https://journals.sbmu.ac.ir/aaem/index.php/AAEM/issue/feed Archives of Academic Emergency Medicine 2023-01-31T17:42:08+00:00 Somayeh Saghaei Dehkordi ma.saghaei63@gmail.com Open Journal Systems <p><strong>Welcome to "Archives of Academic Emergency Medicine (AAEM)"</strong></p> <p>This journal was published under the title <strong>"Emergency"</strong> from 2013 to 2018. From the beginning of 2019, the journal is published on this website. Archives of Academic Emergency Medicine (AAEM) is an international, peer-reviewed, and open access journal. The journal publishes articles on critical care, disaster and trauma management, environmental diseases, toxicology, pediatric emergencies, emergency medical services, emergency nursing, and other related topics.</p> https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1763 Extracting the Factors Affecting the Survival Rate of Trauma Patients Using Data Mining Techniques on a National Trauma Registry 2022-11-19T12:14:33+00:00 Mehdi Nasr Isfahani mni.papillon@gmail.com Mohammad Sattari msattarimng.mui@gmail.com Nahid tavakoli tavakoli@mng.mui.ac.ir Hossein Bagherian h_bagherian1924@yahoo.com Neda Al Sadat Fatemi ns.fatemi63@gmail.com Peyman Salamati psalamati@tums.ac.ir <p><strong>Introduction</strong>: Thousands of people die due to trauma all over the world every day, which leaves adverse effects on families and the society. The main objective of this study was to identify the factors affecting the mortality of trauma patients using data mining techniques.</p> <p><strong>Methods</strong>: The present study includes six parts: data gathering, data preparation, target attributes specification, data balancing, evaluation criteria, and applied techniques. The techniques used in this research are all from the decision tree family. The output of these techniques are patterns extracted from the trauma patients dataset (National Trauma Registry of Iran). The dataset includes information on 25,986 trauma patients from all over the country. The techniques that were used include random forest, CHAID, and ID3.</p> <p><strong>Results</strong>: Random forest performs better than the other two techniques in terms of accuracy. The ID3 technique performs better than the other two techniques in terms of the dead class. The random forest technique has performed better than other techniques in the living class. The rules with the most support, state that if the Injury Severity Score (ISS) is minor and vital signs are normal, 98% of people will survive. The second rule, in terms of support, states that if ISS is minor and vital signs are abnormal, 93% will survive. Also, by increasing the threshold of the patient's arrival time from 10 to 15 minutes, no noticeable difference was observed in the death rate of patients.</p> <p><strong>Conclusion</strong>: Transfer time of less than ten minutes in patietns whose ISS is minor, can increase the chance of survival. Impaired vital signs can decrease the chance of survival in &nbsp;traffic accidents. Also, if the ISS is minor in non-penetrating trauma, regardless of vital signs and if the victim is transported in less than ten minutes, the patient will survive with 99% certainty.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2022 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1825 A Clinical Score for Predicting the Paroxysmal Supraventricular Tachycardia’s Recurrence Risk; a Retrospective Cross-sectional Study 2022-11-19T12:15:22+00:00 Chaiyaporn Yuksen chaipool0634@hotmail.com Welawat Tienpratarn pedz_welawat@hotmail.com Rungrawin Promkul rungrawin.promkul@gmail.com Chetsadakon Jenpanitpong chetsadakon.jen@mahidol.ac.th Sorawich watcharakitpaisan sorawich38@gmail.com Jenjira Yaithet chaipool063456@gmail.com Viruji Phonphom Viruji_29@icloud.com <p><strong>Introduction:</strong> Identifying prognostic variables associated with the probability of recurrent paroxysmal supraventricular tachycardia (PSVT) would aid decision-making regarding disposition of the patients. This study aims to develop a clinical scoring system to predict PSVT recurrence after adenosine administration in the emergency department (ED).</p> <p><strong>Methods: </strong>This retrospective cross-sectional study was conducted on patients who were referred to the emergency department of Ramathibodi Hospital, a university-affiliated super-tertiary care hospital in Bangkok, Thailand, with diagnosis of PSVT during a 10-year period from 01 January 2010 until 31 December 2020. The cases were divided into recurrent and non-recurrent PSVT based on the response to standard treatment and the independent predictors of recurrence were studied using multivariable logistic regression analysis.</p> <p><strong>Results: </strong>264 patients were diagnosed with PSVT and successfully converted by adenosine. 24 (9.1%) had recurrent PSVT, and 240 (90.9%) had no recurrent PSVT in the same ED visit. The risk of PSVT recurrence in ED corresponded with the history of hypertension (p = 0.059), valvular heart disease (p = 0.052), heart rate ≥ 100 (p = 0.012), and systolic blood pressure &lt; 100 after electrocardiogram (ECG) converted to sinus rhythm (p = 0.022) and total dose of adenosine (p = 0.002). We developed a clinical prediction score of PSVT recurrence with an accuracy of 79.5%. A score of 0 (low risk), 1–2 (moderate risk), and &gt; 2 (high risk) had a positive likelihood ratio (LR+) of 0.31, 0.56 and 2.33, respectively.</p> <p><strong>Conclusion: </strong>It seems that, using the PSVT recurrence score we could screen the high-risk patients for PSVT recurrence (score&gt;2) who need to be observed for at least 6-12 hours and receive cardiologist consultation in ED. In addition, the moderate and low-risk group (score 0-2) need to be observed for 1 hour and can be discharged from ED.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2022 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1771 Level of Self-Care and Patient Care Against COVID-19 Among Emergency Medical Services Personnel; a Cross-sectional Study 2022-11-19T16:44:41+00:00 Sirvan Abbasi Ghocham abbasi01@gmail.com Sina Valiee valiee01@gmail.com Naser Kamyari kamyari01@gmail.com Salam Vatandost vatandost1366@gmail.com <p><strong>Introduction</strong>: Provision of pre-hospital care by emergency medical services (EMS) requires paying attention to self-care and patient care against possible infections. The present study was conducted with the aim of determining the level of self-care and patient care against COVID-19.</p> <p><strong>Methods:</strong> The present correlational, descriptive, analytical study was carried out on 301 EMS personnel in Iran. Data were collected using a demographic information form and questionnaires made by the researcher on the level of self-care and patient care against COVID-19.</p> <p><strong>Results:</strong> The results showed that more than half of the participants (55%) were aged 27 to 34 years. The majority of the participants had an experience of participating in self-care (88.7%) and patient care (83.7%) training courses against COVID-19. The overall score of self-care was 55.96 ± 6.97 out of 72 and that of patient care was 26.86± 3.39 out of 32, both of which revealed a favorable level. However, in some questions, the mean score was lower than the optimal level. The lowest mean score among items related to self-care against COVID-19 was allocated to wearing protective clothing (1.77±1.19). Among items related to patient care against COVID-19, the lowest mean score was related to training the patient about hand hygine after touching contaminated equipment (2.83±1.08 out of 4). There was a positive (r=0.491) and significant correlation between self-care and patient care against COVID-19 (p=0.001) based on our findings.</p> <p><strong>Conclusion</strong>: Although the general level of self-care and patient care against COVID-19 was favorable, due to the undesired level of some domains, it seems necessary to implement corrective planning through periodical training and monitoring the performance of the personnel.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2022 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1892 The Effect of Intravenous Metoclopramide on Gastric Emptying of Opium-dependent Patients based on Ultrasonographic Criteria; a Case-control Study 2022-12-05T16:48:47+00:00 Faramarz Mosaffa Faramarzmosaffa@sbmu.ac.ir Ali Arhami Dolatabadi Aliarhami@yahoo.com Masoomeh Raoufi masomeraoufi@gmail.com Faezeh Golpour behrooz.hashemi@gmail.com Mahshid Ghasemi mahshid.ghasemi@yahoo.com Mohammad Javad Yazdipoor mjyazdipooor@gmail.com Elham Memary drmemary@gmail.com <p><strong>Introduction:</strong> Induction of anesthesia for emergency procedures, without prior gastric preparation and incomplete fasting, is associated with the risk of reflux of stomach contents and aspiration. This study aimed to evaluate the effect of intravenous (IV) metoclopramide administration on gastric emptying in opium users, candidate for procedural sedation and analgesia (PSA).</p> <p><strong>Methods:</strong> In the present case-control study, opium-dependent (case) and non-dependent (control) patients in need of PSA were administered with 10 mg IV metoclopramide after undergoing gastric ultrasonography for determination of its area and contents. Then, 30 minutes after the administration of metoclopramide, the area and contents of the stomach were measured again and compared with the measures obtained before the intervention.</p> <p><strong>Results:</strong> 135 patients were evaluated in three groups of 45, including the case, control, and placebo groups. The three groups were similar regarding mean age (p = 0.068), sex (p = 0.067), weight (p = 0.596), height (p = 0.671), body mass index (BMI) (p = 0.877), duration of fasting (p = 0.596), and type of gastric contents (p = 0.124). Mean antral cross-sectional area (CSA) of the study participants in the case, control, and placebo groups before the administration of the drug was 8.49 ± 1.40, 8.31 ± 2.56, and 6.56 ± 1.72 cm<sup>2</sup>, respectively. Mean gastric area in the case (p &lt; 0.001) and control (p &lt; 0.001) groups had significantly decreased after the intervention. Mean antral gastric grade of gastric contents in the case (p &lt; 0.001) and control (p &lt; 0.001) groups had significantly decreased after the intervention.</p> <p><strong>Conclusion:</strong> It seems that metoclopramide administration in opium users in need of PSA leads to a significant decrease in mean gastric area and increases gastric emptying.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2022 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1774 The Effect of L-Citrulline Supplementation on Outcomes of Critically Ill Patients under Mechanical Ventilation; a Double-Blind Randomized Controlled Trial 2022-12-19T16:50:52+00:00 Mohammadreza Asgary Mohammadreza.askary1994@GMAIL.COM Sayid Mahdi Mirghazanfari smmirghazanfary@gmail.com Ebrahim Hazrati dr.hazraty.e@gmail.com Vahid Hadi vahiddhadi1@gmail.com Mojgan Mehri Ardestani m-mehry@razi.tums.ac.ir Faeze bani Yaghoobi Faeze.baniyaghooby@gmail.com Saeid Hadi s.hadiinut@yahoo.com <p><strong>Introduction:</strong> Effective parenteral and enteral amino acid replacement is crucial for critically ill patients with altered amino acid metabolism. This study aimed to assess the effects of l-citrulline supplementation on the clinical and laboratory outcomes in critically patients.</p> <p><strong>Methods:</strong> This was a double-blind placebo-controlled randomized clinical trial. 82 critically ill patients who were expected to receive mechanical ventilation for more than 72 hours were selected. The patients were assigned to either a placebo or an intervention group. The patients in the placebo group received 10 gr of microcrystalline cellulose and the ones in the intervention group were given l-citrulline daily for 7 days. &nbsp;Serum levels of fasting blood sugar (FBS), lipid profile, hepatic enzymes, serum electrolytes, urea nitrogen, creatinine, and C-reactive protein (CRP) were evaluated before and after the intervention. Duration of invasive ventilation, intensive care unit (ICU) length of stay, ventilator-free days, and 28-day mortality rate were recorded and compared between groups.</p> <p><strong>Results:</strong> Eighty-two patients completed the trial. No statistically significant differences were observed between the two groups in terms of age (p = 0.46), sex (p = 0.49), body mass index (BMI) (p = 0.41), Sequential Organ Failure Assessment (SOFA) Score (p = 0.08), Clinical Pulmonary Infection Score (CPIS) score (p = 0.76), Acute Physiology and Chronic Health Evaluation (APACHE II) score (p = 0.58), risk factors (p = 0.13), ICU stay before randomization (p = 0.32), and reason of admission (p = 0.50) before the intervention. Citrulline group had a notable reduction in FBS (p = 0.04), total cholesterol (TC) (p = 0.02), low density lipoprotein (LDL-C) (p &lt;0.001) and high-sensitivity CRP (hs-CRP) (p &lt;0.001). Also, a significant increase in lactate dehydrogenase (LDH) concentration (p &lt;0.001) was observed in the intervention group at the end of the trial. Total duration of invasive ventilation and the mean SOFA score on 7th day were significantly lower in the citrulline group compared to the control group. Moreover, a significant increase in days alive and ventilator-free days within 28 days after admission was found in the citrulline group at the end of the trial. Also, there were no significant differences between the groups in terms of mortality rate during intervention, serious adverse events, endotracheal intubation, the use of tracheotomy or non-invasive ventilation after extubation, length of ICU stay, ICU-free days at 28 days, and CPIS and APACHE II scores.</p> <p>For mortality, in the citrulline group, there was two deaths compared to eight deaths in the control group. This resulted in an absolute risk reduction (ARR) of 14.05% (95% CI: 0.39–27.71%) and a number needed to treat (NNT) of 7.1 (95% CI: 3.6–29.5), regarding mortality.</p> <p><strong>Conclusions:</strong> The results of the present study demonstrated the probable positive effects of citrulline supplementation on lipid profile, hs-CRP levels, duration of invasive ventilation, and SOFA score. Also, l-citrulline consumption may increase the probability of survival without mechanical ventilation.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1764 Dizziness Evaluation and Characterisation of Patients with Posterior Circulation Stroke in the Emergency Department; a Case Series Study 2022-12-18T16:55:44+00:00 Miguel Saro- Buendía msarobuendia@gmail.com Lidia Torres García Lidiatorresgarcia@gmail.com Natalia Jaramillo Angel jaranatis@hotmail.com Raul Mellidez Acosta raulmellidezacosta@usal.es Javier Cabrera Guijo javicg8@gmail.com Catalina Bancalari Díaz Cbancalarid@gmail.com Alfonso García Piñero garcia_alfpin@gva.es Vanesa Pérez Guillén vanesaperez2005@yahoo.es Miguel Armengot Carceller miguel.armengot@gmail.com <p><strong>Introduction</strong>: &nbsp;Dizziness is a common scenario in the Emergency Departments (EDs). Among dizziness underlying causes, the posterior circulation stroke is especially relevant due to its mobimortality and concerning misdiagnosis rates. Therefore, we conducted this study to assess dizziness evaluation and baseline characteristics of patients with PS in the ED.</p> <p><strong>Methods</strong>: We conducted a 3-year retrospective observational study on PS cases confirmed by magnetic resonance imaging (MRI). Concretely, we analysed the demographic profile of these patients, the initial PS clinical presentation, and diagnostic workup (with emphasis on dizziness evaluation) performed at the ED.</p> <p><strong>Results</strong>: During the study period, 85 cases were registered. Risk factors for cardiovascular disease were present in 85.5% and previous visits to the ED due to dizziness were recorded in 16.5%. The main clinical presentation was dizziness, concretely as an acute vestibular syndrome (38.8%) with additional neurological signs or symptoms (80%). Evaluation by the otolaryngologist on call was requested in less than 10% of the cases and included the HINTS protocol use with a sensitivity of 100% for central nervous system underlying causality. A brain CT study was always performed with a sensitivity of 27%. However, 96.47% of patients were primarily admitted to the Neurology hospitalization ward and MRI was always performed in a mean time of 3.21 days confirming the diagnosis.</p> <p><strong>Conclusions</strong>: Dizziness is the most frequent symptom of PS. Patients usually present an AVS (associated with additional N-SS or not) and HINTS bedside examination is the most adequate protocol to differentiate a PS from other AVS causes until the diagnostic confirmation via MRI. Interestingly, mainly otolaryngologists seem to use HINTS. However, the use of CT is widespread despite its poor value.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1867 Comparing the Emergency Medicine Residency Programs in Iran and around the World; a Descriptive Study 2022-12-17T16:55:02+00:00 Mahdi Talebi Reihanihr@mums.ac.ir Morteza Talebi Doluee Reihanihr@mums.ac.ir Mohamadali Jafari Reihanihr@mums.ac.ir Hamid Zamani Moghaddam Reihanihr@mums.ac.ir Mojtaba Moazzami Reihanihr@mums.ac.ir Mahdi Foroughian mf2600@gmail.com Hassan Gholami Reihanihr@mums.ac.ir Hamidreza Reihani Reihanihr@mums.ac.ir <p><strong>Introduction: </strong>To identify the strengths and weaknesses of emergency medicine residency curriculum in Iran, and to benefit from the experiences of successful universities, comparative studies are crucial. This study compared the components of the national curriculum of emergency medicine in the United States, Canada, the European Union, Australia, and Saudi Arabia with Iran.</p> <p><strong>Method: </strong>Data for this research was collected by searching the&nbsp;websites of different universities and&nbsp;also&nbsp;contacting them for requesting curriculums. The leading countries in emergency medicine and one of the countries in the Middle East region&nbsp;(Saudi Arabia) along with the World Federation of Emergency Medicine&nbsp;were selected as the sample. The model used in this field is a range model that identifies four stages of description, interpretation, proximity, and comparison in comparative studies.</p> <p><strong>Results:</strong> In the curriculum of the United States, Canada, the European Union, Australia, and Saudi Arabia, there were lots of similarities in expressing the general characteristics of the curriculum, mission elements, vision, values, and ​beliefs of the discipline, educational strategy, techniques, expected competencies, rotation programs, and evaluation method, which were also similar to the Iranian curriculum.&nbsp;However, the duration of residency for emergency medicine in Iran is three years, which is shorter than other countries. As expected, the number and duration of rotations are less than other countries. Also, the process of entering into this field is different in Iran and is based on an exam for entrance, while most other countries use self-requested residency program.</p> <p><strong>Conclusion:</strong> Considering the results of comparing the Iranian curriculum with the curriculums of the United States, Canada, the European Union, Australia, and Saudi Arabia, it seems that Iran's program is comprehensive and complete; but, a reappraisal of the course duration and entering options are necessary to eliminate or improve the inadequacies.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1870 Effect of Ticagrelor Compared to Clopidogrel on Short-term Outcomes of COVID-19 Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention; a Randomized Clinical Trial 2022-12-19T16:50:33+00:00 Reza Arefizadeh r.arefizadeh@gmail.com Seyed Hossein Moosavi dr.shmusavi@yahoo.com Sayied Towfiqie tufeeqees@yahoo.com Seyed Abolfazl Mohsenizadeh dr.mohseni959@gmail.com Mehdi Pishgahi mpishgahi.cr@gmail.com <p><strong>Introduction: </strong>Acute COVID-19 infection is associated with increased adverse clinical outcomes in patients with acute coronary syndromes (ACS). Given that some studies suggested improved pulmonary function with Ticagrelor, this clinical trial aimed to compare the effects of Ticagrelor versus Clopidogrel on the short-term outcomes of these patients.</p> <p><strong>Methods: </strong>In this multicenter clinical trial, 180 COVID-19 patients with ACS who underwent urgent percutaneous coronary intervention (PCI) were randomized to receive Ticagrelor (180mg loading dose followed by 90mg twice daily, n=90) or Clopidogrel (600mg loading dose with 75mg daily, n=90), and then followed for one month after their procedure. The primary composite endpoint was a combination of all-cause mortality, myocardial infarction, and early stent thrombosis within the first month after stent implantation.</p> <p><strong>Results: </strong>After thirty days of follow-up, the primary composite endpoint was non-significantly lower in the Ticagrelor compared to the Clopidogrel group (18.5% vs 23.5% respectively, p = 0.254). Based on the time-to-event analysis, the mean survival rate was 26.8 ±7.7 and 24.7 ±9.9 days, respectively, for the Ticagrelor and the Clopidogrel arms (Log-rank p = 0.275). Secondary endpoints were similar in the two trial arms, except for the mean oxygen saturation, which was higher in the Ticagrelor group (95.28 ±2.68 % vs. 94.15 ± 3.55 %, respectively; p = 0.021).</p> <p><strong>Conclusion: </strong>Among COVID-19 patients with concomitant ACS, who were treated with urgent PCI, the composite outcome of death, myocardial infarction, and early stent thrombosis was not different between Ticagrelor and Clopidogrel groups. However, administration of Ticagrelor was associated with a slight but statistically significant increase in oxygen saturation compared to Clopidogrel, but this difference wasn’t clinically important.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1853 Clinical Risk Factors of Need for Intensive Care Unit Admission of COVID-19 Patients; a Cross-sectional Study 2023-01-01T17:09:18+00:00 Farshid Sharifi sharififarshid2018@gmail.com Mohammad Hossain Mehrolhassani mhmhealth@gmail.com Milad Ahmadi Gohari mi.ahmadi@yahoo.com Ali Karamoozian alikaramooz69@gmail.com Yunes Jahani u.jahani@kmu.ac.ir <p><strong>Introduction:</strong> It could be beneficial to accelerate the hospitalization of patients with the identified clinical risk factors of intensive care unit (ICU) admission, in order to control and reduce COVID-19-related mortality. This study aimed to determine the clinical risk factors associated with ICU hospitalization of COVID-19 patients.</p> <p><strong>Methods: </strong>The current research was a cross-sectional study. The study recruited 7182 patients who had positive PCR tests between February 23, 2020, and September 7, 2021 and were admitted to Afzalipour Hospital in Kerman, Iran, for at least 24 hours. Their demographic characteristics, underlying diseases, and clinical parameters were collected. In order to analyze the relationship between the studied variables and ICU admission, multiple logistic regression model, classification tree, and support vector machine were used.&nbsp;</p> <p><strong>Results: </strong>It was found that 14.7 percent (1056 patients) of the study participants were admitted to ICU. The patients’ average age was 51.25±21 years, and 52.8% of them were male. In the study, some factors such as decreasing oxygen saturation level (OR=0.954, 95%CI: 0.944-0.964), age (OR=1.007, 95%CI: 1.004-1.011), respiratory distress (OR=1.658, 95%CI: 1.410-1.951), reduced level of consciousness (OR=2.487, 95%CI: 1.721-3.596), hypertension (OR=1.249, 95%CI: 1.042-1.496), chronic pulmonary disease (OR=1.250, 95%CI: 1.006-1.554), heart diseases (OR=1.250, 95%CI: 1.009-1.548), chronic kidney disease (OR=1.515, 95%CI: 1.111-2.066), cancer (OR=1.682, 95%CI: 1.130-2.505), seizures (OR=3.428, 95%CI: 1.615-7.274), and gender (OR=1.179, 95%CI: 1.028-1.352) were found to significantly affect ICU admissions.</p> <p>C<strong>onclusions: </strong>As evidenced by the obtained results, blood oxygen saturation level, the patient's age, and their level of consciousness are crucial for ICU admission.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1613 Associated Factors of In-hospital Mortality among Intubated Older Adults in Emergency Department; a Cross-sectional Study 2023-01-03T17:14:24+00:00 Mohd Idzwan Zakaria idzwan@ummc.edu.my Norhadila Che Manshor nhadila14@yahoo.com Maw Pin Tan mptan@ummc.edu.my <p><strong>Introduction:</strong> A decision-making guideline on when to intubate an older person based on predictors of intubation outcome would be extremely beneficial. This study aimed to identify the associated factors that could predict the outcomes of endotracheal intubation among older adults in the Emergency Department (ED).</p> <p><em><strong>Methods:</strong></em> In this retrospective cross-sectional study, patients aged ≥65 years intubated at the ED of University of Malaya Medical Centre, Kuala Lumpur, Malaysia, from 2015 to 2019 were studied. The association between age, gender, place of inhabitation, Identification of Seniors at Risk (ISAR) score for frailty, Charlson Comorbidity Index (CCI), Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score, indication for intubation, and diagnosis on admission with in-hospital mortality (primary outcome) and duration of ventilation, and length of stay (secondary outcomes) were evaluated using univariate analysis and Cox’s regression survival analysis.</p> <p><em><strong>Results:</strong></em> 889 cases aged 65 years and above were studied (61.5% male). The rate of in-hospital mortality was 71.4%. There was a significant association between age (p &lt; 0.001), nursing home residency (p = 0.008), CCI≥ 5 (p = 0.001), APACHE-II (p &lt; 0.001), pre-intubation Glasgow Coma Scale (GCS) (p &lt; 0.001), cardiac arrest as indication of intubation (p &lt; 0.001), diagnosis on admission (p &lt; 0.001), length of stay (p &lt; 0.001), and length of ventilation (p = 0.003) and in-hospital mortality. &nbsp;Age ≥ 85 years (HR= 1.270; 95%CI=1.074 to 1.502) and 75 to 84 years (HR=1.642; 95%CI=1.167 to 2.076), cardiac arrest as indication of intubation (HR: 1.882; 95% CI: 1.554 – 2.279), and APACHE-II scores 25 – 34 (HR: 1.423; 95% CI: 1.171 - 1.730) and ≥ 35 (HR: 1.789; 95%CI: 1.418 - 2.256) were amongst the independent predictive factors of in-hospital mortality.&nbsp;</p> <p><em><strong>Conclusion:</strong></em> Nearly three out of four individuals aged ≥65 years intubated at the ED died during the same admission. Older age, cardiac arrest as indication of intubation, and APACHE-II score were independent predictors of in-hospital mortality.</p> 2023-01-03T05:47:52+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1785 Long-term Complications of COVID-19 in Nursing Staff; a Retrospective Longitudinal Study 2023-01-09T17:21:34+00:00 Koorosh Etemad etemadk@gmail.com Hossein Hatami hatami21102@gmail.com Mahnaz Nikpeyma Nikpeyma110@yahoo.com Forough Mowla Mowla1361@gmail.com Fatemeh Fallah Atatalab fallahniloufar@yahoo.com <p><strong>Introduction: </strong>Although the lungs are the main target of coronavirus disease (COVID-19), infection is also associated with a high rate of extra-pulmonary complications. This study aimed to evaluate the one-year incidence of long-term COVID-19 complications among the nursing staff.</p> <p><strong>Methods: </strong>This study is a retrospective longitudinal study. All nursing staff working in public hospitals affiliated with Shahid Beheshti University of Medical Sciences who had been affected with COVID-19 were included in the study via convenience sampling method. The patients were recruited from 20<sub>th</sub> February 2020 to 20<sub>th</sub> March 2021.</p> <p><strong>Result: </strong>1762 nursing staff with a mean age of 35.08 ± 8.02 (Range: 22-66) years were studied (73.5% female). The results showed that among those who reported at least one type of complication, the duration of complications was significantly longer than 1 week and the median was 8 weeks.</p> <p>The findings demonstrated that complications occurred in 65% of infected females. For men, this rate was 62.3%. Generalized pain, anxiety disorders, and skin complications were among the complications that were significantly more common in women than in men. Additionally, the incidence of anosmia, ageusia, anxiety disorders, and skin complications was significantly higher in younger people than in older people. &nbsp;The comparison of complications revealed that nurses were significantly more likely than other occupations to experience respiratory complications, anosmia and ageusia, generalized pain, and skin complications and that outpatients experienced significantly more complications than hospitalized patients.</p> <p><strong>Conclusion: </strong>The one-year cumulative incidence of long-term complications in nursing staff with COVID-19 was 64.3%. The most common complications were respiratory complications, generalized pain, anosmia, and ageusia, respectively.</p> 2023-01-09T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1813 Pattern of Neurological Disorders among Patients Evaluated in the Emergency Department; Cross–Sectional Study 2023-01-21T17:33:30+00:00 Mohamed Sheikh Hassan dr.m.qalaf@gmail.com Nor Osman Sidow ziidoow113@gmail.com Alper GÖKGÜL dralper_10@hotmail.com Bakar Ali Adam atiika2009@gmail.com Mohamed Farah Osman mfhidig@gmail.com Hussein Hassan Mohamed abuucabdalla44@gmail.com Ismail Gedi Ibrahim ismaaciilg2@gmail.com Ishak Ahmed Abdi isakabdi70@gmail.com <p><strong>Introduction:</strong> Neurologic disorders are common reasons for emergency consultations. Most neurologic disorders seen in the emergency department (ED) are life-threatening and require urgent treatment. The goal of this study is to investigate the pattern of neurological disorders among patients evaluated in the ED.</p> <p><strong>Methods:</strong> This is a cross-sectional study conducted in the ED of Mogadishu Somali Turkish&nbsp;Training and Research Hospital, from July 2021 to February 2022. &nbsp;The clinical and epidemiological characteristics of adult patients with neurologic manifestations in the ED were evaluated. Age, gender, distribution of neurological disease manifestations, neurological examination findings, and neurological diagnoses made by consultant neurologists were assessed.</p> <p><strong>Results:</strong> During the study period, 321 patients were assessed (3.7 % of all ED admissions). The majority of the patients in the study were above 50 years of age (62.6% male). Hypertension was the most common comorbidity among these patients with 122 (38%) cases, followed by diabetes mellitus with 65 (20.2%), and heart diseases with 26 (8.1%) cases. The main reasons for neurology consultations were altered mental status with 141 (44%) cases, motor weakness with 102 (31.8%), seizures with 33 (10%), headache with 17 (5.3%), and vertigo with 9 (2.8%) cases. 196 (61%) had hemiplegia, 60 (18.7%) had consciousness impairment, and 38 (11.8%) had normal neurological examination. The most frequent neurological diagnoses were ischemic strokes with 125 (39%) cases, hemorrhagic strokes with 65 (20.2%), epileptic seizures with 28 (8.7%), and metabolic encephalopathies with 13 (4%) cases. The median duration of the neurology consultations was 20 minutes. 251 (78%) of the patients were admitted to the hospital, while 70 (22%) were discharged from the emergency department. After neurology consultation, the neurology department made the most admissions with 226 (90%) cases, while 25 (10%) were admitted by other departments. Of those admitted, 186 (74.2%) were admitted to the neurology ward, and 65 (25.8%) were admitted to the intensive care unit.</p> <p><strong>Conclusion:</strong> In our study, neurologic emergencies accounted for 3.7% of all emergency admissions. Stroke, epileptic seizures, cerebral venous thrombosis, encephalopathies, and acute spinal cord diseases were the most common neurological disorders.&nbsp; The admission rate was very high following neurologic assessment by neurologists.</p> 2023-01-21T10:42:35+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1839 Effect of Out-Of-Hour Admission on Fluid Treatment of Emergency Department Patients with Suspected Infection; a Multicenter Post-Hoc Analysis 2023-01-31T17:42:08+00:00 Marie Kristine Jessen marie.jessen@rm.dk Anna Drescher Petersen annadrescherp@gmail.com Hans Kirkegaard hanskirk@rm.dk <p><strong>Introduction:</strong> Sepsis is a life-threatening and common cause of Emergency department (ED) referrals. Out-of-hour staffing is limited in ED, which may potentially affect fluid administration. This study aimed to investigate fluid volume variation in out-of-hour vs. routine-hour admissions.</p> <p><strong>Methods:</strong> The present study is a post-hoc analysis of a multicentre, prospective, observational study investigating fluid administration in ED patients with suspected infection, from Jan 20<sup>th </sup>- March 2<sup>nd, </sup>2020. Patient groups were “routine-hours” (RH): weekdays 07:00-18:59 or “out-of-hours” (OOH): weekdays 19:00-06:59 or Friday 19:00-Monday 06:59. Primary outcome was 24-hour total fluid volumes (oral + intravenous (IV)). Secondary outcomes were total fluids 0-6 hours, oral fluids 0-6 and 0-24 hours, and IV fluids 0-6 and 0-24 hours. Linear regression adjusted for site and illness severity was used.</p> <p><strong>Results:</strong> 734 patients had suspected infection; 449 were admitted during RH and 287 during OOH. Mean (95% CI) total 24-hour fluid volumes were equal in simple infection and sepsis regardless of admission time: Simple infection RH: 3640 (3410 - 3871) ml and OOH: 3681 (3451 - 3913) ml. Sepsis RH: 3671 (3443;3898) ml and OOH: 3896 (3542;4250) ml. Oral fluids 0-6h were reduced in simple infection and sepsis among OOH vs. RH. Sepsis patients received more 0-6-hour IV fluid when admitted OOH vs. RH. There were no associations between admission time and 0-24-hour oral or IV volumes in simple infection or sepsis.&nbsp;</p> <p><strong>Conclusion:</strong> Admission time did not have an association with 24-hour total fluid volumes. Sepsis patients admitted during OOH received more 0-6-hour IV fluids than RH patients, and simple infection and sepsis patients received less oral fluid in 0-6 hours if admitted during OOH vs. RH.</p> 2023-01-31T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1833 Canadian C-spine Rule versus NEXUS in Screening of Clinically Important Traumatic Cervical Spine Injuries; a systematic review and meta-analysis 2023-01-21T10:48:47+00:00 Mohammadhossein Vazirizadeh-mahabadi1 sepehrvaziri.zm@gmail.com Mobina Yarahmadi moyaahmadi@gmail.com <p><strong>Introduction:</strong> The Canadian C-spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) are two criteria designed to rule-out clinically important traumatic cervical Spinal Cord Injury (SCI). In this systematic review and meta-analysis, we reviewed the articles comparing the performance of these two models.</p> <p><strong>Methods: </strong>Search was done in Medline, Embase, Scopus and Web of Science until June 2022. Observational studies with direct comparison of CCR and NEXUS criteria in detection of clinically important cervical SCI were included. Two independent reviewers screened the relevant articles and summarized the data. Certainty of evidence was assessed based on QUADAS-2. Data were recorded as true positive, true negative, false positive, and false negative. Then, using “<em>diagma</em>” package and applying weighted random effect model, area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, negative likelihood ratio, positive likelihood ratio, and diagnostic odds ratio (DOR) were calculated with 95% confidence interval (95% CI).</p> <p><strong>Results: </strong>We included 5 studies with direct comparison. Area under the ROC curve of NEXUS in screening of patients with clinically important cervical SCI was 0.708 (95% CI: 0.647 to 0.762). Pooled sensitivity and specificity of NEXUS criteria in screening of patients with clinically important cervical SCI were 0.899 (95% CI: 0.845 to 0.936) and 0.398 (95% CI: 0.315 to 0.488). The positive and negative likelihood ratios of NEXUS were 1.494 (95% CI: 1.146 to 1.949) and 0.254 (95% CI: 1.155 to 1.414), respectively. Diagnostic odds ratio of NEXUS was 5.894 (95% CI: 3.372 to 10.305). Furthermore, area under the ROC curve of CCR in screening of clinically important cervical SCI was 0.793 (95% CI: 0.657 to 0.884). Meta-analysis results showed that pooled sensitivity of CCR criteria in screening of patients with clinically important cervical SCI was 0.987 (95% CI: 0.957 to 0.996) and specificity was 0.167 (95% CI: 0.073 to 0.336). The positive and negative likelihood ratios of CCR were 1.184 (95% CI: 0.837 to 1.675) and 0.081 (95% CI: 0.021 to 0.308), respectively. Diagnostic odds ratio of CCR was 14.647 (95% CI: 3.678 to 58.336).</p> <p><strong>Conclusion: </strong>Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2022 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1808 Value of N-Terminal Pro-Brain Natriuretic Peptide for Embolic Events Risk Prediction in Patients with Atrial Fibrillation; a Systematic Review and Meta-Analysis 2022-12-19T16:50:34+00:00 Koohyar Ahmadzadeh Koohyar.ahmadzadeh@gmail.com Amirali Hajebi hajebi.a.a@gmail.com Hamzah Adel Ramawad hamzahr.adel@gmail.com Yaser Azizi azizi.y@iums.ac.ir Mahmoud Yousefifard yousefifard20@gmail.com <p><strong>Introduction:</strong> A comprehensive conclusion has yet to be made about the predictive value of serum N-terminal pro-brain natriuretic peptide (NT-proBNP) for stroke/systemic embolic events (SEE) in patients with atrial fibrillation (AF). This study aims to review the evidence for evaluating the value of NT-proBNP in predicting the risk of stroke/SEE in patients with AF through a systematic review and meta-analysis.</p> <p><strong>Method:</strong> Two independent reviewers screened all relevant studies that were retrieved from the database of Medline, Embase, Scopus, and Web of Science until December 7th, 2021. The predictive value of NT-proBNP in the prediction of stroke/SEE was recorded as hazard ratio (HR) and 95% confidence interval (95% CI).</p> <p><strong>Results:</strong> Nine articles (38,093 patients, 3.10% stroke/SEE) were included in our analysis. There was no publication bias in these studies (P=0.320). Our analysis showed that NT-proBNP can be a good predictor of stroke/SEE risk in AF patients, even at different cut-off values (HR=1.76; 95% CI: 1.51, 2.02; P &lt; 0.001). Subgroup analysis showed that diabetes could have a possible effect on the predictive value of NT-proBNP (meta-regression coefficient = 0.042; P = 0.037).</p> <p><strong>Conclusion:</strong> Measurement of NT-proBNP during the first admission could be used to assess the short- or long-term risk of stroke/SEE in patients with AF. Further studies are needed to evaluate the possible applicability of serum NT-proBNP measurement in the settings in which stroke is the sole outcome of the investigation.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1682 Serum Glial Fibrillary Acidic Protein in Detecting Intracranial Injuries Following Minor Head Trauma; a Systematic Review and Meta-Analysis 2022-12-08T16:53:48+00:00 Sajjad Ahmadi dr.ahmadi96993@gmail.com Shayan Roshdi Dizaji shayanroshdi@gmail.com Asrin Babahajian babahajian3@yahoo.com Mohammadreza Alizadeh dr.alizadeh.d@gmail.com Arash Sarveazad arashsarveazad@gmail.com Mahmoud Yousefifard yousefifard20@gmail.com <p><strong>Introduction: </strong>Developing novel diagnostic and screening tools for exploring intracranial injuries following minor head trauma is a necessity. This study aimed to evaluate the diagnostic value of serum glial fibrillary acidic protein (GFAP) in detecting intracranial injuries following minor head trauma.</p> <p><strong>Methods: </strong>An extensive search was performed in Medline, Embase, Scopus, and Web of Science databases up to the end of April 2022. Human observational studies were chosen, regardless of sex and ethnicity of their participants. Pediatrics studies, report of diagnostic value of GFAP combined with other biomarkers (without reporting the GFAP alone), articles including patients with all trauma severity, defining minor head trauma without intracranial lesions as the outcome of the study, not reporting sensitivity/specificity or any other values essential for computation of true positive, true negative, false positive and false-negative, being performed in the prehospital setting, assessing the prognostic value of GFAP, duplicated reports, preclinical studies, retracted articles, and review papers were excluded. The result was provided as pooled sensitivity, specificity, diagnostic score and diagnostic odds ratio, and area under the summary receiver operating characteristic (SROC) curve with a 95% confidence interval (95% CI).</p> <p><strong>Results: </strong>Eventually, 11 related articles were introduced into the meta-analysis. The pooled analysis implies that the area under the SROC curve for serum GFAP level in minor traumatic brain injuries (TBI) was 0.75 (95% CI: 0.71 to 0.78). Sensitivity and specificity of this biomarker in below 100 pg/ml cut-off were 0.83 (95% CI: 0.78 to 0.89) and 0.39 (95% CI: 0.24 to 0.53), respectively. The diagnostic score and diagnostic odds ratio of GFAP in detection of minor TBI were 1.13 (95% CI: 0.53 to 1.74) and 3.11 (95% CI: 1.69 to 5.72), respectively. The level of evidence for the presented results were moderate.</p> <p><strong>Conclusion: </strong>The present study's findings demonstrate that serum GFAP can detect intracranial lesions in mild TBI patients. The optimum cut-off of GFAP in detection of TBI was below 100 pg/ml. As a result, implementing serum GFAP may be beneficial in mild TBI diagnosis for preventing unnecessary computed tomography (CT) scans and their related side effects.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1856 Monkeypox Disease with a Focus on the 2022 Outbreak; a Narrative Review 2023-01-19T17:33:00+00:00 Zohreh Tehranchinia zohreh_tehranchi@yahoo.com Reza M Robati rmrobati@gmail.com Hamideh Moravvej hamideh_moravvej@yahoo.com Mojtaba Memariani memaryani@gmail.com Hamed Memariani h.memariani@gmail.com <p>Monkeypox is a zoonotic disease caused by a double-stranded DNA virus belonging to the genus <em>Orthopoxvirus</em>. Despite being endemic in Central and West Africa, the disease has received relatively little research attention until recent times. As the Coronavirus disease 2019 (COVID-19) pandemic continues to affect the world, the rising number of monkeypox cases in non-endemic countries has further stoked global public health concerns about another pandemic. Unlike previous outbreaks outside Africa, most patients in the present outbreak had no history of travel to the endemic regions. The overwhelming majority of patients were initially identified amongst homosexual men, who had attended large gatherings. Mutations in the coding regions of the viral genome may have resulted in fitness adaptation, enhancement of immune evasion mechanisms, and more efficient transmissibility of the 2022 monkeypox virus. Multiple factors such as diminished cross-protective herd immunity (cessation of smallpox vaccination), deforestation, civil war, refugee displacement, farming, enhanced global interconnectedness, and even climate change may facilitate the unexpected emergence of the disease. In light of the increasing number of cases reported in the present outbreak, healthcare professionals should update their knowledge about monkeypox disease, including its diagnosis, prevention, and clinical management. Herein, we provide an overview of monkeypox, with a focus on the 2022 outbreak, to serve as a primer for clinical practitioners who may encounter the disease in their practice.</p> 2023-01-16T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1860 Posterior Lingual Abscess; Report of Two Cases 2023-01-14T17:25:26+00:00 Miguel Saro- Buendía msarobuendia@gmail.com Pedro Suárez Urquiza pedrosurquiza@gmail.com Judit Amigo González judit.amigo95@gmail.com Maria José Lesmas Navarro mjlesmas@gmail.com Miguel Mazón mazonmig@gmail.com Miguel Armengot Carceller miguel.armengot@gmail.com <p>The lingual abscess is rare due to several protective mechanisms against infection in this location. Concretely, the abscess in the base of the tongue (posterior lingual abscess) is even more exceptional. Its prompt detection is crucial to avoid potentially fatal airway complications. To familiarize physicians with this condition, we report 2 cases of posterior lingual abscess. Both were referred to our emergency department due to minor oropharyngeal complaints. Finally, both were diagnosed and required surgical drainage. The clinical evolution was successful: both were discharged in less than 72 hours and follow-up one week later confirmed clinical recovery.</p> 2023-01-14T09:08:57+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1849 An Adult Female with Periumbilical Pain and Intractable Vomiting; a Photo quiz 2022-12-08T16:48:47+00:00 Hamzah Adel Ramawad hamzahr.adel@gmail.com Amirmohammad Toloui toloui.amir@gmail.com Adelaide Viguri adelaideviguri@gmail.com <p>A 25-year-old female with no significant past medical history presented to the emergency room with complaints of worsening, sharp, periumbilical pain for two days, with an intensity of 8 out of 10 based on the visual analogue scale. &nbsp;She complained of fever, nausea, anorexia, and multiple episodes of non-bloody, non-bilious emesis. &nbsp;The patient appeared unwell and diaphoretic. &nbsp;Her vital signs were as follows, blood pressure of 108/66 mmHg, heart rate of 106 beats/minute and body temperature of 39.3<sup>°</sup>C. Physical examination showed a distended abdomen with localized tenderness and guarding in the periumbilical region. &nbsp;A point-of-care ultrasound (POCUS) of the abdomen did not reveal any free fluid. Laboratory testing, which included electrolytes, complete blood count, and renal and liver function revealed no significant abnormalities. Pregnancy test was negative, and urinalysis was unremarkable. The findings of oral and intravenous contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis are shown in figures 1a and 1b.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2023 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1882 Analysis of articles in the Journal of Archives of Academic Emergency Medicine in 2022 2022-11-19T12:09:36+00:00 Somayeh Saghaei Dehkordi ma.saghaei63@gmail.com Mehrnoosh Yazdanbakhsh mehrnoosh.y@gmail.com <p>In 2022, <strong><em>Archives of Academic Emergency Medicine (AAEM)</em></strong> has published 90 articles, all of which are indexed by SCOPUS, Web of Sciences, PubMed and some other databases. They have been authored by more than four hundred researchers from various countries, including but not limited to the United States, Japan, Korea, Canada, Ghana, France, Norway, India, China, Thailand, Malaysia, Pakistan, Greece, Viet Nam and Iran. In this editorial, we intend to&nbsp;provide an overview of the journal’s flow in 2022, like we did in 2021 (1), so that we can identify our strengths and weaknesses and provide a brief report on our performance to readers and authors, which they might find useful in becoming more familiar with the journal. This article could help the authors who are interested in publishing with us to become more familiar with the journal’s aim and scope, and also the editorial priorities and preferences.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2022 Archives of Academic Emergency Medicine https://journals.sbmu.ac.ir/aaem/index.php/AAEM/article/view/1848 Piperonylbutoxide as a Dubious Cause of Cardiac Manifestations in Pyrethroid Insecticide Poisoning; a Letter to Editor 2022-12-15T16:49:02+00:00 Foroozan Faress for.farsi@gmail.com Maryam Ameri Ameri.m@iums.ac.ir Maryam Vasheghani Farahani vasheghani_m@yahoo.com Sayed Mahdi Marashi marashi.mh@iums.ac.ir <p>There is little evidence regarding pyrethroid poisoning manifesting with cardiac problems in the literature. Many authors, however, adopted that pyrethroids have a direct effect on heart tissue and can cause cardiotoxicity. Interestingly, no experimental studies have yet determined its mechanism of toxicity on cardiac muscle cells. This letter aims to describe the probable cause of clinical manifestations attributed to piperonylbutoxide, an ignored ingredient in pesticide poisoning, which is added to many pesticide products to increase their insecticidal potency. We think that cardiac manifestations in some cases of pyrethroid poisoning are due to the concomitant piperonylbutoxide toxicity and its possible effect on norepinephrine release from adrenal gland, which might explain changes in cardiac findings. Thus, it is necessary for all clinical toxicologists to determine suspicious ingredients when they are facing a doubtful manifestation.</p> 2023-01-01T00:00:00+00:00 Copyright (c) 2022 Archives of Academic Emergency Medicine