay based on the status of pa tients belonged to acute internal patients with a mean of 35.9 hours length of stay. The total number of available emergency beds is currently 80. On the other hand, based on the number of admitted and discharged patients in 2013, mean emergency bed occupa tion rate was 92.3%. Mean length of ED stay was 14.2 hours in 2013, and bed turnover interval was 1.3/day.
Regular admission capacity of ED includes 13 extra beds and 30 critical condition beds. In addition, if reverse triage could be done to d ischarge sub - acute patients from ED, 22 beds can be added. Considering the occupation percentage of ED beds, there are about 5 empty beds and therefore, based on available resources, the expandable capacity of ED is 68 beds.

Abdominal pain is one of the most common complaints during pregnancy, which is constantly debated due to its numerous differential diagnoses. Acute appendicitis is the most common problem requiring surgery during pregnancy and has a prevalence of 1 in 1500 pregnant women. Existing studies have declared that acute appendicitis during pregnancy is diagnosed with delay in 30 - 35% of cases. This can have severe side effect sand may even lead to death of the mother or fetus. Strong clinical suspicion of the physician in addition to taking proper advanced paraclinical measures can reduce errors in this regard. To emphasize the importance of this subject, we have reported a ca se of appendicitis during pregnancy.