فهرست مطالب

Archives of Academic Emergency Medicine - Volume:6 Issue:1, 2018
  • Volume:6 Issue:1, 2018
  • تاریخ انتشار: 1397/09/21
  • تعداد عناوین: 60
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  • Mitra Rahimi, Somaieh Lookzadeh, Roxana Sadeghi, Kambiz Soltaninejad, Abdolkarim Pajoumand, Hossein Hassanian, Moghaddam, Nasim Zamani, Masoud Latifi, Pour, Shahin Shadnia * Page 1
    Introduction

    Amphetamine type stimulants (ATS) such as amphetamine and methamphetamine (MA) are one of the most important causes of poisoning in the world. In this study we aimed to define the predictive factors of mortality in acute ATS poisoning patients.

    Methods

    This is a retrospective cross-sectional study on all cases with acute ATS poisoning who were referred to a referral center for poisoning, Tehran, Iran, from April 2011 to March 2014. Using patients’ medical records, demographic data, route of exposure, type and amount of ATS, the cause of poisoning, clinical presentations, and electrocardiogram (ECG) and laboratory findings, as well as patient’s outcomes were collected and analyzed regarding the independent predictive factors of mortality.

    Results

    226 cases with the mean age of 32.9 ± 10.9 years were studied (77% male). MA was the most abused ATS (97.4%) and the most frequent route of exposure was oral (55.3%). The mortality rate was 5.4%. There was a significant association between agitation (p = 0.002), seizure (p = 0.001), loss of consciousness (p < 0.001), creatine phosphokinase level (p = 0.002), serum pH (p = 0.002), serum HCO3 (p = 0.02), and PCO2 (p = 0.01) with mortality. However, serum HCO3 [OR=1.27 (95% CI: 1.07-1.50); p value=0.005], PCO2 [OR=0.89 (95% CI: 0.84-0.96); p value=0.002], and loss of consciousness [OR=0.019 (95% CI: 0.003-0.106); p value=0.000] were the only independent predictive factors of mortality.

    Conclusion

    PCO2 ≥ 51 mmHg, serum bicarbonate ≤ 22.6 mEq/L, and loss of consciousness on admission could be considered as prognostic factors of mortality in acute ATS poisoning cases presenting to emergency department.

    Keywords: Amphetamines, patient outcome, prognostic factors, poisoning, substance abuse
  • Neamatollah Ataei, Sonbol Ameli, Mahmoud Yousefifard, Alireza Oraei, Fatemeh Ataei, Behnaz Bazargani, Arash Abbasi, Mostafa Hosseini * Page 2
    Introduction

    There is a controversy regarding accuracy of neutrophil gelatinase-associated lipocalin (NGAL) and Cystatin C in early detection of acute kidney injury (AKI). The present study aimed to compare the diagnostic value of two biomarkers in this regard.

    Method

    In the present diagnostic accuracy study, all children between the ages of 1 month to 14 years were entered. Pediatric Risk, Injury Failure, Loss, End-stage renal disease (pRIFLE) criteria was used for identification of children with AKI as the reference test. Blood samples were taken from all patients at baseline and 48 hours after admission to assess serum creatinine and Cystatin C level. In addition, a urine sample was obtained within 6 hours of admission in order to measure NGAL level. In the end, area under the receiving operating characteristics (ROC) curve, sensitivity, and specificity of urine NGAL (uNGAL) and Cystatin C in early detection of AKI were compared.

    Results

    Data from 96 children with the mean age of 27.31±36.24 months were entered (56.25% girls). Area under the ROC curve of uNGAL level in diagnosis of AKI in children was 0.91 (95% CI: 0.80 to 1.00) and area under the ROC of Cystatin C was 0.90 (95% CI: 0.77 to 1.00). Both tests had the same value in diagnosis of AKI (p=0.89). The best cut-off point of uNGAL for diagnosing AKI was 125 mg/L. uNGAL had a sensitivity and specificity of 0.92 (0.62 to 0.99) and 0.69 (0.57 to 0.78), respectively. The best cut-off point of serum Cystatin C level was 0.4 mg/L. Cystatin C had a sensitivity and specificity of 0.92 (0.62 to 0.99) and 0.64 (0.52 to 0.74), respectively.

    Conclusion

    The present study showed that uNGAL level has the same value as serum Cystatin C level in early diagnosis of AKI.

    Keywords: Cystatin C, Lipocalin-2, Acute Kidney Injury, Early Diagnosis, Dimensional Measurement Accuracy
  • Majid Shojaee, Saeed Safari, Anita Sabzghabaei, Mostafa Alavi, Moghaddam, Ali Arhami Dolatabadi, Hamid Kariman, Soheil Soltani * Page 3
    Introduction

    Pro-brain natriuretic peptide (Pro-BNP) can act as an independent predictor of mortality in septic patients. This study aimed to compare the diagnostic accuracy of pro-BNP and Mortality in Emergency Department Sepsis (MEDS) score in this regard.

    Method

    This cross-sectional study was conducted on > 14 years old sepsis patients of an emergency department (ED), during 2 years. The level of Pro-BNP and MEDS score were measured for all eligible patients and considering one-month mortality as reference, screening performance characteristics of the two tests were compared using SPSS 21 and STATS 11.

    Results

    121 patients with the mean age of 75.87±11.82 years were studied (55.4% male). 85 (70.25%) patients had moderate to high probability of mortality according to MEDS score. The mean Pro-BNP levels of survivor and non-survivor patients were 489.69 ± 327.47 and 3954.98 ± 2717.85 pg/ml, respectively (p < 0.0001). Sensitivity and specificity of Pro-BNP (in 1000 pg/ml cut off) and MEDS score (in level 3) in prediction of 1-month mortality were 93.6 (83.7-97.9), 94.8 (84.7-98.6), 65.0 (51.9-76.3), and 98.2 (89.5-99.9), respectively. Area under the ROC curve of the two tests were 97.36 (95% CI: 92.92-94.48) and 92.31 (95% CI: 86.35-96.53), respectively (p = 0.0543).

    Conclusion

    Pro-BNP and MEDS score both have excellent diagnostic accuracy in predicting 1-month mortality of sepsis patients. However, considering the higher sensitivity as well as availability and ease of calculation, it seems that Pro-BNP can be considered an appropriate tool for screening patients with high risk of mortality following sepsis in ED.

    Keywords: Pro-brain natriuretic peptide, sepsis, mortality, Emergency department, dimensional measurement accuracy
  • Shahrooz Tabrizi, Amir Nejati, Saharnaz Nedjat, Seyed Mojtaba Aghili * Page 4
    Introduction

    The present study is a survey to assess the pros and cons of emergency medicine (EM) from the viewpoint of the scholars from other medicine disciplines to improve the efficiency of EM in the healthcare system.

    Methods

    This is a semi-structured qualitative study. Face-to-face interviews with various physicians with different specialties were performed to gather information on their viewpoints. Study population was selected mainly based on their history of collaboration with emergency medicine specialists in several educational hospitals in Tehran, Iran. All interviews were recorded and then transcribed to paper. Data were mainly categorized and reported into four themes: 1) general aspects of emergency medicine, goals and policies 2) Management of emergency department 3) Educational aspects 4) therapeutic aspects.

    Results

    22 specialist physicians with the mean age of 47.3±7.6 years were studied (77.3% male). The average of their work experience as a specialist was 13.6±7.5 years. From the viewpoint of other experts, the establishment of EM and training of EM specialists is accompanied with relative disadvantages and advantages regarding goals and policies, patient management, therapeutic interventions and student education in the emergency department. Initiating resuscitation and maintaining hemodynamic stability and appropriate triage of the patients can add to the benefits of EM by preventing unreasonable hospitalization, and reducing the workload and difficulty of the work of other professionals working in the hospital.

    Conclusions

    Based on the results of the current study, it seems that most Iranian specialist physicians have a positive attitude towards emergency medicine and think that emergency medicine could have beneficial effects for the health system and hospital management system.

    Keywords: Emergency medicine, emergency service, hospital, attitude of health personnel
  • Gilava Hedayati Emam, Hossein Alimohammadi, Akram Zolfaghari Sadrabad, Hamidreza Hatamabadi * Page 5
    Introduction

    Due to the stressful nature of emergency Department (ED), residents in ED are at risk of violence from patients or their associates. This study aimed to determine the prevalence of workplace violence against ED residents and the reasons for not reporting them.

    Methods

    This cross-sectional study was conducted on ED residents of three educational hospitals, Tehran, Iran, during 2015. The national questionnaire about workplace violence was used for data gathering. In addition, prevalence of reporting the violence and the reasons for not reporting them were determined.

    Results

    280 questionnaires were analyzed. The mean age of residents was 32.2 ± 4.6 years (58.4% female). 224 (80%) residents stated that they had not passed any educational courses on violence management. The most prevalent type of violence was verbal (90.7%) and patients’ associates (85.4%) were the most common source of aggression. The frequency of physical violence was higher in male aggressors (p = 0.001), resident age > 30 years (p = 0.044), aggressor age > 30 years (p = 0.001), and night shift (p = 0.001). The same trend was observed regarding verbal and racial-ethnic violence. There was no significant relationship between residents’ sex, resident's specialty, and presence of security and police with frequency of violence. 214 (76.4%) residents did not report the violence, and the main reasons for not reporting from their viewpoint were uselessness of reporting (37.4%) and insignificance of the violence (36.9%).

    Conclusion

    Based on the findings of the present study more than 90% of ED residents had experienced at least one type of verbal, physical, or racial-ethnic violence during their shifts. It is necessary for residents in EDs to be trained about violence control and also report and follow these issues through legal channels.

    Keywords: Workplace violence, physical abuse, internship, residency, emergency service, hospital
  • Alireza Ala, Farzad Rahmani *, Sima Abdollahi, Zahra Parsian Page 6
    Introduction

    The diagnostic value of clinical signs in early diagnosis of meningitis has been evaluated but the existing results are contradicting. The present study aimed to evaluate the accuracy of Kernig, Brudzinski, neck stiffness, and Jolt Accentuation of Headache (JAH) signs in this regard.

    Methods

    In this diagnostic accuracy study, patients with suspected meningitis who were referred to the emergency department were examined regarding presence or absence of the mentioned clinical signs and screening performance characteristics of the signs were calculated. Cerebrospinal fluid analysis was used as the reference test.

    Results

    120 cases with mean age of 48.79 ± 21.68 years (18 – 93) were studied (63.3% male). Diagnosis of meningitis was confirmed for 45 (37.5%) cases. Neck stiffness (p < 0.001), Kernig (p < 0.001), Brudzinski (p < 0.001), and JAH (p < 0.001) had significantly higher frequency among patients with meningitis. The accuracy of neck stiffness, Kernig, Brudzinski, and JAH signs in early detection of meningitis were 0.676 (95% CI: 0.575-0.776), 0.667 (95% CI: 0.552-0.782), 0.720 (95% CI: 0.619-0.821), 0.749 (95% CI: 0.659-839), respectively.

    Conclusions

    It seems that diagnostic value of JAH is higher than other clinical signs but the accuracy of all signs is in poor to fair range. JAH had the highest sensitivity and Kernig and Brudzinski had the highest specificity.

    Keywords: Meningitis, physical examination, headache disorders, secondary, neurologic manifestations
  • Ali Arhami, Dolatabadi *, Elham Memary, Majid Shojaee, Hossein Kamalifard Page 7
    Introduction

    Currently, using various combinations of narcotic and analgesic drugs has received attention for induction of sedation and analgesia due to their synergy in controlling pain and anxiety. The present study was designed with the aim of comparing dexmedetomidine-fentanyl combination with midazolam-fentanyl in this regard.

    Methods

    In this randomized clinical trial, patients diagnosed with distal radius fracture who had visited the emergency department (ED) were allocated to either the group receiving the combination of fentanyl-midazolam or the one receiving dexmedetomidine-fentanyl for procedural sedation and analgesia (PSA) and were compared regarding analgesic characteristics, time to recovery and side effects.

    Results

    80 patients with the mean age of 42.08 ± 12.17 (18 - 60) years were randomly allocated to 2 groups of 40 (83.80% male). The 2 groups did not have a significant difference regarding baseline characteristics as well as pain severity. Mean pain score at the time of procedure was 3.47 ± 1.37 in dexmedetomidine and 2.85 ± 1.05 in midazolam group (p = 0.025). In addition, time to recovery in dexmedetomidine and midazolam groups was 6.60 ± 1.86 minutes and 12.70 ± 1.70 minutes, respectively (p < 0.001). Out of the 9 patients who experienced treatment failure, 8 (88.90%) patients were in dexmedetomidine group and 1 (11.10%) was in midazolam group (p = 0.029). Absolute risk increase rate of treatment failure in case of using dexmedetomidine instead of midazolam was 17.50% (95%CI: 4.19 – 30.81) and number needed to harm was 6.00 (95% CI: 3.20 – 23.80).

    Conclusion

    Although the combination of dexmedetomidine-fentanyl had a shorter time to recovery compared to midazolam-fentanyl for induction of sedation and analgesia, the treatment failure rate in case of using dexmedetomidine with 1 µg/kg increased 17.5% and about 1 out of each 6 patients needed a rescue dose.

    Keywords: Conscious sedation, analgesia, dexmedetomidine, midazolam, closed fracture reduction, clinical trial
  • Babak Shekarchi, Seyed, Zia Hejripour, Rafsanjani, Nima Shekar, Riz, Fomani *, Mojtaba Chahardoli Page 8
    Introduction

    Using bedside ultrasound in diagnosing acute cholecystitis in the emergency department (ED) can save time, help the decision making process and allocate resources wisely. This study aimed to evaluate the diagnostic accuracy of bedside right upper quadrant (RUQ) ultrasonography in detection of acute cholecystitis.

    Method

    In this diagnostic accuracy study, patients presenting to ED, suffering from RUQ pain in favor of acute cholecystitis underwent RUQ ultrasonography in emergency and radiology departments and interrater agreement between reports was calculated.

    Results

    342 patients with the mean age of 53.92 ± 11.18 (20 – 83) years were studied (63.2% female). The number of patients with at least one sonographic finding of acute cholecystitis were 53 (15.50%) and 48 (14.00%) based on ED and radiology reports (Kappa = 0.826). Sensitivity, specificity, positive and negative predictive values, as well as positive and negative likelihood ratios of bedside sonography were 89.58 (95%CI: 76.55 – 96.10), 96.59 (95%CI: 93.63 – 98.29), 81.13 (95%CI: 67.58 – 90.11), 98.26 (95%CI: 95.77 – 99.36), 4.30 (95%CI: 2.42 – 7.62) and 0.017 (95%CI: 0.007 – 0.041), respectively.

    Conclusion

    There was a very good agreement between ED and radiology departments’ sonography reports regarding the presence or absence of acute cholecystitis. Sensitivity and specificity of bedside RUQ sonography were 89.58 and 96.59, respectively.

    Keywords: Cholecystitis, acute, ultrasonography, diagnostic imaging, emergency service, hospital, emergency medicine
  • Babak Shekarchi, Mohammadreza Mokhdanzadeh, Dashti, Mostafa Shahrezaei, Ebrahim Karimi * Page 9
    Introduction

    Timely diagnosis and treatment of traumatic injury to ulnar collateral ligament (UCL) of thumb is of special importance for preserving the full function of the hand. Therefore, the present study has been designed with the aim of evaluating the accuracy of ultrasonography in detection of these injuries.

    Methods

    The present diagnostic accuracy study was performed on traumapatients over 15 years oldwho had clinical evidence of injury to UCL of thumb and were admitted to the emergency department. All patients were evaluated regarding injury to the mentioned ligament via ultrasonography and MRI and finally, the accuracy of ultrasonography in this regard was measured considering MRI as the reference test.

    Results

    20 individuals with the mean age of 38.60 § 13.45 (16 – 64) years were evaluated (60% male). Based on ultrasonography andMRI findings 7 (35%) individuals and 7 (35%), respectively had complete ligament rupture (kappa: 0.560 (95% CI: 0.179 – 0.942)). Sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of ultrasonography in detecting injuries of the mentioned ligament were 71.42 (30.25 – 94.88), 84.61 (53.66 – 97.28), 71.42 (30.25 – 94.88), 84.61 (53.66 – 97.28), 2.5 (0.71 – 8.82), and 0.18 (0.04 – 0.67), respectively.

    Conclusion

    Based on the findings of the present study, performance of ultrasonography by a radiologist in the emergency department has 80% accuracy in detecting traumatic injuries of UCL of the thumb.

    Keywords: Ultrasonography, collateral ligament, ulnar, injuries, magnetic resonance imaging, dimensional measurement accuracy
  • Javad Tootian Tourghabe, Hamid Reza Arabikhan, Ali Alamdaran, Hamid Zamani Moghadam * Page 10
    Introduction

    Dependence of ultrasonography on the operator’s skill plays a major role in the differences between various studies in reporting its diagnostic accuracy. Therefore, the present study was done with the aim of comparing the ultrasonography findings performed by emergency medicine resident and radiologist in evaluation of acute cholecystitis.

    Methods

    The present diagnostic accuracy study has been carried out on patients presenting to the emergency department with complaint of pain in the right upper quadrant of abdomen suspected with acute cholecystitis. All the patients underwent gallbladder ultrasonography by a trained emergency medicine resident and a radiologist and their findings were compared with surgical and pathology findings regarding gallstone and increased gallbladder wall thickness.

    Results

    51 patients with the mean age of 42.3±15.8 (17-81) years were analyzed (82.4% female). The overall agreement between emergency medicine resident and radiologist in ultrasonographic diagnosis of cholecystitis was 0.421 (95% CI: 0.118-0.724). Based on the pathology and surgical findings, acute cholecystitis was confirmed for all 51 (100%) patients. Meanwhile, based on the ultrasonographic report of radiologist and emergency medicine resident only 45 (88.2%) and 34 (66.7%) patients, respectively, were diagnosed with cholecystitis. Screening performance characteristics of ultrasonography by radiologist for detection of gallbladder stone (p = 0.010) and gallbladder wall thickness (p < 0.0001) were significantly better than emergency medicine resident.

    Conclusion

    The screening performance characteristics of ultrasonography by radiologist in detection of gallstones and increased wall thickness of gallbladder were significantly better.

    Keywords: Gallstones, cholecystitis, acute, diagnostic imaging, ultrasonography
  • Mehrdad Esmailian, Mahboubeh Koushkian Esfahani *, Farhad Heydari Page 11
    Introduction

    Efficient treatment of asthma can play an important role in controlling asthma attacks, rapid recovery and decrease of patient mortality. Therefore, in the present study the therapeutic effect of low-dose ketamine is evaluated in patients with acute asthma attack.

    Methods

    In the present single-blind, randomized clinical trial with placebo control, the effect of low-dose intravenous ketamine in treating 18 to 85 year-old asthmatic patients who presented to the emergency department was evaluated. Peak expiratory flow rate (PEFR) and the patients’ response to treatment were measured before and 1 hour after treatment. Additionally, using SPSS 22.0, effectiveness of ketamine with 0.3, 0.4, and 0.5 mg/kg doses followed by infusion of the same dose during 30 minutes were compared with placebo.

    Results

    92 patients were enrolled (59.8% female, mean age 48.5 ± 13.9 years). 15 (16.3%) patients were treated with 0.3 mg/kg ketamine, 14 (15.2%) with 0.4 mg/kg, and 16 (17.4%) with 0.5 mg/kg doses. Mean PEFR was 336.2 ± 101.5 liters in the placebo group and 345.8 ± 84.7 liters in the ketamine group before intervention (p = 0.6), while after intervention, they were 352.1 ± 101.2 and 415.8 ± 76.2 liters, respectively (p = 0.001). Ketamine treatment with 0.4 and 0.5 mg/kg doses led to a higher increase in PEFR compared to 0.3mg/kg dose (df: 3, 88; F = 23.8; p < 0.001).

    Conclusion

    It seems that administration of 0.4 - 0.5 mg/kg doses of intravenous ketamine followed by infusion of the same dose during 30 minutes can be effective for rapid recovery of PEFR in patients with mild to moderate asthma.

    Keywords: Ketamine, asthma, efficiency, peak expiratory flow rate, emergency service, hospital
  • Ali Arhami Dolatabadi, Aida Mohammadian *, Hamid Kariman Page 12
    Introduction

    Finding a fast-acting compound with minimal side-effects to induce a safe and efficient analgesia with short or medium duration of action is of great interest in the emergency department. The present study has been designed with the aim of comparing the effect of midazolam + fentanyl + lidocaine combination with midazolam + fentanyl + placebo in pain management of anterior shoulder dislocation reduction.

    Methods

    The present two-arm parallel double-blind randomized controlled trial was performed on patients who presented to emergency department with anterior shoulder dislocation. Patients were randomly allocated to the 2 treatment groups of midazolam + fentanyl + placebo (double-drug group) and midazolam + fentanyl + intravenous (IV) lidocaine (triple-drug group). Then outcomes such as treatment success rate and side-effects following prescription of drugs were compared between the 2 groups.

    Results

    100 patients were included in the present study (50 patients in each group; mean age of the studied patients 27.3±8.9 years; 93.0% male). Using the double-drug regimen led to 35 (70%) cases of complete analgesia, while this rate in the triple-drug group was 41 (82%) cases (p=0.16). The calculated number needed to treat was 9 cases. This means that about one in every 9 patients in treatment arm will benefit from the treatment. The most important side-effects observed included dysrhythmia (1 patient in double drug and 1 patient in triple-drug group), apnea (2 patients in each group) and SPO2<90% (2 patients in triple-drug group) (p=0.78). Number needed to harm was 25 cases. In other words, for each 25 patients treated with the triple drug regimen, 1 case of SPO2<90% is observed.

    Conclusion

    Findings of the present study showed that adding IV lidocaine to IV midazolam + fentanyl drug combination does not provide additional analgesia in sedation for anterior shoulder reduction.

    Keywords: Conscious Sedation, Midazolam, Fentanyl, Lidocaine, Combined Modality Therapy
  • Mohamad Sorani, Sogand Tourani *, Hamid Reza Khankeh, Sirous Panahi Page 13
    Introduction

    Prehospital Emergency Medical Care (EMC) is a critical service in disaster management. The aim of this study was to explore the challenges of prehospital Emergency Medical Services (EMS) during disaster response in Iran.

    Methods

    A qualitative study was conducted from April 2015 to March 2017. Data were collected through in-depth, semi-structured interviews with 23 experienced individuals in the field of disaster that were selected using purposeful sampling. Data were analyzed using content analysis approach.

    Results

    Fifteen sub-themes and the following six themes emerged in the analysis: challenges related to people, challenges related to infrastructure, challenges related to information management systems, challenges related to staff, challenges related to managerial issues and challenges related to medical care.

    Conclusions

    Iran’s prehospital EMS has been chaotic in past disasters. Improvement of this process needs infrastructure reform, planning, staff training and public education.

    Keywords: Disaster planning, emergency medical services, qualitative research, earthquakes
  • Saeed Safari, Behrouz Hashemi, Mohammad Mehdi Forouzanfar, Mehrnoush Shahhoseini, Meysam Heidari * Page 14
    Introduction

    Elimination of preventable deaths due to acute kidney injury (AKI) in low-income countries by 2025 is an important healthcare goal at the international level. The present study was designed with the aim of evaluating the prevalence and outcome of AKI in patients presenting to emergency department.

    Methods

    The present cross-sectional, retrospective study was performed on patients that presented to the emergency departments of 3 major teaching hospitals, Tehran, Iran, between 2005 and 2015 and were diagnosed with AKI. Patient selection was done using consecutive sampling and required data for this study was extracted by referring to the medical profiles of the patients and filling out a checklist designed for the study.

    Results

    770 AKI patients with the mean age of 62.72 ± 19.79 (1 – 99) years were evaluation (59.1% male). 690 (89.61%) cases of AKI causes were pre-renal or renal. Among the pre-renal causes, 74 (73.3%) cases were due to different types of shock (p < 0.001). The most common etiologic causes of AKI in pre-renal group were hypotension (57.3%) and renal vascular insufficiency (31.6%). In addition, regarding the renal types, rhabdomyolysis (35.0%), medication (17.5%) and chemotherapy (15.3%) and in post-renal types, kidney stone (34.5%) were the most common etiologic causes. 327 (42.5%) patients needed dialysis and 169 (21.9%) patients died. Sex (p = 0.001), age over 60 years (p = 0.001), blood urea nitrogen level (p < 0.001), hyperkalemia (p < 0.001), metabolic acidosis (p < 0.001), cause of failure (p = 0.001), and type of failure (p = 0.009) were independent risk factors of mortality.

    Conclusion

    The total prevalence of AKI in emergency department was 315 for each 1000000 population and preventable mortality rate due to AKI was estimated to be 28.2 cases in each 1000000 population. The most important preventable AKI causes in the pre-renal group included shock, sepsis, and dehydration; in the renal group they included rhabdomyolysis and intoxication; and stones in the post-renal group.

    Keywords: Acute kidney injury, outcome assessment (health care), prevalence, epidemiology, renal insufficiency
  • Ali Shahrami, Saba Ahmadi *, Saeed Safari Page 15
    Introduction

    Screening of high risk patients and accelerating their treatment measures can reduce the burden of the disease caused by acute upper gastrointestinal (GI) bleeding. This study aimed to compare the full and modified Glasgow-Blatchford Bleeding Score (GBS and mGBS) in prediction of in-hospital outcomes of upper GI bleeding.

    Methods

    In the present retrospective cross-sectional study, the accuracy of GBS and mGBS models were compared in predicting the outcome of patients over 18 years of age with acute upper GI bleeding confirmed via endoscopy, presenting to the emergency departments of 3 teaching hospitals during 4 years.

    Results

    330 cases with the mean age of 59.07 ± 19.00 years entered the study (63.60% male). Area under the curve of GBS and mGBS scoring systems were 0.691 and 0.703, respectively, in prediction of re-bleeding (p = 0.219), 0.562 and 0.563 regarding need for surgery (p = 0.978), 0.549 and 0.542 for endoscopic intervention (p = 0.505), and 0.767 and 0.770 regarding blood transfusion (p = 0.753). Area under the ROC curve of GBS scoring system regarding need for hospitalization in intensive care unit (0.589 vs. 0.563; p = 0.035) and mortality (0.597 vs. 0.564; p = 0.011) was better but the superiority was not clinically significant.

    Conclusion

    GBS and mGBS scoring systems have similar accuracy in prediction of the probability of re-bleeding, need for blood transfusion, surgery and endoscopic intervention, hospitalization in intensive care unit, and mortality of patients with acute upper GI bleeding.

    Keywords: Gastrointestinal hemorrhage, decision support techniques, outcome assessment (Health Care), hospital mortality
  • Alireza Majidi, Tala Shahhosseini *, Sadrolla Mahmoudi Page 16
    Introduction

    Compared to ordinary people, addicts usually have a lower pain threshold. The current work attempts to compare the performance of local analgesia with lidocaine among opium addicts and non-addicts.

    Methods

    In this case-control study, opium addicts and healthy patients with skin laceration referring to emergency departments of two educational hospitals were compared regarding the response to local anesthesia with lidocaine, as well as side effects.

    Results

    197 cases with the mean age of 43.44 ± 20.12 years were studied (72.1% male). 98 (49.8%) cases were addicts and 99 (50.2%) were healthy people. Two groups were similar regarding age (p = 0.281), sex (p = 0.666), and wound size (p = 0.272). The amount of pain reduction 5 (df =1.5, F=0.38, p = 0.88) and 10 (df =1.5, F=0.58, p = 0.72) minutes after lidocaine injection was not different between the groups. Subgroup analysis based on sex and age of patient did not show any differences between the groups (p > 0.1 for all analysis). The mean duration of analgesia was 16.4 ± 5.37 minutes in addicts and 16.95±1.79 in control group (p = 0.334).

    Conclusion

    Lidocaine, as a commonly used local anesthetic agents, does not show different effects in addicts and non-addicts in repairing skin laceration.

    Keywords: Lidocaine, opium dependence, anesthetics, local, case-control studies, pain management
  • Esraa Ghanem, Muhammad Elgazar, Khaled Oweda, Hussien Tarek, Fathy Assaf, Mostafa Wanees, Ahmed Elgebaly, Abdelrahman Ibrahim Abushouk * Page 17
    Introduction

    It is important for all medical and paramedical staff to be aware of basic life support (BLS) maneuvers. In this study, we aimed to evaluate the level of BLS awareness among Egyptian medical students.

    Methods

    The level of BLS knowledge was assessed using a validated questionnaire and the results were analyzed using an answer key, prepared from the Advanced Cardiac Life Support (ACLS) manual. We used the Student's t-test to analyze the association between awareness level and year of study, previous BLS training and practical experience.

    Results

    A total of 823 medical students with the mean age of 20.3 ± 2.7 years, from Al-Azhar medical schools completed the questionnaire (463 and 360 in academic and clinical years, respectively). About 72% and 84% of students failed to recognize the proper point of chest compression in adults and infants, respectively. Moreover, the majority (80%) did not know how to give rescue breathing in infants. Only 18% of students correctly identified early signs of shock and only 22% knew how to help patients with myocardial infarction. Being in clinical years, previous BLS training or practical experience were significantly associated with higher BLS knowledge scores (p < 0.001).

    Conclusion

    The level of BLS awareness among Egyptian medical students is generally poor. Introduction of regular BLS courses into the undergraduate curriculum is a must to increase the level of BLS knowledge among Egyptian future physicians.

    Keywords: Awareness, Basic Life Support, Medical Education, Students
  • Ramazan Güven * Page 18
    Introduction

    This study aims to analyze the references that the authors and editors used during the writing of Rosen’s Emergency Medicine, 8th edition.

    Methods

    15,209 references, which were used in 197 chapters of Rosen’s EmergencyMedicine, 8th edition, were examined regarding the distribution of countries, journals, publication year, and the department of the affiliation of the first author.

    Results

    A total of 63.1% (n = 9591) of the references were led by authors from the United States (US). US-based journals were mostly used, and Annals
    of Emergency Medicine was the journal from which the references were most frequently extracted, with a percentage of 5.2% (n = 756). The studies conducted by emergency physicians have increased in recent years, and emergency physicians, with a percentage of 17.8% (n = 351), were the leading authors of studies conducted between 2010 and 2013, which were cited in the references of Rosen’s Emergency Medicine, 8th edition.

    Conclusion

    US-based studies make up a significantly bigger portion of the references used in Rosen’s Emergency Medicine, 8th edition. If Europe and other countries give due importance to emergency medicine, they will have the capability to produce studies that can be used as references in textbooks asmuch as the US.

    Keywords: Emergency medicine, reference books, Europe, publications, United States, writing
  • Mitra Rahimi, Mahboubeh Elmi, Hossein Hassanian, Moghaddam, Nasim Zamani, Kambiz Soltaninejad, Reza Forouzanfar, Shahin Shadnia * Page 19
    Introduction

    Parenteral form of lidocaine is the best-known source of lidocaine poisoning. This study aimed to evaluate the characteristics of acute lidocaine toxicity.

    Methods

    In this retrospective cross-sectional study, demographics, clinical presentation, laboratory findings, and outcome of patients intoxicated with lidocaine (based on ICD10 codes) admitted to Loghman Hakim Hospital, during April 2007 to March 2014 were analyzed.

    Results

    30 cases with the mean age of 21.83 ± 6.57 year were studied (60% male). All subjects had used either 6.5% lidocaine spray or 2% topical formulations of lidocaine. The mean consumed dose of lidocaine was 465 ± 318.17 milligrams. The most frequent clinical presentations were nausea and vomiting (50%), seizure (33.3%), and loss of consciousness (16.7%). 22 (73.3%) cases had normal sinus rhythm, 4 (13.3%) bradycardia, 2 (6.7%) ventricular tachycardia, and 2 (6.7%) had left axis deviation. 11 (36.6%) cases were intubated and admitted to intensive care unit (ICU) for 6.91 ± 7.16 days. Three patients experienced status epilepticus that led to cardiac arrest, and death (all cases with suicidal intention).

    Conclusion

    Based on the results of this study, most cases of topical lidocaine toxicity were among < 40-year-old patients with a male to female ratio of 1.2, with suicidal attempt in 90%, need for intensive care in 36.6%, and mortality rate of 10%.

    Keywords: Lidocaine, poisoning, drug-related side effects, adverse reactions, administration
  • Mona Zamanian, Azodi, Mostafa Rezaei, Tavirani *, Mohammad Rostami, Nejad, Fatemeh Tajik, Rostami Page 20
    Introduction

    Cardiopulmonary resuscitation (CPR) is a method to improve survival of patients with cardiac arrest. This study aimed to identify the key genes affected five minutes after cardiac arrest, hoping to elevate the efficacy of CPR.

    Methods

    In this bioinformatics study differentially expressed genes of six pigs were downloaded from GEO and screened. The significant and characterized genes were analyzed via calculating fold change and protein-protein interaction (PPI) networks. The crucial nodes were determined based on centrality parameters and their related biological processes were investigated via ClueGO.

    Results

    17 significant up-regulated (LogFC ≥ 2) and 22 down-regulated (LogFC < -0.5) genes were detected. Transthyretin (TTR logFC = 4.59) and Gonadotropin-releasing hormone receptor (GNRHR logFC = 3.84) had higher logFC among up-regulated and down-regulated genes, respectively. The critical genes including four up-regulated and five down-regulated genes were detected from network analysis. GNRHR and Prolactin precursor (PRL) were among the most important down res 5 minutes after cardiac arrest and Beta-2 adrenergic receptor and Cadherin-1 were among the most important up regulated gens.

    Conclusion

    The introduced potential biomarkers could reveal a new molecular aspect for CPR performance and pituitary gland protection was highlighted in this respect.

    Keywords: Cardiac Arrest, Cardiopulmonary Resuscitation, Protein Interaction Maps, Gene Ontology, Biomarkers
  • Nader Tavakoli, Seyed Hosein Shaker, Siamak Soltani, Mohsen Abbasi, Milad Amini, Ali Tahmasebi, Seyed Mohammad Hosseini Kasnavieh * Page 21
    Introduction

    Job burnout, stress, and satisfaction are linked to quality of care, patient outcomes and retention of staff. This study was conducted to determine the mentioned issues among emergency nurses.

    Methods

    This cross-sectional study was conducted on all nurses working in the emergency departments of 10 hospitals in Tehran, Iran, in 2017. Standard questionnaires were used for gathering the data of participants regarding job burnout, stress, and satisfaction.

    Results

    709 (90%) participants returned the completed questionnaires (58.9% female). The mean age of the nurses was 33 (SD = 7) years. The level of job burnout was moderate in 76.1%, low in 22.5%, and high in 1.4% of the nurses. The level of burnout in the married nursing staff was lower than single nurses (3.78 ± 0.98 versus 4.14 ± 0.58, p = 0.049). The level of job satisfaction was moderate in 61.1%, low in 22.2%, and high in 16.7%. There was a significant correlation between age and job satisfaction (p = 0.027, r = 0.3). Job burnout was directly correlated with job stress (p ≤0.001, r = 0.57) and job burnout was negatively correlated with job satisfaction (p = 0.001, r = -0.41).

    Conclusion

    More than 60% of the studied emergency nurses had moderate levels of job burnout, stress, and satisfaction. Job burnout had a direct correlation with job stress and indirect correlation with job satisfaction. Planning to reduce burnout of the emergency nursing staff seems to be necessary.

    Keywords: Burnout, Professional, occupational Stress, Job Satisfaction, nurses, emergency responders, hospitals
  • Parisa Ghelichkhani, Maryam Esmaeili *, Mostafa Hosseini, Khatereh Seylani Page 22
    Introduction

    Many scoring models have been proposed for evaluating level of consciousness in trauma patients. The aim of this study is to compare Glasgow coma scale (GCS) and Full Outline of UnResponsiveness (FOUR) score in predicting the mortality of trauma patients.

    Methods

    In this diagnostic accuracy study trauma patients hospitalized in intensive care unit (ICU) of 2 educational hospitals were evaluated. GCS and FOUR score of each patient were simultaneously calculated on admission as well as 6, 12 and 24 hours after that. The predictive values of the two scores and their area under the receiver operating characteristics (ROC) curve were compared.

    Results

    90 patients were included in the present study (mean age 39.4±17.3; 74.4% male). Comparing the area under the ROC curve of GCS and FOUR score showed that these values were not different at any of the evaluated times: on admission (p=0.68), and 6 hours (p=0.13), 12 hours (p=0.18), and 24 hours (p=0.20) after that.

    Conclusion

    The results of our study showed that, GCS and FOUR score have the same value in predicting the mortality of trauma patients. Both tools had high predictive power in predicting the outcome at the time of discharge.

    Keywords: Glasgow Coma Scale, Wounds, Injuries, Trauma Severity Indices, Outcome Assessment (Health Care), Critical Care, Intensive Care Units
  • Mohammadali Jafari, Amir Aliheidari Biuki *, Majid Hajimaghsoudi, Mehdi Bagherabadi, Ehsan Zarepur Page 23
    Introduction

    Conversion disorder is a condition in which the patient shows psychological stress in physical ways. This study aimed to compare the effects of haloperidol versus midazolam in patients with conversion disorder.

    Methods

    This double-blind randomized clinical trial was conducted on patients with conversion disorder who had presented to the emergency department, throughout 2015. Patients were randomly divided into two groups and were either treated with 2.5 mg of intravenous (IV) haloperidol or 2.5 mg of IV midazolam. Recovery rate, time to recovery, and side effects of both drugs 1 hour, 24 hours, and 1 week after treatment were compared using SPSS19.

    Results

    140 patients were divided into two groups of 70. There were no significant differences between the groups regarding the baseline characteristics. 12 (17.1%) patients who were treated with IV haloperidol experienced drug side effects within 1 hour and 12 (17.1%) within 24 hours, while only 3 (4.3%) patients in IV midazolam experienced side-effects within 1 hour after drug administration (p = 0.026). The symptoms of the disease subsided in 45 (success rate: 64.3%) patients in midazolam and in 64 (success rate: 91.5%) participants in haloperidol group (P<0.001). Mean recovery time was 31.24 ± 7.03 minutes in IV midazolam and 30.53 ± 7.11 minutes in IV haloperidol group (p = 0.592). Absolute risk reduction (ARR) of treating patients with haloperidol compared to midazolam is about 27%.

    Conclusion

    The response of patients to treatment with haloperidol is clearly better than midazolam. Although more transient and minor side-effects were observed in the group treated with haloperidol compared to midazolam group, serious side-effects were rare for both treatments.

    Keywords: Conversion disorder, hysteria, Haloperidol, Midazolam, side effects, intravenous
  • Saeed Reza Ghanbarizadeh, Hossein Dinpanah *, Reza Ghasemi, Yaser Salahshour, Samaneh Sardashti, Mostafa Kamali, Seyed Reza Khatibi Page 24
    Introduction

    About 5% of visits to emergency departments are made up of conversion disorder cases. This study was designed with the aim of comparing the effectiveness of quetiapine and haloperidol in controlling conversion disorder symptoms.

    Methods

    The present single-blind clinical trial has been performed on patients with conversion disorder (based on the DSM-IV definition) presenting to emergency department of 9-Day Hospital, Torbat Heydariyeh, Iran, from January 2017 until May 2018.

    Results

    73 patients were allocated to haloperidol and 71 to quetiapine group. Mean age of these patients was 32.03 ± 12.80 years (62.50% female). Two groups were similar regarding the baseline characteristics. Within 30 minutes, 90.41% of haloperidol cases and 91.55% of quetiapine cases were relieved (p=0.812). The most common side effects after 30 minutes were extrapyramidal symptoms (9.59%) in the haloperidol group and fatigue and sleepiness (7.04%) in the quetiapine group. Extrapyramidal symptoms was significantly higher than the quetiapine group (p=0.013).

    Conclusion

    The results of the present study showed that although quetiapine and haloperidol have a similar effect in relieving the patients from conversion disorder symptoms, the prevalence of extrapyramidal symptoms is significantly lower in the group under treatment with quetiapine. Therefore, it seems that quetiapine is a safer drug compared to haloperidol.

    Keywords: Conversion disorder, hysteria, dissociative disorders, quetiapine fumarate, haloperidol, emergency service, hospital
  • Mohammad, Reza Motie Motie, Anvar Soleimani, Arash Soltani, Seyed Isaac Hashemy * Page 25
    Introduction

    Finding an accurate diagnostic test can reduce the rate of unnecessary abdominal surgery in cases of suspected acute appendicitis (AA). This study aimed to evaluate the diagnostic value of serum lactoferrin (LF) and procalcitonin (PCT) in detection of patients with acute appendicitis.

    Methods

    In this diagnostic accuracy study, screening performance characteristics of PCT and LF were calculated in patients suspected with acute appendicitis and healthy volunteers as control group.

    Results

    131 cases participated (61 as case and 70 as control). The mean serum level of LF (0.9±0.14 vs 0.2±0.13 µg/ml; p 0.0001) and PCT (0.15±0.21 vs 0.11±0.02 ng/dl; p = 0.02) were significantly higher in patients suspected with AA. The AUC of PCT and LF were 0.46 (95% CI: 0.31-0.61) and 0.61 (95%CI: 0.47 - 0.76), respectively. At a 0.90 µg/ml cut-off value, LF had 77% (95 % CI: 63 - 91) sensitivity and 43% (95 % CI: 31 - 55) specificity. Also, at a 0.11 ng/dl cut-off value, PCT had 41% (95 % CI: 26 - 56) sensitivity and 69% (95 % CI: 53 - 85) specificity.

    Conclusion

    Based on the main finding of present study, the overall accuracy of serum PCT and LF in detection of patients with acute appendicitis are in poor to failed range and it seems that they could not be considered as good screening tools for this purpose.

    Keywords: Diagnosis, Marker, Procalcitonin, Lactoferrin, Acute Appendicitis
  • Arash Beiraghi, Toosi, Roya Askarian, Faezeh Sadrabadi Haghighi, Mohammad Safarian, Fereshteh Kalantari, Seyed Isaac Hashemy * Page 26
    Introduction

    Several studies have shown the role of oxidative stress in pathophysiology of burn injuries. This study aimed to evaluate the changes of oxidant-antioxidant levels during the week following burn injuries and its correlation with grade of burn.

    Methods

    In this prospective cross-sectional study, changes of total glutathione, reduced glutathione (GSH), oxidized GSH (GSSG), GSH/GSSG ratio, as well as Pro-oxidant-antioxidant balance (PAB) were investigated on the 1st, 2nd and 7th days of admission in patients with > 15 % burns.

    Results

    40 patients with the mean age of 21.1 ± 14.5 were studied (47.5% male). More than 50% of patients were in the 18 – 55 years age range and over 70% had 20% – 60% grade of burn. Total serum glutathione level and GSH had significant decreasing trends (P < 0.001) and GSSG and GSH/GSSG ratio had increasing trends (p < 0.001). No significant correlation was observed between serum GSH level and the total body surface area (TBSA) of burn injury (r = 0.047; p = 0.779). The evaluation of PAB and its correlation with TBSA showed a significant and direct association between them on the 1st (coefficient = 0.516; p = 0.001), 2nd (coefficient = 0.62; p <0.001), and 3rd (coefficient = 0.471; p = 0.002) day of follow up.

    Conclusion

    According to this study, the redox perturbation occurred in burn injury which was measured and proved by decreased GSH/GSSG ratio as well as the shift of PAB in favour of oxidants. Besides, since PAB positively correlated with the severity of dermal damage, it might suggest the application of antioxidants as a part of therapeutic protocol for which the dosage should be proportionate to the surface area of the damaged skin.

    Keywords: Oxidative stress, oxidants, antioxidants, Glutathione, Burns
  • Majid Hajimaghsoudi, Mehdi Bagherabadi, Ehsan Zarepur, Vahid Ahmadi Hanzaei * Page 27
    Introduction

    The quality of interventions in children is largely dependent on their control. Hence, this study compared the sedative effects of subcutaneous (SC) and intravenous (IV) Midazolam in pediatric sedation induction.

    Methods

    This randomized clinical trial was conducted on children aged 1-6 years presenting to emergency departments of Shahid Sadoughi and Shahid Rahnemoon Hospitals, Yazd, Iran. Participants were randomly assigned to IV or SC midazolam using a jet injector and success rate, degree of sedation, and satisfaction of parents and physician were compared between groups.

    Results

    60 cases with the mean age of 3.15±1.43 (1-6) years were randomly assigned to the SC (30 cases) or IV (30 cases) groups (56.7% female). SC and IV groups were similar regarding the mean age (p = 0.165) and sex (p = 0.121).

    Depth of sedation (p=0.900), control of child (p=0.711), in-charge physician’s satisfaction (p=0.467), successful sedation and need for rescue dose (p=0.519) were not different between groups. IV midazolam group had a significantly shorter recovery time (about 10 minutes; p=0.040) and SC midazolam group had a significantly higher level of parent satisfaction (p=0.001).

    Conclusion

    The findings indicate no significant difference in depth of sedation, control of child, in-charge physician’s satisfaction, successful sedation (reaching stage 1 of sedation or higher), and need for rescue dose of SC and IV midazolam. Parents’ satisfaction was significantly greater with SC administration and IV injection had shorter recovery time.

    Keywords: Midazolam, sedation, jet injector, Injections, Subcutaneous, Personal satisfaction, children
  • Mauro Giordano *, Tiziana Ciarambino, Pietro Castellino, Lorenzo Malatino, Giuseppe Signoriello, Giuseppe Paolisso, Luigi Elio Adinolfi Page 28
    Introduction

    Early detection is crucial for prompt management of acute kidney injury (AKI) patients in emergency department (ED). This study aimed to investigate the usefulness of hyperchloremic metabolic acidosis (HCMA) levels in this regard.

    Methods

    In this retrospective observational study, > 18 years old critically ill patients presenting to ED of Marcianise Hospital, Italy, were divided into non-AKI and AKI group according to KDIGO guideline. The level of HCMA ((arterial pH x bicarbonate)/chloride) was compared between groups and correlation of HCMA with estimated glomerular filtration rate (e-GFR) in ARF patients was evaluated.

    Results

    134 patients with the mean age of 76.5 ± 3.1 years were enrolled (64 non-AKI and 70 AKI; 64% female). Two groups were similar regarding mean age (p = 0.251), sex (p = 0.091), APACHII score (p = 0.215), Charlson Comorbidity Index (p= 0.187), and body mass index (p = 0.129). The mean HCMA level was 1.98 ± 0.09 in the non-AKI group and 1.56 ± 0.07 in the AKI group (p=0.039). There was a positive correlation between HCMA and e-GFR levels in AKI group (r: 0.467, p=0.0092).

    Conclusions

    If confirmed and validated in a future study, ABG derived formula for HCMA may be a useful tool for early detection of AKI patients in emergency department.

    Keywords: Acute kidney injury, hyperchloremic metabolic acidosis, emergency department, renal function
  • Saeed Abbasi, Hossein Shaker, Fariba Zareiee, Davood Farsi, Peyman Hafezimoghadam, Mahdi Rezai, Babak Mahshidfar, Mani Mofidi * Page 29
    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.

    Keywords: Diagnosis, emergency service, hospital, diagnostic imaging, ultrasonography, thoracic injuries
  • Shahrzad Ghiyasvandian, Afshin Khazaei *, Masoumeh Zakerimoghadam, Rasoul Salimi, Ali Afshari, Abbas Mogimbeigi Page 30
    Introduction

    Infrequency and low exposure to critically ill patients requiring airway management will lead to reduction in the skills and performance of the Emergency Medical Technicians (EMTs) over time. The present study was conducted primarily aiming to evaluate airway management in stationary ambulance simulations and identify the factors affecting Endotracheal Intubation (ETI) success rate.

    Method

    This is a simulation study. The study population comprised of active EMTs in prehospital emergency bases in Hamadan province. The participants were placed at the back of an ambulance to perform the airway management scenario, which had already been prepared. To investigate the factors affecting the success (≤3 attempts) or failure rate of intubation, both unadjusted and adjusted odds ratios (95% confidence intervals) for univariate and multivariate regressions were reported.

    Results

    184 subjects with the mean age of 33.91+6.25 years and the median work experience of 8 years were studied (54.3% with a history of training in the past year). The median number of previous intubations performed by technicians in the last year was 7 times (IQR 4-9). The total success rate at ventilation, intubation and back-up airway were 50.67%, 53.29%, and 50.0%, respectively. Out of the total 552 attempts for ETI placement, 58.2% of the technicians were able to perform ETI within 3 attempts. Univariate analysis showed that age (OR=1.06, P=0.022), previous number of ETIs (OR=2.49, P<0.001), work experience (OR=1.13, P<0.001), and previous ETI training (OR=1.85, P=0.041) were significantly associated with ETI success rate. After adjustment, previous number of ETIs (OR=2.66, P<0.001) was the most effective factor on ETI success rate.

    Conclusion

    Success rate in airway management, especially ETI, is low. Therefore, improvement in modifiable factors such as increasing the number of ETIs performed and gaining experience in the same conditions as pre-hospital emergency is necessary.

    Keywords: Airway Management, Endotracheal Intubation, Emergency Medicine Technicians
  • Afshin Amini, ali arhami, hamid kariman, Hamidreza Hatamabadi, elham Memary, Sohrab Salimi, Shahram Shokrzadeh * Page 31
    Introduction

    Need for procedural sedation and analgesia (PSA) is felt in emergency department (ED) more and more each day. This study aimed to compare the effectiveness of low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination with regular dose of propofol and fentanyl combination for induction of deep sedation.

    Methods

    In this single-blind clinical trial, candidate patients for sedation and analgesia aged more than 15 and less than 60 years old, with pain score ≥6 were allocated to one of the groups using block randomization and were compared regarding onset of action, recovery time, and probable side effects.

    Results

    125 patients with the mean age of 37.8 ± 14.3 years were randomly allocated to each group. 100% of the patients in group 1 (5 drugs) and 56.5% of the patients in group 2 (2 drugs) were deeply sedated in the 3rd minute after injection. The 2 groups were significantly different regarding onset of action (p = 0.440), recovery time (p = 0.018), and treatment failure (p < 0.001).

    Conclusion

    Low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination was more successful in induction of deep sedation compared to regular dose of propofol and fentanyl combination. Recovery time was a little longer in this group and both groups were similar regarding drug side effects and effect on vital signs.

    Keywords: Clinical trial, deep sedation, emergency service, hospital, ketamine, propofol, analgesia
  • Parisa Eizadi, Mohammad Jalili *, Ahmadreza Dehpour Page 32
    Introduction

    Appropriate pain relief enhances patient satisfaction and reduces patient anxiety. This study aimed to compare oral oxycodone with intravenous (IV) morphine sulfate (MS) in pain management of acute limb trauma.

    Method

    In this randomized double-blind clinical trial, patients over 14 years old, with acute isolated limb trauma were randomized to receive either 5mg IV MS or 5 mg oral oxycodone. Pain intensity and adverse effects of medications were recorded 0, 30 and 60 minutes after drug administration and compared between the groups.

    Result

    58 patients were studied. Pain intensity was similar between the two studied groups at 30 minutes (P = 0.834) and 60 minutes (P = 0.880) after drug administration. Furthermore, there was no significant difference between the two groups regarding decrease in pain within the defined time interval. Drowsiness was reported more frequently in MS group after 30 minutes (p = 0.006). Patients in MS group asked for more rescue analgesia. Other adverse effects were similar in both groups.

    Conclusion

    Oral oxycodone is as effective as IV morphine sulfate in treatment of acute musculoskeletal pain following blunt limb trauma.

    Keywords: oxycodone, morphine, wounds, injuries, acute pain
  • Hamed Aminiahidashti, Sajad Shafiee, Alieh Zamani Kiasari *, Mohammad Sazgar Page 33

    Capnograph is an indispensable tool for monitoring metabolic and respiratory function. In this study, the aim was to review the applications of end-tidal carbon dioxide (ETCO2) monitoring in emergency department, multiple databases were comprehensively searched with combination of following keywords: “ETCO2”, “emergency department monitoring”, and “critical monitoring” in PubMed, Google Scholar, Scopus, Index Copernicus, EBSCO and Cochrane Database.

    Keywords: Capnography, Emergency service, hospital, exhalation, carbon dioxide, monitoring, physiologic
  • Maysam Yousefi, Davood Yadegarynia, Ensieh Lotfali *, Zahra Arab, Mazar, Ali Ghajari, Alireza Fatemi Page 34
    Introduction

    Febrile neutropenic patients are at risk of serious infections. The aim of the present study is to identify the frequency, species, and susceptibility patterns of candidemia in febrile neutropenic patients.

    Methods

    This cross-sectional study was conducted on febrile neutropenic patients suspected with candidemia who had been referred to 3 educational hospitals during 9 months.

    Results

    The blood samples of 80 febrile neutropenic patients with the mean age of 48§16.6 years were studied (60% female). Five (6.25%) episodes of candidemia were identified. The underlying disease was acute myeloid leukemia in 4 (80%) cases and all 5(100%) cases had central venous catheter and were receiving prophylactic ciprofloxacin and acyclovir. 100% of isolates were found to be susceptible to Voriconazole, 80% to Caspofungin, 60% to Amphotericin B, and 40% to Fluconazole.

    Conclusion

    The frequency of candidemia among the studied febrile neutropenia patients was 6.25%, with 80% mortality rate, and themost frequently identified yeastwas Candida albicans (100% susceptible to Voriconazole).

    Keywords: Candidemia, febrile neutropenia, antifungal agents, drug resistance, multiple, fungal
  • Ali Vafaei, Amin Shams Akhtari, Kamran Heidari, Somayeh Hosseini * Page 35
    Introduction

    Adhering to existing guidelines on cardiopulmonary resuscitation (CPR) can increase the survival rate of the patients. The present study has been designed with the aim of determining the quality of CPR performed in the emergency department based on the latest protocol by the American heart association (AHA).

    Methods

    In this prospective cross-sectional study CPR process was audited in patients above 18 years old in need of CPR presenting to the emergency departments of 3 teaching hospitals based on the AHA 2015 guidelines. Less than 60% agreement was considered as fail, 60-70% as poor, 70-80% as moderate, 80-90% as good, and 90-100% as excellent.

    Results

    80 cases of CPR were audited (55% male). Location of arrest was the hospital in 58 (72.5%) cases and 48 (60.0%) of the cases happened during the day. 28 (35.0%) cases had orotracheal intubation before the initiation of CPR. 30 (37.5%) patients had a shockable rhythm at the initiation of CPR. Based on the findings, out of the 31 studied items, 9 (29.03%) had excellent agreement, 10 (32.25%) had good, 4 (12.90%) had moderate, 2 (6.45%) had poor, and 6 (19.35%) had fail agreement rate.

    Conclusion

    Based on the findings of the present study, the quality of applying the principles of basic and advanced CPR in the emergency department of the studied hospital had intermediate, poor and fail agreement with the recommendations of the AHA 2015 in at least one third of the cases.

    Keywords: Physical Education, Training, Cardiopulmonary Resuscitation, Clinical Audit, Emergency Service, Hospital, Internship, Residency
  • Fares Najari *, Babak Mostafazadeh, Asadollah Akbari, Ideh Baradaran kaya, Dorsa Najari Page 36
    Introduction

    Pulmonary embolism (PE) is introduced as the third major cause of death after trauma in those who survive more than 24 hours. This study aimed to describe the characteristics of mortalities due to trauma related PE in cases referred to the forensic medicine department.

    Methods

    The present cross sectional study was conducted on medical profiles of cadavers that were registered as trauma related mortality in the dissection department of the Forensic Medicine Organization, Tehran, Iran, during 2011 to 2016.

    Results

    The cause of death for 92 of the 10800 (0.85%) evaluated cadavers was diagnosed as trauma related PE. The mean age of these patients was 58.37 ± 19.39 years (66.3% male). Only 14 (15.2%) hospitalized patients had received anticoagulant agents. The most frequent trauma related PE mortality cases were male (p = 0.003) and aged > 55 years (p = 0.005), with trauma to death time of < 3 weeks (p = 0.004), lower limb injury (p = 0.003), car crash trauma mechanism (p = 0.003), and no anticoagulant prescribed (p = 0.001).

    Conclusion

    According to the results of the present study, the prevalence of trauma related PE mortality was 0.85%. It seems that, having a clear anticoagulation therapy protocol in trauma centers could be helpful in decreasing the prevalence of traumatic thromboembolism and its’ related mortality.

    Keywords: Venous Thromboembolism, multiple trauma, Pulmonary Embolism, mortality, forensic medicine
  • Abdolkarim Pajoumand, Farshid Fahim *, Meisam Akhlaghdoust, Nasim Zamani, Zeinab Amirfirooz, Mahnaz Dehdehasti Page 37
    Introduction

    Some studies have reported creatinine phosphokinase (CPK) as a new emerging way in predicting the outcomes of poisoned patients. This study aimed to evaluate the association of serum CPK level in the first 24 hours with outcomes of poisoned patients.

    Methods

    This retrospective cross-sectional study was performed using the medical profiles of poisoned patients aged between 13 and 70 years old who were referred to the emergency department of a big referral medical toxicology center during 6 years and whose necessary data for this study was available.

    Results

    318 patients with the mean age of 34.9±14.5 years were studied (77.1% male). The mean serum CPK level of patients was 4693.1 ± 10303.8 (35–89480) IU/L. There was no significant correlation between serum CPK level and cause of poisoning (r= 0.16; p=0.51), age (r = -0.021; p = 0.651), sex (r = 0.131; p = 0.281), seizure (r = -0.022; p = 0.193), level of consciences (r = -0.138; p = 0.167), and duration of hospital stay (r= 0.242, p = 0.437). The mean serum CPK level was significantly higher in ICU admitted (p<0.0001), AKI (p<0.0001), hyperkalemia (p<0.0001), hypophosphatemia (p=0.045), and hypocalcaemia (p=0.008) cases. The best cut off point of serum CPK level in predicting acute kidney injury (AKI) was estimated to be 10000 IU/L (sensitivity = 83.8% and specificity = 68.8%).

    Conclusion

    It seems that CPK could be considered as a candidate tool for screening the intoxicated patients in need for ICU admission and at risk for AKI.

    Keywords: Poisoning, creatine kinase, rhabdomyolysis, patient outcome assessment
  • Ahmad Bagheri, moghaddam, Hassan Abbaspour, Shahrad Tajoddini, Vahideh Mohammadzadeh, Ali Moinipour, Bita Dadpour * Page 38
    Introduction

    Aluminium phosphide (Alp) poisoning mortality rate has been reported as high as 70-100%, and refractory hypotension and cardiogenic shock are the two most common presentations leading to death. Due to lack of specific antidote, all treatments are focused on supportive care and recently, intra-aortic balloon pump (IABP) has been suggested to treat cardiogenic shock resulting from toxic myocarditis. In the current paper, we introduce three Alp poisoned patients for whom IABP was applied to manage their refractory shock.

    Case presentation

    Two men and one woman who were admitted to emergency department (ED) of Imam Reza academic Hospital, Mashhad, Iran due to intentional Alp poisoning are reported. The cases visited the ED shortly after ingestion and nearly all of them showed hypotension, tachycardia and metabolic acidosis during early hospitalization. Due to persistent shock state, despite receiving intravenous fluid therapy and vasopressor agents, IABP insertion was performed in these cases. Finally, one of them survived and the other two died.

    Conclusion

    It still cannot be decided whether IABP insertion is effective in cases of Alp poisoning or not. It might be reasonable to try this intervention along with other conservative treatments in patients who survive more than 12 hours and consistently suffer from refractory hypotension.

    Keywords: Poisoning, shock, cardiogenic, intra-aortic balloon pumping, patient outcome assessment
  • Zulfiqar Qutrio Baloch *, Muhammad Hussain, Shabber Agha Abbas, Jorge L. Perez, Muhammad Ayyaz Page 39

    The development of methamphetamine-associated cardiomyopathy (MACM) represents a severe complication of chronic methamphetamine abuse. MACM-induced irreversible structural and functional changes in the heart can eventually lead to decompensated heart failure, ultimately requiring heart transplantation. In this case report we present a 47-year old male with a previous history of chronic amphetamine abuse who presented to the emergency room with severe dyspnea at rest associated with mild substernal non-radiating chest pain. He denied any previous cardiac history but had a positive urinary toxicology for methamphetamine. A complete cardiac workup ruled out all other etiologies. The patient required a 3-week intensive pharmacotherapy intervention to stabilize acute heart failure symptoms. At discharge he was classified as having New York Association Class III (NYHA-III) heart failure. His medical symptoms did not improve and he was considered for heart transplantation. With the increase in availability and abuse of methamphetamine, case of MACM such as ours are more frequently being encountered in the emergency departments. In addition to raising awareness, our case provides an outline of how MACM patients likely may present and the subsequent morbid sequela. Clinicians should maintain a high degree of suspicion when assessing all patients with a history of methamphetamine abuse. Early cardiac evaluation can help identify ventricular compromise in asymptomatic patients providing an opportunity to intervene prior to the development of irreversible MACM.

    Keywords: Methamphetamine, Cardiomyopathies, Emergency Service, Hospital
  • Mohammad Ali Emamhadi, Fares Najari *, Mohammad Javad Hedayatshode, Shokoufeh Sharif Page 40

    According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), pica is described as eating one or more non-nutritive, non-food substances over a period of at least 1 month that is severe enough to warrant clinical attention. The present case is a 44-year-old man who was brought to emergency department following severe abdominal pain, but died before admission or receiving any treatments. On the autopsy, 64 bolts and metal fittings (3700 grams) were found in the esophagus, stomach, small intestine, and large intestine of the patient.

    Keywords: Death, sudden, intestinal perforation, peritonitis, pica, case report
  • Alireza Majidi, Sasan Saket, Zohreh Nabizadeh Gharghozar, Ehsan Akrami, Seyed Mohsen Fayyazi * Page 41

    Hopkins syndrome (HS) is a flaccid paralysis resembling poliomyelitis that has been seen in some children who are recovering from an acute episode of asthma. This syndrome should be suspected based on clinical findings even before the occurrence of characteristic breathing patterns and epilepsy. We report a 14-year-old boy who had experienced an episode of HS.

    Keywords: Pitt-Hopkins syndrome, nervous system diseases, rare diseases, asthma
  • Mahdi Pishgahi, Toktam Alirezaei *, Behzad Hajimoradi, S.Mojtaba Nekooghadam, Shima Shahi Page 42

    In massive pulmonary embolism (PE), fibrinolytic therapy is a potential lifesaving treatment; therefore, if other treatments are not available, the physicians encounter this question: can we accept the risk of complications from fibrinolytic therapy, especially intracranial hemorrhage, in the presence of absolute contraindication, in order to save the patient’s life? Here, we describe three cases of massive PE with absolute contraindication for fibrinolytic therapy who presented to emergency department following dyspnea. Since, surgical or catheter embolectomy were not available and patients were very high risk for transferring to another hospital, systemic fibrinolytic was administered. The patients improved clinically and were discharged from hospital. It seems that, if no other acceptable treatments are available, physicians could consider fibrinolytic therapy, even at the presence of contraindication, to save the patient’s life.

    Keywords: Massive Pulmonary embolism, fibrinolytic therapy, anticoagulant, absolute contraindication
  • Mohammadreza Maleki, Verki, Hasan Motamed * Page 43

    Rectus sheath hematoma is a rare but well-known problem. Exercise, pregnancy, subcutaneous injection of insulin, abdominal surgery and severe coughs can be predisposing factors of hemorrhage in the mentioned muscle sheath. Here, we will discuss a case of rectus sheath hematoma in a 28 year-old female patient who presented to emergency department with complaint of abdominal pain and improved in 1 week with palliative care.

    Keywords: Rectus abdominis, hemorrhage, abdomen, acute, emergency service, hospital, ultrasonography
  • Nasim Ghafourian, Fatemeh Mahdizadeh *, Mina Zavareh, Mitra Ahmadi, Mohammad Hossein Askarzadeh, Fatemeh Jalili Page 44

    Traumatic pulmonary pseudocyst is a rare complication of chest trauma that has been poorly documented and usually resolves without specific treatment. Here, we present a case of pulmonary pseudocyst in a child with chest trauma without obvious symptoms. It is important to consider this diagnosis in patients with chest trauma to avoid unnecessary invasive procedures.

    Keywords: Thoracic injuries, contusions, wounds, nonpenetrating, Chest trauma, pulmonary pseudocyst, pulmonary contusion
  • Gholamreza Faridaalaee, Javad Ahmadian Heris * Page 45

    Anaphylaxis is a serious life-threatening allergic reaction. Any medication may potentially trigger anaphylaxis, but reaction to pantoprazole is rare. Our case is a 21 year-old girl with anaphylactic reaction to pantoprazole a short time after prescription.

    Keywords: pantoprazole, anaphylaxis, proton pump inhibitors, hypersensitivity
  • Mehdi Mesri, Fares Najari, Ideh Baradaran Kayal, Dorsa Najari * Page 46

    Industrial lead toxicity is more common among miners. This type of toxicity occurs in two forms: acute and chronic. Chronic toxicity is associated with different levels of brain dysfunction, motor impairment, cognitive dysfunction, and neuropsychiatric problems, including depression, anxiety, irritability, and emotional disorders. However, quadriplegia induced by chronic toxicity is very rare. Here we report a 37-year-old male patient with a history of desert hunting, where he used to roll lead bullets in his mouth, who was admitted with sensory impairment, muscle weakness, and quadriplegia and final diagnosis of lead toxicity.

    Keywords: Lead poisoning, nervous system, adult, quadriplegia, emergency service, hospital, case report
  • Zana Ramezani, Asrin Babahajian, Vahid Yousefinejad * Page 47

    Zinc phosphide (ZnP) is low-cost, accessible, and very effective as a rodenticide. It has been used for many human suicide poisonings around the world, including Iran. Nonspecific gastrointestinal symptoms and cardiotoxicity are the most serious complications of ZnP poisoning, which are associated with a high mortality rate. The aim of this paper was to report a poisoned patient that ingested ZnP with suicidal attempt and faced complications due to hemolysis.

    Keywords: Zinc phosphide, poisoning, jaundice, hemolysis
  • Forod Salehi, Hamidreza Riasi, Hamideh Riasi, Arvin Mirshahi * Page 48

    Torsades de pointes (TdP) is a rare but hazardous ventricular dysrhythmia caused by an increase in the QT interval of the heart rhythm and is categorized into congenital or acquired types. Signs and symptoms of TdP include syncope, seizure, ventricular fibrillation, and even sudden death. According to statistics, among these symptoms, syncope and the seizure can be considered as signs that make the TdP diagnosis difficult. Here, we present an infant referring to Vali-e-Asr Hospital in Birjand with frequent seizures and aspiration pneumonia. She was diagnosed with Torsades de Pointes and a medium-sized patent ductus arteriosus, and subsequently underwent a patent ductus arteriosus ligation.

    Keywords: Torsade de Pointes, Seizures, Patent Ductus Arteriosus, Infant
  • Mohammad Khani, Fariba Bayat, Atoosheh Rohani *, Mehdi Pishgahi Page 49

    Patent foramen ovale (PFO) is usually asymptomatic; however, it could be quite dangerous for patients with right side clot in which thrombus can transmit the PFO and paradoxically emboli to systemic circulation. Here we present a patient with ankle fracture and paradoxical embolus to the brain, who was successfully treated with emergent thrombectomy, inferior vena cava (IVC) filter placement and anticoagulation therapy. Despite the high rate of mortality in these patients, fortunately our patient survived with surgical treatment.

    Keywords: Venous thrombosis, pulmonary embolism, embolism, paradoxical, patent foramen ovale, thrombolytic therapy
  • Mohamadjavad Amirian, Sara Sadjadi, Ideh Baradaran Kayal, Fares Najari* Page 50

    Many critically ill patients need aggressive procedures, such as central venous catheterization. The complication rate of central venous line placement is estimated to be 15%. Common complications include arterial puncture, hematoma, pneumothorax, hemothorax, arrhythmia, thoracic duct injury, infection, and thrombosis. Cardiac tamponade, pericardial effusions, pleural effusions, air or guidewire embolisms, and lost guide wires are rare but severe complications. Here we report a case of lost guide wire following central venous line insertion.

    Keywords: Catheterization, central venous, intraoperative complications, emergency service, hospital, case report, rare diseases
  • Mohammad Ali Emam Hadi, Fares Najari *, Leila Soleimani Page 51

    Echinococcosis is an infection caused in human by complex parasites that causes cystic hydatid disease. These infections are prevalent in most areas where livestock is raised in association with dogs. These parasites are found in all continents. Slowly enlarging cysts generally remain asymptomatic until their size has expanded. Here we present a case of sudden death following cyst emboli to the large veins and right heart of a young adult female.

    Keywords: Death, sudden, echinococcosis, embolism, case report
  • Hamideh Feiz, Disfani, Mostafa Kamandi *, Kazem Rahmani Page 52

    Syncope is a serious problem with life-time prevalence of 35%. It is estimated that 1 -3% of referrals to emergency departments and in-patient admissions are due to syncope. The underlying conditions can be cardiac or neurologic. Considering the completely different circumstances ruling the encounters with cardiac and neurologic syncope, in recent years many attempts have beenmade to find the proper tool for differentiating cardiac and non-cardiac causes of syncope. The result of which is formation of some clinical decision rules including San Francisco Syncope Rule (SFSR), Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL), Evaluation of Guidelines in Syncope Study (EGSYS), risk stratification of syncope in the emergency department (Rose), and Boston Syncope Rules. The serum marker brain natriuretic peptide (BNP), which is becoming increasingly established in emergency departments for diagnosis of acute heart failure, can reflect the presence of a structural heart disease. It seems that BNP could be considered as a screening tool in detection of syncope with cardiac origin. In a study by Wojtowicz J et al. who evaluated BNP in children and adolescents with syncope, there was no significant difference in terms of BNP level between the syncope and control groups. In contrast, Zhang Q et al. concluded that serum BNP is helpful in differentiating cardiac (958.78 § 2443.41 pg/mL) and non-cardiac (31.05 § 22.64 pg/mL) syncope. Tanimoto K et al. considered the cut-off value of 40 pg/ml for BNP in differentiating cardiac and non-cardiac syncope and found that it had 82% sensitivity and 92% specificity. A significant difference was observed in BNP level of the cardiac group (514 pg/ml) compared to the non-cardiac ones (182 pg/ml) in Pfister et al. study. It seems that, more research is needed to clarify this relationship and the variables that might play the role of confounders in a causal inference.
    More studies on children are required because there is some controversy regarding this relationship. Running studies with accurate methodology, large sample sizes, and in a multicentric fashion could be helpful in this regard.

  • Meghdad Sedaghat *, Mahsa Soltani, Mehrdad Solooki Page 53

    Venous Thromboembolism (VTE) is the 3rd most prevalent vascular disease behind myocardial infarction and cerebrovascular ischemic attack. This disorder has received attention from health policy makers because of its major complications including recurrent VTE, post thrombotic syndrome, sudden cardiac death and high mortality rate. In the United States, VTE was reported in approximately 201000 cases annually, 25% of which expired within 7 days after diagnosis and 22% of mortalities did not have a definitive diagnosis. Despite the progression in diagnosis and treatment of VTE since 1979, its incidence did not decrease dramatically.
    This gap declares that VTE risk factors, especially transient ones, have not been detected completely. Obesity, history of VTE, family history of VTE, recent surgery, malignancy, myeloproliferative disorders, trauma, pregnancy, post-menopausal hormone therapy, hereditary syndromes like anti phospholipid syndrome (APS), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), blood transfusion and older age are determined as major risk factors. These factors can be categorized into two major subgroups as intrinsic and predisposing. Recent investigations focused on predisposing ones, which can be justified. Designing a cross sectional study in Imam Hossein Hospital, Tehran, Iran, from 2016 to 2017, we found that inactivity due to disability (30.9%), smoking (29.3%), and active malignancy (18.1%), were the most prevalent transient risks factor of VTE in our sample, respectively. Similar to our results, Kesieme et al. and Cushman et al. declared that VTE is more diagnosed in the elderly. Park MS et al. introduced recent surgery, trauma (73%), and disability to walk (62%) as major independent risk factors of VTE. Fuji T et al. introduced malignancy, recent infectious disease, and obesity as the factors predisposing patients who were admitted for orthopedic surgery to VTE. As can be seen, despite the risk factors of VTE being the same in various studies, their frequency varied between the studies. Population and cultural characteristics and various habits may have an effect in this regard. Therefore, it is suggested to performa multi-center, comprehensive study considering all the racial and ethnic in order to have a correct pattern of the frequency of predisposing factors of this disease in the Iranian population for health and prevention programs.

  • Mehrdad Taghizadeh, Roghayeh Taghipour *, Kamran Heydari Page 54

    Chest pain is a common complaint among those presenting to emergency department (ED) and is associated with a high rate of mortality. Based on National Center for Health Statistics, chest pain leads to about 6 million visits to EDs in United State. In Iran, ischemic cardiac diseases are the second cause of death in people aged 15 to 49 years. While less than 10% of the patients presenting to ED with chest pain are affected with myocardial infarction (MI), 33% of MI cases are silent. Timely diagnosis and revascularization of ischemic part, using thrombolytic agents or percutaneous coronary intervention (PCI), can save cardiac function and the patient’s life. Therefore, in this regard the emphasis is on rapid referral of the patients to treatment centers, initiation of diagnostic measures such as electrocardiography (ECG) and in case of meeting the required criteria, transfer to cat lab for PCI. American Heart Association (AHA) has introduced the proper door to ECG time as 10 minutes if it has not been done in the ambulance. Based on this recommendation, AHA has defined the aims of coronary reperfusion as prescription of thrombolytic in the initial 30 minutes after admission of the patient to ED or PCI in the initial 90 minutes after admission to ED.

  • Ali Reza Amiri, Kiarash Ghazvini, Hamid Zamani Moghadam * Page 55

    Currently, control and prevention of respiratory illnesses is considered a health priority in most developed countries and managing the risk factors is necessary for improving the population’s health. Chronic obstructive pulmonary disease (COPD) is the 5th cause of death around the world and estimations have indicated that due to an increase in environmental pollution, this disease will become the 3rd cause of death in the future.
    In previous studies, pulmonary infection with mycoplasma pneumoniae has been introduced as one of the causes for COPD exacerbation. Mycoplasma pneumoniae affects the upper and lower respiratory tract and its clinical manifestation is trachea-bronchitis accompanied by restlessness and dry coughs. The pathogenesis spectrum of this bacterium ranges from mild pharyngitis and trachea-bronchitis to acute pneumonia. Epidemiologic studies have shown that this bacterium is responsible for more than 20% of community acquired pneumonias.
    In a cross-sectional study by the authors of the present letter, 66 patients over the age of 18 years who had presented to the emergency department of Imam Reza Hospital, Mashhad, Iran, with diagnosis of COPD exacerbation were evaluated. Sputum sample of the patients was obtained and sent to the laboratory for performing polymerase chain reaction (PCR). Mean age of the patients participating in this study was 67.28 ± 13.68 years (60.6% male). The result of PCR was positive in 6 patients out of the total of 66 patients (9.1%). The results of the present study showed that there was no correlation between age (p=0.18), sex (p=0.25), duration of being affected with COPD (p=0.20), consumption of antibiotics (p=0.35), smoking (p=0.62), opioid abuse (p=0.44), corticosteroid use (p=0.57), underlying illness (p=0.94) and health care—associated pneumonia (HCAP) (p=0.46) with mycoplasma infection. However, prevalence of leukocytosis (p=0.01) and myalgia (p=0.02) was significantly higher in the mycoplasma group.

    Numerous studies have confirmed the presence of mycoplasma pneumoniae in exacerbation of COPD using serologic diagnosis. For instance, in a study by Lieberman et al. prevalence of mycoplasma pneumoniae in patients with COPD exacerbation was reported as 14.2% and in Meloni et al. study the prevalence of this infection was expressed to be 6.7%. These rates were reported between 5% and 14% in other studies.
    Thus, it seems that prevalence of mycoplasma is high in COPD exacerbation, but there is still no answer to the question if this infection results in exacerbation of COPD or not and there is controversy between the studies in this regard. Therefore, it is suggested to design case-control or cohort studies to find the answer to this question.

  • Isabel FitzGerald, Andrew Appelboam * Page 56

    We read with interest the article by Motamedi and colleagues about the use of a hand held manometer to measure strain pressure during Valsalva manoeuvre (VM) treatment of supraventricular tachycardia (SVT). We also used a manometer in our study (REVERT) of a postural modification of the VM and are currently investigating the use of a simple, single patient use device to control VM strain pressure, NCT number: NCT03298880. Such a device would be useful as blood pressure manometers are not always available and cannot be left with patients and other methods of generating the recommended strain such as syringes have been shown to be unreliable. We note that Motamedi’s study demonstrated a cardioversion rate of 14.8% in supine participants, which was similar to the rate achieved in the REVERT trial by control participants in the semi recumbent position (17%). In contrast, participants randomised to the modified VM in the REVERT trial, had a markedly improved cardioversion rate of 43%. This modification required participants to perform a 40 mmHg pressure strain for 15 seconds in a semi recumbent position but with supine repositioning and passive leg raise immediately after the Valsalva strain. To our knowledge this is the first trial to study this modification and was not described in the ‘new modified version’ quoted and referenced in Motamedi’s paper. To achieve the best cardioversion rates, we recommend use of a modified VM as described above with the strain controlled by a manometer where possible. A simple, single patient use device designed to deliver the recommended pressure may be helpful to facilitate this in practice and could be kept by patients for future use.

    Keywords: Valsalva Manoeuvre, Supraventricular Tachycardia, Manometry, Cardioversion
  • Matthias Wittstock *, Johannes Buchmann, Uwe Walter, Johannes R?sche Page 57

    External defibrillation in patients with implanted neuromodulatory devices is a crucial therapeutic challenge. We report a 63-year-old male patient with refractory epilepsy (RE) after recurrent ischaemic strokes in the middle cerebral artery and in the anterior cerebral artery territory 26 and 23 years ago. He received various therapeutic interventions to achieve seizure control with insufficient success. Therefore, vagus nerve stimulation (VNS) (model Pulse 102, Aspire SR, Cyberonics Inc, Houston, Texas) was applied via insertion of a pulse generator in the left upper chest in 2011. VNS stimulation settings were: output current 1.0 mA, pulse width 500 µs, frequency 30 Hz, 30s ON, 3.0 minute OFF.
    A reduction of seizure frequency was achieved. Last antiepileptic therapy consisted of levetiracetam 1500 mg td, valproate 1000 mg td, and eslicarbazepine 800 mg td.
    In 2016, he was admitted because of generalized seizure and aspiration pneumonia. During hospital stay he suffered a cardiac arrest (CA) with pulseless ventricular tachycardia (VT) caused by fulminant pulmonary artery embolism. After successful resuscitation, the patient experienced return of spontaneous circulation (ROSC). During resuscitation, biphasic electric shocks were applied using 150 Joule and subsequently 360 Joule with patches placed approximately 10 cm parasternal and at the left chest below the VNS. After successful ROSC the VNS was checked again and no malfunction could be detected. Stimulation settings were not changed. Impedance was normal. Seizures were not observed during the remaining day. Unfortunately, the patient died within one day after successful resuscitation and ROSC because of therapy refractory circulatory insufficiency.
    VNS is an established therapeutic approach in treatment of TRE in children and adults to achieve reduction of seizure frequency with proven safety and efficacy. The safety of VNS in emergency situations like cardiac arrest due to VF with need of external defibrillation and application of large amounts of electrical energy is not clear. External defibrillation in VNS patients may potentially be harmful. The literature concerning external defibrillation during resuscitation or external cardioversion (EC) in patients with implanted electronic devices in neurological disorders is sparse. In patients with cardiac pacemakers external defibrillation may damage the cardiac device. EC applied to deep brain stimulation (DBS) patients may cause thalamotomy or DBS failure. Application of electroconvulsive therapy in psychiatric disorders seems to be safe. Two cases of electroconvulsive therapy (ECT) in VNS have been reported by Sharma et al. The first patient was a 66-year old female with major depression and the second one, a 57-year-old male with a history of bipolar disorder. Both had VNS for therapy refractory psychiatric illness. ECT was applied because of further worsening of the mental state without malfunction of the VNS device. To our knowledge, this is the first case of external defibrillation in a patient with VNS for TRE without alteration of the neurostimulator’s function. External defibrillation applied to VNS patients seem to be safe and effective. Several steps should be taken to minimize the electrical current flowing through the neurostimulator. First, position the patches as far away as possible from the VNS at least 10 cm each. Second, position the patches perpendicular to the VNS; use the lowest clinically appropriate output setting, and, finally, confirm that the VNS is functioning properly after defibrillation.

    Keywords: emergency medicine, epilepsy, vagus nerve stimulation, resuscitation, external defibrillation
  • Keshvad Hedayatyanfard, Shahin Mohammad, Sadeghi *, Iman Habibi Page 58

    Pain is defined as an unpleasant feeling caused by a real or potential tissue injury and is classified into neuropathic, somatic and visceral types. Characteristics such as severity, location, duration and site of pain referral are very helpful in correct diagnosis and treatment of the disease. Pain control in the emergency department is one of the first measures that should be taken for the patients and for this purpose, a wide range of analgesic drugs such as NSAIDs, opioids, and corticosteroids are used.
    For evaluating the success rate as well as determining the best medication required for controlling the patient’s pain, being aware of the pain severity is of great importance. Therefore, a device or a method that can monitor pain severity and therefore, the process of patient treatment with high accuracy is very interesting. Currently, various methods exist for assessing pain severity. One way is to ask the patient (self-report) for determining pain severity. Among the most important methods based on self-report of the patient, numerical rating scales (NRS) and verbal rating scales (VRS) can be mentioned. In cases that self-report by the patient is not possible, methods such as Behavioral pain scale (BPS) and critical care pain observation tool (CPOT) can be used.
    One of the common methods for assessing pain severity and threshold in animal studies is using monofilaments. These monofilaments are made from polyethylene and the base of their function is the bend that occurs at the time of applying pressure on the surface of the intended organ. A wide range of these filaments is available, each of which apply a pre-determined force depending on the bend.
    Results of a study were indicative of 41% to 93% sensitivity and 68% to 100% specificity of monofilaments in determining pain threshold. However, temperature and humidity of the environment can affect the bending and therefore, the accuracy of the monofilaments.
    Considering the aforementioned points, researchers of the present study attempted to design a digital device for assessing pain severity and threshold with characteristics such as accuracy, reproducibility, sensitivity, specificity, and ease of use. Among the most important uses of this device, quantitative measurement of response to the external stimulant, pain threshold, and assessing the trend of response to treatment with various analgesic drugs can be pointed out.
    The device is made up of 2 parts of body and probe, the body includes an LCD with touch screen and internal memory for recording the performed tests. Its accuracy in measurement is about 100 mg and it can show a maximum of 1000 g. The device can record the maximum force inflicted on the desired organ and can be connected to the computer and data can be printed out. In addition, the trend of force inflicted on the organ of the animal or human can be observed as a curve on the graph.
    Inside the probe there is a load cell with high sensitivity for measuring the inflicted force used and a there is also a steel rod, 1 mm in diameter, placed on the probe, which has a smooth cross section. This metal rod can be changed and various diameters can be used for animal and human study purposes.
    Method of using the device
    For evaluating the patient’s pain severity a force will be inflicted on the intended organ of the patient and when a pain equal to the original pain of the patient is felt and the patient responds to the performed stimulation and moves the intended organ, the maximum force is recorded. This test is performed 5 times and the mean inflicted force is recorded as pain severity.
    This device has been registered in the Iranian office of intellectual and mental property under the number 87068. In addition, it has been chosen as the favorite invention in the festival of inventions of the Iranian national elites foundation (in 2015).

    Keywords: Letter
  • Payman Asadi *, Ehsan Modirian, Nazanin Dadashpour Page 59

    Medical error is the third leading cause of death in the United States of America and almost 100000 patients lose their life due to medical errors every year.

    Keywords: Medical errors, patient safety, emergency service, hospital, diagnostic errors, medication errors
  • Amir Mirhaghi *, Mohsen Ebrahimi Page 60

    Triage is sorting patients based on acuity in order to manage care in the emergency department (ED) {Mirhaghi, 2017 #60}(1). Medical institutes are trying to develop triage scales compatible with their own culture of care. A triage scale must be precise and comprehensive enough to guide triage nurses and eliminate uncertainty.

    Keywords: triage, validity, emergency