Archives of Academic Emergency Medicine <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> SBMU Journals en-US Archives of Academic Emergency Medicine 2645-4904 <p>Based on the obtained author agreement upon submission, "Archives of Academic Emergency Medicine" is the copyright owner of the published material. However, according to Bethesda Statement, all works published in this journal are open access and freely available to anyone on the journal web site without cost under creative common license BY-NC. Based on this license, under the condition of proper citation, "Archives of Academic Emergency Medicine" grants to all users the following rights:</p> <p>1. Free, irrevocable, worldwide, perpetual access to all published materials.</p> <p>2. To copy, use, distribute, transmit and display the work on third party repositories and social media.</p> <p>3. To make and distribute derivative works in any digital medium for any non-commercial purpose.</p> Proposing an Emergency Medicine Ethical Guideline; a Qualitative Study <p><strong>Introduction:</strong> Emergency medicine physicians face major ethical challenges in their practices. Furthermore, they need to be aware of the principles of ethical analysis and clinical decision-making in order to provide quality care. This study aimed to propose professional ethics codes in the emergency medicine department.</p> <p><strong>Method:</strong> This is a qualitative study, which was performed using narrative review and expert panel, and was conducted in three steps, including: literature review and preparation of the initial draft of the ethical concepts, obtaining expert opinions on this initial draft and its validation, and finalizing main ethical components in emergency medicine. In this study, we received the opinions of an expert panel including 10 medical ethicists and 12 emergency medicine specialists using a survey form.</p> <p><strong>Results:</strong> The ethical guide to emergency medicine can be formulated in 34 key ethical concepts, 6 sub-components, and 5 main components including emergency physician-patient relationship, and emergency physicians’ relationships with other professionals, students, researchers, and community.</p> <p><strong>Conclusion:</strong> Emergency care providers need to be familiar with ethical guidelines in order to improve quality of care in emergency departments. The findings of this study suggest that a guideline on patient-physician relationship as well as the emergency physicians’ ethical obligations for other professionals, students, researchers, and community should be developed in line with ethical norms.</p> Leili Asadabadi Kamran Soltani Nejad Atefeh Zolfagharnasab Mina Mobasher Copyright (c) 2021 Archives of Academic Emergency Medicine 2022-01-01 2022-01-01 10 1 e1 e1 10.22037/aaem.v10i1.1391 Remote Analysis and Transmission System of Electrocardiogram in Prehospital Setting; a Diagnostic Accuracy Study <p><strong>Introduction:</strong> One of the trends in the development of medical technologies is considered to be telemedicine. This study aimed to evaluate the accuracy of a remote electrocardiogram (ECG) analysis and transmission system in prehospital setting.</p> <p><strong>Methods:</strong> In this cross-sectional study, the data of 19,265 ECGs was gathered from emergency medical service (EMS) database of Almaty city, Kazakhstan, from 2015 to 2019. All ECGs were recorded in the prehospital setting by a paramedic, using "Poly-Spectrum" ECG recording device. Subsequently, all ECGs were sent to the cardiologist for interpretation and the findings were compared between software and cardiologist.</p> <p><strong>Results: </strong>19,265 ECGs were registered. The average time from taking ECGs to receiving an expert’s conclusion was 9.2 ± 2.5 minutes.&nbsp;The medical teams were called in 17.9% of cases after paramedic ECG recording; however, in the rest of the cases there was no need to call those teams. Using the device reduced the number of visits of specialist teams.</p> <p>The overall sensitivity, specificity, and accuracy of ECG analysis device in diagnosis of ECG abnormalities were 83.8% (95%CI: 82.6 – 84.9), 95.5% (95%CI: 95.1 – 95.8), and 93.3% (95%CI: 92.9 – 93.7), respectively.</p> <p><strong>Conclusion:</strong> The findings of this study showed the 93.3% accuracy of automatic ECG analysis device in interpretation of ECG abnormalities in prehospital setting compared with the cardiologist interpretations. Using the device causes a decrease in the number of cardiologist visits needed as well as reduction in cost and elapsed time.</p> Elmira Almukhambetova Murat Almukhambetov Abdugani Musayev Ainur Yeshmanova Vildan Indershiyev Zhadira Kalhodzhaeva Copyright (c) 2021 Archives of Academic Emergency Medicine 2022-01-01 2022-01-01 10 1 e5 e5 10.22037/aaem.v10i1.1399 Nifekalant versus Amiodarone for Out-Of-Hospital Cardiac Arrest with Refractory Shockable Rhythms; a Post Hoc Analysis <p><strong>Introduction: </strong>It is still unclear that which anti-arrhythmics are adequate for treating refractory dysrhythmia. This study aimed to compare amiodarone and nifekalant in management of out-of-hospital cardiac arrest cases with refractory shockable rhythm.</p> <p><strong>Methods: </strong>This was a post hoc analysis of cases registered in a nationwide, multicentre, prospective registry that includes 288 critical care medical centres in Japan. From June 2014 to December 2017, we included all out-of-hospital cardiac arrest patients aged ≥18 years who presented with refractory arrhythmia (sustained ventricular fibrillation or ventricular tachycardia following delivery of at least two defibrillator shocks) and treated with nifekalant or amiodarone after arrival to hospital. Overlap weight was performed to address potential confounding factors.</p> <p><strong>Results: </strong>1,317 out-of-hospital cardiac arrest patients with refractory arrhythmia were enrolled and categorized into amiodarone (n = 1,275) and nifekalant (n = 42) groups. After overlap weight was performed, there were no significant intergroup differences in increased the rate of admission after return of spontaneous circulation [–5.9% (95%CI: –7.1 to 22.4); p = 0.57], 30-day favourable neurological outcome [0.1% (95%CI: –14 to 13.9); p = 0.99], and 30-day survival [–3.9% (95% CI: –19.8 to 12.0); p = 0.63].</p> <p><strong>Conclusion: </strong>This nationwide study showed that nifekalant was not associated with improved outcomes regarding admission after return of spontaneous circulation, 30-day survival, and 30-day favourable neurological outcome compared with amiodarone.</p> Hiraku Funakoshi Shotaro Aso Yosuke Homma Ryuta Onodera Yoshio Tahara Copyright (c) 2021 Archives of Academic Emergency Medicine 2022-01-01 2022-01-01 10 1 e6 e6 10.22037/aaem.v10i1.1425 Association of CT Scan Parameters with the Risk of Renal Angiomyolipoma Rupture; a Brief Report <p><strong>Introduction: </strong>Rupture of renal angiomyolipoma (AML) is an emergency and life-threatening complication. This study aimed to evaluate the association of computed tomography (CT) scan parameters with the risk of rupture in renal AMLs.</p> <p><strong>Methods: </strong>In this retrospective cross-sectional study, patients who were referred to a referral university hospital with diagnosis of AML, between 2007 and 2019, were included. Patients were divided into ruptured and non-ruptured cases based on surgery and CT scan findings and the baseline characteristics as well as CT scan parameters were compared between the two groups.</p> <p><strong>Results:</strong> 20 AML patients with the mean age of 39.6 ± 12.5 years were included (75% female). The lesion was ruptured in 8 (40%) patients. The mean size of the lesion was ‎97.0 ± 15.9 mm‎‏ in the ruptured and ‏‎72.0 ± 29.4‎‏ in the non‎-‎ruptured AML ‏‎(‎p ‎= ‎‏0.045). The ‎mean fat density based on non-contrast enhanced CT (NCCT) scan (-‎56.1 ± 16.3 ‎vs ‎-‎‎74.9±24.1; ‏p = ‏‎0.018) and contrast enhanced CT (CECT) scan (-‎20.8 ± 16.9 ‎vs ‎-‎‎50.5 ± 31.7; ‏p ‏= ‏‎0.‎016) was significantly higher in the ruptured cases. Total tumor density based on NCCT scan was significantly greater in the ruptured ‎AMLs ‏(‏‎19.6 ± 25.9 ‎‏ vs‎ ‎-22.7±41.6, p=0.033).</p> <p><strong>Conclusion:</strong> It seems that some CT scan parameters such as mean fat density and ‎total tumor density ‏could be used for differentiation between ruptured and non-ruptured AMLs.</p> Razieh Heidari Mostafa Ghadamzadeh Mansour Bahardoust Forugh Khezrian Afrooz Moradkhani Parmida Ghadimi Seyed Morteza Bagheri Copyright (c) 2021 Archives of Academic Emergency Medicine 2022-01-01 2022-01-01 10 1 e7 e7 10.22037/aaem.v10i1.1472 Risk Stratification of Pulmonary Thromboembolism using Brain Natriuretic Peptide and Troponin I; a Brief Report <p><strong>Introduction:</strong> Pulmonary thromboembolism (PTE) is one of the most prevalent medical disorders, with a notable annual fatality rate. This study aimed to evaluated the accuracy of serum pro-BNP and troponin I levels in PTE diagnosis.</p> <p><strong>Methods:</strong> This cross-sectional study was implemented on 267 patients with suspected PTE (sudden chest pain or sudden dyspnea) in Imam Reza Hospital in Mashhad, Iran. All patients underwent pulmonary computed tomography (CT) angiography (as the gold standard test) and their serum levels of troponin I and pro-BNP were measured. The screening performance characteristics of pro-BNP in detection of PTE cases were measured and reported using receiver operating characteristic (ROC) curve analysis.</p> <p><strong>Results:</strong> Two-hundred-sixty-seven patients with a mean age of 67.7 ±11.5 years were evaluated (60.1% male). PTE was confirmed via CT angiography in 121 patients. The area under the ROC curve of troponin I and pro-BNP in detection of PTE was 0.501 ng/mL and 0.972 pg/mL, respectively. The sensitivity and specificity of proBNP at the best cut-off point (100 pg/ml) were 85.4% and 80.2%, respectively. The sensitivity and specificity of troponin I at the best cut-off point (0.005 ng/ml) were 65.5% and 42%, respectively.</p> <p><strong>Conclusion:</strong> Due to the comparatively good sensitivity and specificity of proBNP in diagnosis of pulmonary thromboembolism, it can be employed as a diagnostic determinant in patients with suspected pulmonary thromboembolism along with other laboratory tests.</p> Mohsen Ebrahimi Mohammad Mohsen Arab Hamid Zamani Moghadam Majid Jalal Yazdi Esmail Rayat doost Mahdi Foroughian Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-01-08 2022-01-08 10 1 e8 e8 10.22037/aaem.v10i1.1453 Clinical Predictors of Testicular Torsion in Patients with Acute Scrotum; a Cross-Sectional Study <p><strong>Introduction: </strong>Testicular torsion is an important and critical issue in patients with acute scrotum referring to emergency department (ED). Early detection is very important to save the testicles. This study aimed to determine the diagnostic accuracy of clinical variables in predicting the presence of testicular torsion.</p> <p><strong>Methods:</strong> This prospective cross-sectional study was done using the information of patients hospitalized from September 2015 to September 2020, with complaint of acute scrotum (ICD 10 code: N50.8), referring to ED for evaluation of the clinical predictors of testicular torsions, which were confirmed by surgery.</p> <p><strong>Results: </strong>81 patients with the mean age of 20.07 ± 9.64 (3- 45) years were studied. After surgical exploration, 70 patients (86.4%) had testicular torsion. Patients with torsion had lower age (p &lt; 0.0001), lower time from symptom to ED visit (p &lt; 0.0001), sudden onset pain (p = 0.003), left side pain (p &lt; 0.0001), and lower white blood cell (WBC) count (p = 0.001). The frequency of dysuria (p = 0.032), diarrhea/vomiting (p = 0.005), and fever (p = 0.002) was significantly lower in patients with torsion. The cremasteric reflex was absent in 57 (81.4%) cases who suffered from testicular torsion (p = 0.001). Based on the results of binary logistic regression analysis, age (B = -0.175, SE = 0.45; p &lt; 0.0001) was the sole independent predictor of testicular torsion. The highest area under the receiver operating characteristics (ROC) curve in predicting the presence of torsion belonged to lower age [91.0 (95%CI: 83.2 – 98.7)], pain in left testis [0.931 (95%CI: 0.828-0.987)], and lower WBC count [0.805 (95%CI: 0.684-0.926)], respectively.</p> <p><strong>Conclusion: </strong>It seems that clinical variables are not accurate enough to be considered as the sole predictor of testicular torsion and they should be used with caution and in combination with other available screening tools like Doppler ultrasonography in this regard.&nbsp;&nbsp;</p> Mohammad Sazgar Seyed Hossein Montazer Seyed Mohammad Hosseininejad Fatemeh Jahanian Behkam Rezaimehr Mohammad Behbohaninia Hamed Aminiahidashti Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-01-11 2022-01-11 10 1 e9 e9 10.22037/aaem.v10i1.1484 Clinical, Laboratory and Imaging Characteristics of Hospitalized COVID-19 Patients with Neurologic Involvement; a Cross-Sectional Study <p><strong>Introduction:</strong> Although neurologic involvement and neuroimaging abnormalities have been frequently identified in COVID-19 patients, the underlying factors remain unclear. In this study, we assessed the association of the neurological manifestations and neuroimaging features of hospitalized COVID-19 patients with their clinical, laboratory, and imaging characteristics.</p> <p><strong>Methods: </strong>This multicenter cross-sectional study was conducted between September 2020 and March 2021 at two large academic hospitals in Tehran, Iran. We used census sampling from medical records to enroll hospitalized patients with a positive COVID-19 Polymerase chain reaction (PCR) test who underwent brain imaging due to presenting any acute neurologic symptom during hospital stay.</p> <p><strong>Results: </strong>Of the 4372 hospitalized patients with COVID-19, only 211 met the inclusion criteria (35.5% with severe infection). Central nervous system and psychiatric manifestations were significantly more common in severe cases (p ≤ 0.044). Approximately, 30% had a new abnormality on their neuroimaging, with ischemic (38/63) and hemorrhagic (16/63) insults being the most common. The most frequent reasons that provoked cranial imaging were headache (27%), altered consciousness (25.6%), focal neurologic signs (19.9%), and delirium (18%). Analysis revealed a positive correlation for age, neutrophilia, lymphopenia, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) with the emergence of neuroimaging abnormalities (p ≤ 0.018). In addition, patients with new neuroimaging abnormalities had a significantly higher lung CT score than those without any pathologic findings (11.1 ± 4.8 vs. 5.9 ± 4.8, p &lt; 0.001).</p> <p><strong>Conclusion: </strong>Approximately 30% of the study population had various acute neuroimaging findings. The lung CT score, neutrophil count, and age were strong predictors of acute neuroimaging abnormalities in hospitalized COVID-19 patients.</p> Ali Zare Dehnavi Mohammadreza Salehi Mehran Arab Ahmadi Mohammad Hossein Asgardoon Farzad Ashrafi Nasrin Ahmadinejad Atefeh Behkar Ramin Hamidi Farahani Hassan Hashemi Abbas Tafakhori Hamze Shahali Mohammad Rahmani Alireza Ranjbar Naeini Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-01-30 2022-01-30 10 1 e10 e10 10.22037/aaem.v10i1.1507 Clinical Features and Outcomes of Acute Chlorine Gas Inhalation; a Brief Report <p><strong>Introduction:</strong> On March 6<sup>th</sup>,2020, chlorine gas leak was reported at Engro Polymer &amp; Chemicals Plant in Karachi City, Pakistan. This study aimed to evaluate the clinical features and outcomes of patients who presented to emergency department (ED) following this event.</p> <p><strong>Methods: </strong>This retrospective cross-sectional study, evaluated the clinical features and outcomes (length of hospital stay, complications, and mechanical ventilation requirement) of patients presenting to ED of Aga Khan University Hospital, Karachi, Pakistan, with history of chlorine gas exposure at the Engro Plant from 6<sup>th</sup> March to 14<sup>th</sup> March 2020.</p> <p><strong>Results: </strong>38 patients with mean age of 33.1 ± 8.1 years presented to ED with history of chlorine gas exposure (100% male). &nbsp;4 (10.5%) cases&nbsp;had comorbid diseases. Most common presenting symptom was dyspnea, observed in 33 (86.8%) cases, followed by cough, seen in 27 (71.1%) subjects. 13.2% (5/38) patients had infiltration on chest x-ray and 33 (86.8 %) required hospitalization. 6 (15.8%) patients had repeat presentation requiring hospitalization or ED visit. 18 (47.4%) were managed with high flow oxygen therapy, 9 (23.7%) required non-invasive ventilation and one patient was intubated due to development of pneumo-mediastinum. Mean length of stay was 1.55 ± 1.58 days and no patients died. Presence of tachycardia was the only finding significantly associated with need for oxygen (p = 0.033) and non-invasive ventilation (p = 0.012).</p> <p><strong>Conclusion: </strong>The majority of patients presenting with acute chlorine gas exposure showed good clinical outcomes and rapid recovery, however, a high index of suspicion and vigilance should be maintained for complications such as pneumomediastinum and acute respiratory distress syndrome in these patients.</p> Taymmia Ejaz Sheema Saadia Safia Akhlaq Adil Aziz Muhammad Arslan Ahmed Aisha Fareed Siddiqui Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-02-14 2022-02-14 10 1 e15 e15 10.22037/aaem.v10i1.1448 Correlation Between TIMI Risk Score and the Number of Vessels Involved in the Angiographic Study; a Cross-sectional Study <p><strong>Introduction: </strong>TIMI (Thrombolysis in Myocardial Infarction) score is a model for predicting the severity of vascular diseases. This study aimed to evaluate the correlation between this score and the number of vessels involved in patients with Unstable Angina (UA) or Non-ST Elevation Myocardial Infarction (NSTEMI).</p> <p><strong>Methods: </strong>This prospective cross-sectional study was designed to evaluate the correlation between TIMI score, and the number of vessels involved in the angiographic study of NSTEMI and UA patients presenting to emergency department.</p> <p><strong>Results: </strong>297 patients with the mean age of 62.16±36.59 years were entered (58.2% male; 193 (65%) UA and 104 (35%) NSTEMI). The Mean TIMI score among patients was 3.21±1.55. Based on the TIMI score, patients were categorized into 3 groups. 105 (35.35%) patients had a TIMI score of 0 to 2, 120 (40.40%) had a score of 3 to 4, and 72 (24.24%) had a score of 5 to 7. Patients with a TIMI score of 5 to 7 had a greater likelihood of three-vessel coronary artery disease compared to patients with a TIMI score of 3 to 4 (OR: 5.34, 95% CI: 2.64 to 10.80; p &lt; 0.0001) or those with a TIMI score of 0 to 2. (OR: 29.45, 95% CI: 12.87 to 67.37; p &lt; 0.0001). Two-vessel coronary artery disease was more likely to be found in patients with a TIMI score of 3 to 4 or those with a score of 5 to 7 compared to patients with a TIMI score of 0 to 2 (OR: 3.69, 95% CI: 1.60 to 8.51; p &lt;0.0001 and OR: 2.67, 95% CI: 1.04 to 6.82; p = 0.04, respectively).</p> <p><strong>Conclusion:</strong> There is a direct and significant correlation between TIMI score and the number of coronary vessels involved in patients presenting to emergency department following UA or NSTEMI.</p> Mohammad Hasan Namazi Seyedeh Slimeh Mazloomi Mohammad Kalate Aghamohammadi Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-02-14 2022-02-14 10 1 e16 e16 10.22037/aaem.v10i1.1466 Propofol + Granisetron vs. Propofol + Metoclopramide in Symptom Management of Acute Migraine Headache; a Double-Blind Randomized Clinical Trial <p><strong>Introduction:</strong> Acute headache is one of the most common reasons for emergency department (ED) visits. This study aimed to compare the combination of propofol and granisetron with propofol and metoclopramide in symptom management of acute migraine headache.</p> <p><strong>Methods:</strong> In this double-blind randomized clinical trial, 60 adult patients with acute migraine headache who referred to ED were randomly divided into two groups of propofol + metoclopramide and propofol + granisetron. Pain and nausea/vomiting severity as well as blood pressure were compared between groups 30, 45, and 60 minutes after treatment.</p> <p><strong>Results:</strong> The two groups had similar situation regarding mean age (p = 0.606), sex distribution (p = 0.793), baseline severity of pain (p = 0.642), frequency of nausea/vomiting (p = 0.488), and vital signs (p &gt; 0.05). The severity of pain was similar in the two groups 30 (p = 0.731), 45 (p = 0.460), and 60 (p = 0.712) minutes after treatment. The number of patients with resistant nausea and vomiting 60 minutes after treatment was significantly higher in metoclopramide group (30.0% versus 10.0%; p = 0.033). Diastolic pressure 60 minutes after treatment (81.43 ±8.94 vs. 74.97 ± 4.8; p = 0.001) and heart rate 30 minutes after treatment (68.87 ±6.52 vs. 73.57± 7.62; p = 0.013) had statistically significant differences between the groups.</p> <p><strong>Conclusion:</strong> The combination of propofol and granisetron was superior to propofol and metoclopramide in case of controlling nausea and vomiting of cases with acute migraine headache; meanwhile, no differences were observed in case of pain relief and hemodynamic status between the two groups.</p> Samaneh Abiri Mehdi Chegin Reza Soleimani Naser Hatami Navid Kalani Esmail Rayatdoost Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-03-05 2022-03-05 10 1 e19 e19 10.22037/aaem.v10i1.1561 Skin Cooling to Reduce the Pain Associated with Local Anesthetic Injection; a Randomized Controlled Trial <p><strong>Introduction: </strong>Different methods have been proposed for the reduction of the pain caused by the injection of local anesthetics. This study aimed to evaluate the effect of skin cooling on reduction of pain associated with local injection of lidocaine buffered with sodium bicarbonate.</p> <p><strong>Methods: </strong>This randomized controlled trial included 108 adult patients with arm/forearm wounds who referred to the emergency departments. Participants were randomly allocated to two equal groups. Patients in both groups received subcutaneous injection of buffered lidocaine. In the intervention group, an ice cube measuring 2 × 2 × 2 cm (at 0 ° C) in sterile gloves were placed on the wound for 2 minutes before the injection of buffered lidocaine. The primary outcome was severity of pain during lidocaine injection using a visual analog scale (VAS).</p> <p><strong>Results: </strong>One hundred and eight patients were enrolled in the study, 54 in each group. There was no statistically significant difference in age (p = 0.777), sex (p = 0.466), and length of laceration (p = 0.410) between the two groups. The pain scores during lidocaine injection were significantly lower in the intervention group compared to control group (2.39 ± 1.14 vs 4.26 ± 0.94, p &lt; 0.001).</p> <p><strong>Conclusions: </strong>Skin cooling prior to the injection of local anesthetics can significantly reduce the pain caused by local anesthetic infiltration</p> Saeed Majidinejad Farhad Heidari Amir Chitgarian Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-03-10 2022-03-10 10 1 e20 e20 10.22037/aaem.v10i1.1562 Relationship Between Income Level and Hospitalization Rate in COVID-19 Cases; an Example of Social Factors Affecting Health <p><strong>Introduction:</strong> Considering the population's socioeconomic status and clinical features is essential in planning and performing interventions related to disease control. The main purpose of this study was to investigate the relationship between income level and hospitalization rate of COVID-19 patients‌.</p> <p><strong>Methods: </strong>A cross-sectional study was performed on 198,944 hospitalized COVID-19 patients in Tehran province between March 2020 and March 2021. Data of hospitalized COVID-19 patients was obtained from the Hospital Intelligent Management System (HIM). The income data of patients were obtained from the Iranian Database on Targeted Subsidies belonging to the Ministry of Cooperatives, Labor, and Social Welfare. Data analyses were performed using SPSS software.</p> <p><strong>Results: </strong>About 2.5% of the inpatients were from the first decile, while 20.6% were from the tenth. The share of the lower three deciles of total hospitalization was about 11%, while the share of the upper three deciles was 50%. There was a big difference between the upper- and lower-income deciles regarding death rates. In the first decile, 30% of inpatients died, while the proportion was 10% in the tenth decile. There was a significant and positive relationship between income decline and hospitalization (r = 0.75; p = 0.02). Also, there was a significant and negative relationship between income decline and death rate (r = -0.90; p = 0.01).</p> <p><strong>Conclusion: </strong>Low-income groups use fewer inpatient services, are more prone to severe illness and death from COVID-19‌, and treatment in this group has a lower chance of success. Using a systemic approach to address socioeconomic factors in healthcare planning is crucial.</p> Ali Maher Hamed Dehnavi Elham Salehian Mona Omidi Khatereh Hannani Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-09 2022-04-09 10 1 e23 e23 10.22037/aaem.v10i1.1600 Glasgow Coma Scale Versus Physiologic Scoring Systems in Predicting the Outcome of ICU admitted Trauma Patients; a Diagnostic Accuracy Study <p><strong>Introduction: </strong>There is no consensus on the performance of decision rules in predicting the prognosis of trauma patients. Therefore, the present study aimed to compare the value of Glasgow coma scale (GCS) and physiologic scoring systems in predicting mortality and poor outcome of trauma patients.</p> <p><strong>Methods:</strong> This diagnostic accuracy study was conducted on multiple trauma patients admitted to the intensive care units of two hospitals in Tehran, Iran, from 21 November 2020 to 22 May 2021. The patients' demographic characteristics, length of stay in the intensive care unit (ICU), the vital signs, and the GCS on admission were recorded. Finally, the mortality, disability, and complete recovery of patients at the time of discharge were evaluated and receiver operating characteristics (ROC) curve analysis was used to compare the performance of physiologic scoring systems with GCS.</p> <p><strong>Results:</strong> 200 trauma patients with the mean age of 43.53±19.84 years were evaluated (74% male). The area under the ROC curve for New Trauma Score (NTS), Revised Trauma Score (RTS), Worthing Physiological Scoring System (WPSS), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), National Early Warning&nbsp; Score (NEWS), Glasgow Coma Scale (GCS), Age, and Systolic Blood Pressure (GAPS) in prediction of mortality were 0.95, 0.95, 0.83, 0.89, 0.91, 0.84, 0.77, 0.98, and 0.97 respectively. The performance of GCS was statistically superior to RTS (P=0.005), WPSS (P=0.0001), RAPS (P=0.0002), REMS (P=0.002), MEWS (P&lt;0.0001), and NEWS (P&lt;0.0001). However, the performance of GCS, NTS (P=0.146), and GAPS (P=0.513) were not significantly different. Also, in prediction of poor outcomes, the AUC of GCS (0.98) was significantly higher than RTS (0.95), RAPS (0.85), REMS (0.85), MEWS (0.84), NEWS (0.77), and WPSS (0.75).</p> <p><strong>Conclusion:</strong> The GCS score seems to be a better instrument to predict mortality and poor outcome in trauma patients compared to other tools due to its high accuracy, wide application, and easy calculation.</p> Sorour Khari Mitra Zandi Mahmoud Yousefifard Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-09 2022-04-09 10 1 e25 e25 10.22037/aaem.v10i1.1483 Potential Impact of 3% Hypertonic Saline Infusion on Tramadol Poisoning-Induced Electrocardiogram Changes; a Randomized Clinical Trial <p><strong>Introduction: </strong>Tramadol is a synthetic analgesic with weak mu-opioid receptor agonist activity. Tramadol overdose is associated with adverse cardiac effects due to inhibiting cardiac Na+ and K+ channels. This study aimed to investigate the potential ameliorative role of 3% hypertonic saline on the electrocardiogram (ECG) changes in patients presenting with tramadol poisoning.</p> <p><strong>Methods: </strong>This was a single-center, controlled, randomized, single-blind clinical trial. Patients were randomized into the case (received hypertonic saline) and control (received placebo) groups. ECG was obtained twice in each group (upon arrival and following the intervention). Response to therapeutic interventions was evaluated using Wilcoxon Signed Ranks Test.</p> <p><strong>Results: </strong>A total of 76 patients were included. The mean age of patients was 24.88 ± 4.29 years, and 62 (81.6%) were male. The mean ingested dose of tramadol was 1673.68 ± 608.85 (range: 550-2750) mg. The number needed to treat and the absolute risk reduction of 3% hypertonic saline in the treatment of wide QRS were 1 (95% CI: 1.00 – 1.00) and 100%, respectively. In the treatment of long QTc, these measures were 1.9 (95%CI: 1.2 – 4.5) and 53.85% (95%CI: 22.00 – 85.69), respectively.</p> <p><strong>Conclusion: </strong>Given that hypertonic saline infusion can significantly ameliorate tramadol-mediated ECG changes, including QRS prolongation and QT lengthening, it can be regarded as a potential therapeutic strategy to prevent the development of life-threatening ventricular arrhythmias caused by tramadol toxicity.</p> Ali Omraninava Ahmad Mehdizade Ebrahim Karimi Amir Ghabousian Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-13 2022-04-13 10 1 e26 e26 10.22037/aaem.v10i1.1567 Efficacy of Sumatriptan/Placebo versus Sumatriptan/Propofol Combination in Acute Migraine; a Randomized Clinical Trial <p><strong>Introduction:</strong> Migraine headaches can cause severe pain for patients and lead them to multiple visits to the emergency department (ED). This study aimed to evaluate the efficacy of propofol + sumatriptan combination in comparison with sumatriptan alone in the management of acute migraine headaches.</p> <p><strong>Methods:</strong> This triple-blind clinical trial involved patients who referred to two emergency departments with acute migraine headaches. Patients were randomly assigned to control (sumatriptan and placebo) or intervention (propofol and sumatriptan) groups for comparison of the efficacy and side effects of treatment.</p> <p><strong>Results: </strong>In this study, 60 patients were included whose mean age was 31±8.8 years, and headaches were more common among women. After 30 and 60 minutes from the beginning of treatment, the mean pain score reduction in the intervention group was significantly greater than that in the control group (p=0.012, p=0.024). In addition, the rate of chest tightness in the control group was significantly higher than the intervention group. The&nbsp;absolute risk reduction of adverse events (Chest tightness, Bradycardia, hypotension, and etc.), in patients with acute migraine headache taking propofol and sumatriptan treatment, was 32.18% (95% CI: 8.02 – 56.35).</p> <p><strong>Conclusions:</strong> This study supports the use of propofol for treatment of acute migraine headaches and shows that combining sumatriptan with propofol is more effective in relieving migraine headaches and the associated symptoms than using sumatriptan alone. However, more studies with longer follow-ups are still needed.</p> Reza Farahmand Rad Akram Zolfaghari Sadrabad Mohammadali Jafari Marzieh Ghilian Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-14 2022-04-14 10 1 e27 e27 10.22037/aaem.v10i1.1510 Alveolar Arterial Gradient and Respiratory Index in Predicting the Outcome of COVID-19 Patients; a Retrospective Cross-Sectional Study <p><strong>Introduction: </strong>Alveolar arterial (A-a) oxygen gradient and respiratory index can be of immense help for the critical care physician in clinical decision making. This study aimed to evaluate the potential application of A-a oxygen gradient and respiratory index in predicting the survival of COVID-19 patients in intensive care unit (ICU).</p> <p><strong>Method: </strong>This is a retrospective cross-sectional study involving 215 adult patients with COVID-19 disease, admitted to the ICU between 1<sup>st</sup> April 2020 and 30 June 2021. Details regarding demographic variables, comorbidities, laboratory and arterial blood gas (ABG) findings were recorded. Alveolar-arterial gradient and respiratory index were calculated and tested as predictors of survival.</p> <p><strong>Result: </strong>The mean age of the patients was 51.92 years (65.6 % male). Hypertension was the most common comorbidity and oxygen via non-rebreathing mask was the most common modality used at the time of ICU admission. Mortality was 28.37% and average length of stay was 12.84 days. Patients who died were older (p=0.02), mostly male (p=0.017), had at least one comorbidity (p&lt;0.001), and higher heart rate and respiratory rate (&lt;0.001 and p=0.03, respectively), lower pH on arterial blood gas (ABG) (p=0.002), higher FiO2 requirement (p&lt;0.001), and increased A-a oxygen gradient on admission compared to survivors. According to receiver operating characteristic (ROC) curve analysis, A-a oxygen gradient and respiratory index were not sensitive or specific in predicting mortality in the studied patient subset.</p> <p><strong>Conclusion: </strong>A-a oxygen gradient and respiratory index calculated at time of admission to ICU in patients with COVID-19 were poor predictors of survival.</p> Abhishek Singh Kapil Dev Soni Yudhyavir Singh Richa Aggarwal Vineeta Venkateswaran Mohd Suhail Ashar Anjan Trikha Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-14 2022-04-14 10 1 e28 e28 10.22037/aaem.v10i1.1543 Factors Associated with 24-Hour Clinical Outcome of Emergency Patients; a Cohort Study <p><strong>Introduction:</strong> Pre-hospital and in-hospital emergency management play an important role in quality of care for emergency patients. This prospective cohort study aimed to determine factors associated with the 24-hour clinical outcome of emergency patients.</p> <p><strong>Methods:</strong> The sample included 1,630 patients, randomly selected through multi-stage stratified sampling from 13 hospitals in 13 provinces of Thailand. Data were collected during January-November 2018. Clinical outcome was determined using pre-arrest sign score. Data were analyzed via ordinal multivariate regression analysis.</p> <p><strong>Results:</strong> Factors influencing 24-hour clinical outcome of emergency patients were age (OR: 0.965; 95% CI: 0.96-0.97), having coronary vascular disease (CAD) (OR: 1.41; 95% CI: 1.05-1.88), and severity of illness based on Rapid Emergency Medical Score (REMS) (OR:1.09; 95% CI: 1.05-1.15). Self-transportation and being transported by emergency medical service ambulance with non-advanced life support (EMS-Non-ALS) did not influence clinical outcome when compared to EMS-ALS transport. Being transported from a community hospital increased pre-arrest sign score 1.78 times when compared to EMS-ALS (OR: 1.78; 95% CI: 1.17-2.72). Increased transportation distance increased the risk of poor clinical outcome (OR: 1.01; 95% CI: 1.002-1.011). Length of stay in emergency department (ED-LOS) more than 4 hours (OR: 0.21; 95% CI: 0.15-0.29) and between 2-4 hours (OR: 0.60; 95% CI: 0.47-0.75) decreased the risk of poor clinical outcome when compared to ED-LOS less than 2 hours.</p> <p><strong>Conclusion:</strong> Having CAD, severity of illness, increased transport distance, and ED-LOS less than 2 hours were found to negatively influence 24-hour clinical outcome of emergency patients.</p> Kannika Katsomboon Siriorn Sindhu Ketsarin Utriyaprasit Chukiat Viwatwongkasem Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-24 2022-04-24 10 1 e30 e30 10.22037/aaem.v10i1.1590 Mortality and Years of Life Lost due to Burn Injury Among Older Iranian People; a Cross-Sectional study <p><strong>Introduction</strong>: The mortality of burn injury is a serious health problem among older people. The present study aimed to determine the epidemiological characteristics of burn mortality and Years of Life Lost (YLLs) among people aged ≥ 60.</p> <p><strong>Methods</strong>: The National and Subnational Burden of Disease (NASBOD) study includes population-based cross-sectional data from the death registration system of Iran and those recorded by the cemeteries of Tehran and Esfahan were used in this study. Spatio-temporal and Gaussian process regression models were applied to estimate rates and trends of mortality and cause-specific mortality fractions. YLLs were calculated using Iranian life expectancy and the number of deaths.</p> <p><strong>Results</strong>: The mortality rate for 1990 and 2015 was 17.4 and 4.5 per 100,000, respectively. From 1990 through 2015, the annual percentage of change in burn mortality rate was -6.1% in females and -4.4% in males. During 2015, there were 326 deaths following burns in people aged 60+ with 4586 person YLLs, and in 1990 there were 523 deaths with 4862 person-YLLs. The male-female ratio for 1990 and 2015 were 0.80 and 0.88, respectively. The age-standardized mortality rate was higher than 8.5 per 100,000 in border provinces in 2015. The provinces with better socioeconomic situations, such as Tehran, had a lower mortality rate than poor provinces, such as Sistan va Baluchistan.</p> <p><strong>Conclusion</strong>: Although burn mortality in old people decreased in those 26 years, it is still high compared to high-income countries. Continued efforts to increase preventive measures and adequate access to quality care, especially in border provinces, is suggested.</p> Farideh Sadeghian Sahar Saeedi Moghaddam Zahra Ghodsi Parinaz Mehdipour Ali Ghanbari Gerard O'Reilly Nazila Rezaei Sahar Mohammadi Fateh Ali H. Mokdad Vafa Rahimi-Movaghar Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-27 2022-04-27 10 1 e31 e31 10.22037/aaem.v10i1.1547 Resident Productivity in the Emergency Department After Implementation of an Automated Patient Assignment System; a Brief Report <p><strong>Introduction:</strong> The clinical diversity of patients presenting to the emergency department (ED) allows emergency medicine (EM) and non-EM residents to sharpen their clinical skills. In most EDs, residents self-assign patients at their discretion. Our institution transitioned from a self-assignment-system to an automated-system, after which we sought to determine the productivity of our non-EM residents compared to the previous system.</p> <p><strong>Methods:</strong> In this retrospective cross-sectional study, resident productivity was measured as number of patient visits per hour and per 8.5-hour shift before and after the implementation of an automated patient assignment system in emergency department. The automated-system assigns one patient at the start of the shift, another 30 minutes later, and one patient every hour thereafter, throughout the shift.</p> <p><strong>Results:</strong> 28 residents performed 406 total shifts prior to implementation and 14 residents performed 252 total shifts post-implementation. The average number of patient visits per hour significantly increased from 0.52 ± 0.18 (95% CI 0.45-0.59, IQR 0.43-0.60) to 0.82 ± 0.11 (95% CI 0.75-0.88, IQR 0.74-0.89) after implementation of our assignment system (p&lt;0.00001; figure 1). Additionally, the average number of patient visits per 8.5-hour shift significantly increased from 4.46 ± 1.53 (CI 3.86-5.05, IQR 3.66-5.08) to 6.52 ± 0.86 (CI 6.02-7.02, IQR 5.90-7.09) after the implementation of our system (p&lt;0.00001; figure 1).</p> <p><strong>Conclusion: </strong>These findings warrant further evaluation of the impact of patient assignment systems on trainee education.</p> Christian Rosenow Sophia Aguirre Thomas Polveroni Zachary Ginsberg Jordan Pollock Stephen Traub Douglas Rappaport Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-30 2022-04-30 10 1 e33 e33 10.22037/aaem.v10i1.1516 Demographic and Clinical Characteristics of 907 Cases with Naltrexone Intoxication; a 14-Year Cross-Sectional Study <p><strong>Introduction:</strong> Opioids have been the leading cause of death from poisoning in Iran for several years. This study aimed to evaluate the clinical and para-clinical presentations of naltrexone intoxication, its toxic dose, and its epidemiological properties.</p> <p><strong>Methods</strong><strong>:</strong> This retrospective cross-sectional study was conducted on medical records of patients presenting to Toxicology Department of Loghman Hakim Hospital, Tehran, Iran, following naltrexone intoxication, from 2002 to 2016. Patients’ demographic and laboratory data, clinical signs, supposed ingested dose, and intent of naltrexone consumption were collected, analyzed, and then interpreted.</p> <p><strong>Results:</strong> 907 patients with the mean age of 36.6 ±11.7 years were evaluated (94.3% male).&nbsp; The mean amount of naltrexone consumed by the intoxicated patients reported in the medical records was 105.8 ± 267.8 mg. One hundred thirty patients (14.3%) used naltrexone to treat substance use disorder. Two hundred eighty-seven poisoned patients (31.6%) were current opium users who intentionally or unintentionally used naltrexone concomitantly. The most common symptoms observed in these patients were agitation (41.8%), vomiting (16.4%), and nausea (14.8%). Among patients with naltrexone poisoning, 25 patients were intubated (2.8%), and three passed away. Aspartate aminotransferase (AST) levels were significantly higher in patients intoxicated with naltrexone who needed intubation (p = 0.02).</p> <p><strong>Conclusion</strong>: The probability of intubation of cases with naltrexone intoxication was associated with AST elevation. It seems that, the number of intensive care unit (ICU) admissions and mortality rates are not high among these patients.</p> Mitra Rahimi Alireza Kargar Delara Hazegh Fetratjoo Sayed Masoud Hosseini Arezou Mahdavinejad Shahin Shadnia Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-05-01 2022-05-01 10 1 e34 e34 10.22037/aaem.v10i1.1554 The Challenges of Emergency Medical Services Response to Arasbaran Twin Earthquakes; a Content Analysis <p><strong>Introduction:</strong> One of the most important concerns in responding to disasters is providing Basic Life Support (BLS) services. Considering the key role of Emergency Medical Services (EMS) in providing BLS, the purpose of this study is to investigate the experience of provincial EMS during their response to the Arasbaran twin earthquakes and its challenges in Iran.</p> <p><strong>Methods:</strong> This study was conducted using a qualitative approach and the conventional content analysis method. Data were collected through Focused Group Discussions (FGD) and semi-structured in-depth interviews with purposively-selected EMS paramedics and officials in East Azerbaijan Province, Iran. To form the main categories, the interviews were encoded in three stages and the similar codes were placed under the same subcategories and merged.</p> <p><strong>Results:</strong> A total of 26 EMS paramedics participated in the study. The codes extracted from the interviews, after three stages of reduction, were placed in the top ten categories, including the lack of preparedness and coordination, dead bodies' management challenges, responders’ psychosocial support, deficiencies in supplies and ambulances, difficulty of access to rural areas, volunteer management, non-documentation of the experiences, communication challenges, recalling, and deploying of EMS responders.&nbsp;</p> <p><strong>Conclusion:</strong> Timely response of the EMS and paramedics’ sense of responsibility for providing services were positive and successful points about the emergency response operations. The weaknesses of EMS should, therefore, be addressed through transferring of experiences and by planning and arranging training courses.</p> Mahboub Pouraghaei Javad Babaie Laleh Rad Saeed Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-05-01 2022-05-01 10 1 e35 e35 10.22037/aaem.v10i1.1571 CURB-65, qSOFA, and SIRS Criteria in Predicting In-Hospital Mortality of Critically Ill COVID-19 Patients; a Prognostic Accuracy Study <p><strong>Introduction: </strong>Outcome prediction of intensive care unit (ICU)-admitted patients is one of the important issues for physicians. This study aimed to compare the accuracy of Quick Sequential Organ Failure Assessment (qSOFA), Confusion, Urea, Respiratory Rate, Blood Pressure and Age Above or Below 65 Years (CURB-65), and Systemic Inflammatory Response Syndrome (SIRS) scores in predicting the in-hospital mortality of COVID-19 patients.</p> <p><strong>Methods: </strong>This prognostic accuracy study was performed on 225 ICU-admitted patients with a definitive diagnosis of COVID-19 from July to December 2021 in Tehran, Iran. The patients' clinical characteristics were evaluated at the time of ICU admission, and they were followed up until discharge from ICU. The screening performance characteristics of CURB-65, qSOFA, and SIRS in predicting their mortality was compared.</p> <p><strong>Results:</strong> 225 patients with the mean age of 63.27±14.89 years were studied (56.89% male). The in-hospital mortality rate of this series of patients was 39.10%. The area under the curve (AUC) of SIRS, CURB-65, and qSOFA were 0.62 (95% CI: 0.55 - 0.69), 0.66 (95% CI: 0.59 - 0.73), and 0.61(95% CI: 0.54 - 0.67), respectively (p = 0.508). In cut-off ≥1, the estimated sensitivity values of SIRS, CURB-65, and qSOFA were 85.23%, 96.59%, and 78.41%, respectively. The estimated specificity of scores were 34.31%, 6.57%, and 38.69%, respectively. In cut-off ≥2, the sensitivity values of SIRS, CURB-65, and qSOFA were evaluated as 39.77%, 87.50%, and 15.91%, respectively. Meanwhile, the specificity of scores were 72.99%, 34.31%, and 92.70%.</p> <p><strong>Conclusions: </strong>It seems that the performance of SIRS, CURB-65, and qSOFA is similar in predicting the ICU mortality of COVID-19 patients. However, the sensitivity of CURB-65 is higher than qSOFA and SIRS.</p> Sorour Khari Atefe Salimi Akin Abadi Marzieh Pazokian Mahmoud Yousefifard Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-05-10 2022-05-10 10 1 e36 e36 10.22037/aaem.v10i1.1565 Impact of COVID-19 Pandemic on Emergency Department Referrals with Urologic Complaints; a Retrospective Cross-Sectional Study <p><strong>Introduction: </strong>Medical and surgical priorities were dramatically changed during the COVID-19 pandemic. This study aimed to evaluate the impact of this pandemic on presentation to emergency department (ED) with urologic complaint.</p> <p><strong>Method: </strong>This cross-sectional study was conducted at a tertiary urology referral center in Tehran, Iran. The data of all ED admissions were collected and the frequency of admissions with urologic complain and their outcomes were compared between two 90-day periods (before and during COVID-19 era).</p> <p><strong>Results: </strong>480 ED admissions were studied. The number of patients visiting the ED with urologic complaint during COVID-19 era was significantly lower than the same period in the pre-COVID-19 period (125 vs. 355 admissions; p = 0.01). The mean hospitalization days for patients in the pre-COVID-19 period were significantly higher (5.6 ± 4.4 vs. 3.2 ± 4.2 days; p &lt;0.001). The most common patient complaints before and during COVID-19 period were flank pain (32.7%) and gross hematuria (32.8%), respectively. The number of patients discharged against medical advice in the COVID-19 period was significantly higher than before (22 (17.6%) vs. 10(2.8%); p &lt; 0.001). The number of patients who developed severe complications was significantly higher in the COVID-19 period than in the pre-COVID-19 period (p = 0.001).</p> <p><strong>Conclusion: </strong>During the COVID-19 pandemic we were faced with decreasing frequency of admission with urologic complaint, change in the pattern of referrals, decrease in the duration of hospitalization, increase in the number of patients discharged against medical advice, and increase in the number of cases with irreversible urologic complications or complications requiring surgery due to deferred treatment.</p> Anahita Ansari Djafari Babak Javanmard Amirhossein Rahavian Ahmad Reza Rafiezadeh Rafiezadeh Nasrin Borumandnia Seyyed Ali Hojjati Seyyed Mohammad Hosseininia Hormoz Karami Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-05-17 2022-05-17 10 1 e37 e37 10.22037/aaem.v10i1.1563 Nurses' Knowledge Regarding Oxygen Therapy; a Cross-Sectional Study <p><strong>Introduction:</strong> Oxygen therapy, if done correctly, can save patients' life promptly. However, improper use will be just as dangerous. The present study aimed to investigate the level of nurses’ knowledge on properly using oxygen.</p> <p><strong>Method: </strong>This was a cross-sectional study with a minimum sample size of 72 nurses who were randomly selected from various wards of Masih Daneshvari Hospital, Tehran, Iran. To determine the level of knowledge about oxygen therapy, a questionnaire was used to collect data. This questionnaire consists of seven items, each of which is designed to determine the level of the individual’s knowledge about the various details of oxygen therapy.</p> <p><strong>Results:</strong> Seventy-eight nurses with the mean age of 35.80±7.42 years participated in the study (87% female). The mean knowledge score of nurses regarding oxygen therapy was 8.89 ± 2.79 out of 16 points. 84.6% of the nurses were able to differentiate various types of oxygen masks. Accordingly, 94.9% of nurses had good knowledge on oxygen humidification. Also, 50% of the nurses had sufficient knowledge about the amount of oxygen flow produced by different masks. 10.3% of the nurses could choose the most appropriate mask for different clinical conditions. 6.4% of the nurses had knowledge of working with flowmeters, and 15.4% of the nurses had sufficient information about the maximum level of oxygen required for the patient. 17.9% of the nurses were familiar with measuring the appropriate amount of oxygen for patients. There was no statistically significant relationship between age (p = 0.57), gender (p = 0.09), employment status (p = 0.38), workplace (p = 0.86), current position (p = 0.11), degree (p = 0.27), and graduation time (p = 0.58) of nurses with good knowledge of using oxygen. However, a statistically significant relationship was reported between nurses' related work experience and their knowledge of the proper use of oxygen (p = 0.03).</p> <p><strong>Conclusion:</strong> In general, the nurses’ knowledge at Masih Daneshvari Hospital on how to properly use oxygen is at a moderate level. Nurses' knowledge in some areas, such as working with the flowmeter, choosing the suitable mask for specific clinical conditions, and the maximum oxygen required for patients, is meager and requires training intervention.</p> Maryam Hassanzad Hosseinali Ghaffaripour Mahsa Rekabi Mahsa Mirzendehdel Elham Sadati Nasrin Elahimehr Hojjat Derakhshanfar Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-05-18 2022-05-18 10 1 e38 e38 10.22037/aaem.v10i1.1553 Incidence of Pediatric Perforated Appendicitis during the COVID-19 Pandemic; a Systematic Review and Meta-Analysis <p><strong>Introduction</strong>: COVID-19 has affected the pattern of referral to medical centers and quarantine against COVID-19 might delay referral and management of surgical emergencies. This study aimed to compare the pooled event rate of pediatric perforated appendicitis before and during the COVID-19 pandemic.</p> <p><strong>Methods</strong>: This was a systematic review and meta-analysis study based on the PRISMA guidelines.&nbsp; Scopus, Web of Sciences, and PubMed databases were searched for studies reporting the rate of perforated appendicitis based on the post-appendectomy observations or imaging methods. The Egger bias test and funnel plot were used to detect and depict publication bias. Statistical analysis was performed in Comprehensive Meta-analysis package version 3.</p> <p><strong>Results:&nbsp; </strong>Twelve studies were eligible for inclusion in our study. The pooled prevalence of pediatric perforated appendicitis in the pre-COVID era was 28.5% (CI95%: 28.3 to 28.7%) with a heterogeneity of 99%.&nbsp; In the COVID era, the event rate proportion was 39.4% (CI95%: 36.6 to 42.3%) with a heterogeneity of 99%. There was a significant difference in the subgroup analysis within the pre-COVID and COVID era (P&lt;0.001), showing a higher perforation rate in the COVID era.</p> <p><strong>Conclusion: </strong>Our study showed that during the COVID-19 pandemic, the rate of perforated appendicitis has significantly increased in comparison to before the COVID-19 pandemic.</p> Gholamreza Motazedian Poorya Aryanpoor Ehsan Rahmanian Samaneh Abiri Navid Kalani Naser Hatami Farhad Bagherian Mohammad Etezadpour Roohie Farzaneh Fatemeh Maleki Mahdi Foroughian Mojtaba Ghaedi Copyright (c) 2021 Archives of Academic Emergency Medicine 2022-01-01 2022-01-01 10 1 e3 e3 10.22037/aaem.v10i1.1421 Ultra-early Spinal Decompression Surgery Can Improve Neurological Outcome of Complete Cervical Spinal Cord Injury; a Systematic Review and Meta-analysis <p><strong>Introduction: </strong>Early decompression within the first 24 hours after spinal cord injury (SCI) is proposed in current guidelines. However, the possible benefits of earlier decompression are unclear. Thus, the present meta-analysis aims to investigate the existing evidence regarding the efficacy of ultra-early decompression surgery (within 12 hours after SCI) in improving patients’ neurological status.</p> <p><strong>Methods: </strong>A search was performed in Medline, Embase, Scopus and Web of Science electronic databases, until the end of August 2021. Cohort studies and clinical trials were included in the present study. Exclusion criteria were absence of an early or late surgery group, failure to report neurological status based on the American spinal injury association impairment scale (AIS) grade, failure to perform the surgery within the first 12 hours after SCI, and duplicate reports and review articles. Two independent reviewers performed data collection, and risk of bias and certainty of evidence assessments. The outcome was reported as odds ratio (OR) and 95% confidence interval (CI).</p> <p><strong>Results: </strong>Data from 16 articles, which studied 868 patients, were included. Compared to early or late decompression surgery, ultra-early decompression surgery significantly improves patients’ neurological status (OR = 2.25; 95% CI: 1.41 to 3.58). However, ultra-early surgery in thoracolumbar injuries is not significantly more effective than early to late surgery. Moreover, ultra-early surgery in patients with a baseline AIS A increases the chance of neurologic resolvent up to 3.86 folds (OR=3.86; 95% CI: 1.50 to 9.91). Contrastingly, ultra-early surgery does not result in significant improvement compared to early to late surgery in patients with AIS B (OR = 1.32; 95% CI: 0.51 to 3.45), AIS C (OR = 1.83; 95% CI: 0.72 to 4.64), and AIS D (OR = 0.99; 95% CI: 0.31 to 3.17).</p> <p><strong>Conclusion: </strong>Current guidelines emphasize that spinal decompression should be performed within 24 hours after SCI, regardless of injury severity and location. However, results of the present study demonstrated that certain considerations may be taken into account when performing decompression surgery: 1) in patients with AIS A injury, decompression surgery should be performed as soon as possible, since its efficacy in neurological improvement is 3.86 folds higher in the first 12 hours after injury. 2) ultra-early decompression surgery in patients with cervical injury is more effective than in patients with thoracic or lumbar injuries. 3) postponing decompression surgery to 24 hours in SCI patients with AIS B to D does not significantly affect the neurological outcome.</p> Mahmoud Yousefifard Behrooz Hashemi Mohammad Mehdi Forouzanfar Rozita Khatamian Oskooi Arian Madani Neishaboori Reza Jalili Khoshnoud Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-01-31 2022-01-31 10 1 e11 e11 10.22037/aaem.v10i1.1471 Accuracy of Triage Systems in Disasters and Mass Casualty Incidents; a Systematic Review <p><strong>Introduction</strong>: To prioritize patients to provide them with proper services and also manage the scarce resources in emergencies, the use of triage systems seems to be essential. The aim of this study was to evaluate the accuracy of the existing triage systems in disasters and mass casualty incidents.</p> <p><strong>Methods</strong>: The present study is a systematic review of the accuracy of all triage systems worldwide. The results of this study were based on the articles published in English language journals. In this research, all papers published from the beginning of 2000 to the end of 2021 were sought through different databases. Finally, a total of 13 articles was ultimately selected from 89 articles.</p> <p><strong>Results</strong>: 13 studies on the accuracy of triage systems were reviewed. The START, mSTART, SALT, Smart, Care Flight, ASAV, MPTT, Sieve and ESI triage systems, had an accuracy, sensitivity, and specificity of less than 90%. Only the Smart triage system had an overall accuracy of more than 90%.</p> <p><strong>Conclusion</strong>: According to the findings of the current systematic review, the performance of the existing triage systems in terms of accuracy of prioritizing the injured people and other performance indexes is not desirable. Therefore, to improve the performance and increase the precision of triage systems, the world nations are recommended to change or revise the indexes used in triage models and also identify other influential factors affecting the accuracy of triage systems.</p> Jafar Bazyar Mehrdad Farrokhi Amir Salari Hamid Safarpour Hamid Reza Khankeh Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-30 2022-04-30 10 1 e32 e32 10.22037/aaem.v10i1.1526 Orthopedic Trauma During Pregnancy; a Narrative Review <p><strong>Introduction:</strong> Blunt traumas, like road accidents and falls, are common causes of injuries to pregnant women, and the major risk factors are young age and low socioeconomic level. Due to physiological and anatomical changes specific to pregnancy, such as changes in blood pressure and hemoglobin drop, trauma management involves certain complexities. Physical trauma is estimated to cause at least 1 complication in every 12 pregnancies. This study aims to evaluate orthopedic trauma during pregnancy and appreciate the different approaches to circumvent the resultant challenges.</p> <p><strong>Methods: </strong>&nbsp;We reviewed 55 articles, published on orthopedic trauma during pregnancy between 2011 and 2021. The articles were identified by searching PubMed, google-scholar, Scopus, and Science-Direct. We utilized the search terms: fall in pregnancy, traumas in pregnancy, motor vehicle accident/crash in pregnancy, blunt trauma in pregnancy, pregnant trauma patient, penetrating injury during pregnancy, assault, interpersonal violence in pregnancy, and mortality and pregnancy.</p> <p><strong>Results: </strong>According to available reports, after stabilizing the pregnant patient, diagnostic procedures, including radiography, and even gadolinium-based techniques when needed, can be performed to examine extensive trauma. In contrast to elective orthopedic surgery, emergency orthopedic surgeries, including reduction of open fractures, should be performed promptly.</p> <p><strong>Conclusion:</strong> Based on our investigation, pregnant women with orthopedic injuries that are severe, or even seemingly less severe, experience significantly increased adverse pregnancy outcomes, which include preterm birth, placental abruption, poor infant condition at birth, infant death, and even maternal death.</p> Meisam Jafari Kafiabadi Amir Sabaghzadeh Seyyed Saeed Khabiri Mehrdad Sadighi Amir Mehrvar Farsad Biglari Adel Ebrahimpour Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-05-18 2022-05-18 10 1 e39 e39 10.22037/aaem.v10i1.1573 Removal of Coin Cell Lithium Battery Lodged in the Pediatric Pharyngoesophageal Junction by Rigid Esophagoscopy; a Case Report <p>A coin cell lithium battery is a common foreign body that can become lodged in the pediatric pharyngoesophageal junction. Because the voltage of such batteries is relatively high, their rapid removal is necessary to avoid mucosal necrosis. Despite being the initial choice for removal, flexible endoscopy cannot remove such foreign bodies from the esophagus. Various removal methods, including rigid esophagoscopy, should be considered for removing lithium coin cell batteries. The transcervical approach is feasible for removing esophageal foreign bodies, but it carries the risk of complications such as esophageal stenosis. Here we report a case of lithium coin battery ingestion that was successfully removed using a rigid esophagoscope. A 2-year-old girl was referred to a local doctor with cough and general fatigue. Chest X-ray and flexible endoscopy revealed a coin cell lithium battery stuck in the pharyngoesophageal junction, but it could not be removed. The foreign body was removed using Nishihata forceps through a rigid esophagoscope under general anesthesia.</p> Hisataka Ominato Takumi Kumai Yasuaki Harabuchi Copyright (c) 2021 Archives of Academic Emergency Medicine 2022-01-01 2022-01-01 10 1 e4 e4 10.22037/aaem.v10i1.1430 A 25-Year-Old Chronic Ketamine User with Urinary Symptoms; a Case Report <p>Ketamine is mainly used for short-acting general anesthesia, chronic pain, sedation, depression, and bipolar disorder. Long-term ketamine use may cause lower urinary tract symptoms and voiding dysfunction. Small capacity and fibrotic bladder can be associated with chronic ketamine use. Here, we present a 25-year-old male with a history of chronic ketamine use complicated with contracted heart-shape bladder.&nbsp;&nbsp;</p> Chin-Chu Wu Aming Chor-Ming Lin Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-01-31 2022-01-31 10 1 e12 e12 10.22037/aaem.v10i1.1449 Dorsal Approach in the Surgical Treatment of Complex Dorsal Dislocation of Index Metacarpophalangeal Joint; a Case Report <p>Complex metacarpophalangeal (MCP) joint dislocation is an uncommon entity, which occurs following a hyperextension injury. Closed reduction is not feasible due to entrapped volar plate and/or coexisting fractures. Various approaches and techniques have been proposed for treatment of complex MCP dislocation; however, controversies exist over which one is superior. This study describes a right-handed 14-year-old boy who fell on the outstretched hand and sustained a dorsal dislocation of the left index MCP joint. The dislocation was complicated by an epiphyseal metacarpal head fracture with dorsal-ulnar displacement of the osteochondral fragment. The patient underwent open reduction through the dorsal approach, and the metacarpal head was fixed via the two-screw technique. The patient resumed left-hand function after six weeks. At the two-year follow-up, the range of motion and grip strength were normal, the patient was pain-free, and no sign of growth disturbance or joint stiffness was detected. Dorsal surgical approach with screw fixation is a feasible technique for the treatment of complex MCP dislocation, especially when it is complicated by a large epiphyseal head fracture.</p> Shahab Aldin Sattari Ali Reza Sattari Kamran Heydari Seyed Matin Sadat Kiaei Farshad Zandrahimi Mehdi Mohammadpour Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-02-09 2022-02-09 10 1 e13 e13 10.22037/aaem.v10i1.1479 Inferior Hip Dislocation in a 60-Year-Old Man; a Case Report <p>Inferior hip dislocation or luxatio erecta femoris is among the rarest hip dislocations, which has been described in limited studies. The patients usually present with their hip in flexion, abduction, and external rotation. Hip dislocation is an orthopedic emergency, and a reduction needs to be performed promptly to avoid devastating complications such as avascular necrosis. Here, we present a rare case of inferior hip dislocation in a 60-year-old man following a car-motorcycle collision. The patient presented to the emergency department with left hip flexion, abduction, external rotation, and inability to move his leg due to pain. Closed reduction under procedural sedation was attempted in the emergency department once, which was unsuccessful. The patient was then taken to the operating room for another attempt of closed reduction under general anesthesia. The patient was discharged after two days with pin traction and double crutches. After two weeks, the pin was removed, and full weight-bearing was permitted. After 12 weeks, the patient had mild pain with unusual activity and slight limping; however, imaging revealed no signs of any complications.</p> Ali Yeganeh Nader Tavakoli Mohammad Soleimani Seyed Nima Taheri Sahand Cheraghiloohesara Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-02-27 2022-02-27 10 1 e17 e17 10.22037/aaem.v10i1.1498 Right Upper Quadrant Pain Following Endoscopic Retrograde Cholangiopancreatography; a Case Report <p>Endoscopic retrograde cholangiopancreatography (ERCP) is a standard for diagnosing and treating hepato-pancreatico-biliary (HPB) diseases in clinical settings. ERCP-related complications are relatively common, ranging from 4 to 30%. The most common one is acute pancreatitis. ERCP-related necrotizing pancreatitis accounts for 7.7% of ERCP-related pancreatitis cases. This complication may still be misdiagnosed, which might lead to inappropriate treatment with a worse prognosis. Here, we report a 34-year-old case with ERCP-related necrotizing pancreatitis who was successfully managed, but initially misdiagnosed with biliary peritonitis.</p> Lan Thi Nguyen Dang Hai Do An Duc Thai Hoa Thi Nguyen Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-03-16 2022-03-16 10 1 e21 e21 10.22037/aaem.v10i1.1535 21-Year-Old Female with Pneumothorax and Massive Air Leak Following Blunt Trauma; a Photo Quiz <p>A 21-year-old female presented to the emergency department, about 20 minutes after a motorcycle accident. She was agitated and complaining of shortness of breath. Her vital signs were: heart rate 110 bpm, respiratory rate 32/minute, blood pressure 89/67 mmHg, oxygen saturations 79% on room air, temperature 36.5°C and GCS 15. Chest auscultation revealed decreased breath sounds on the left side. The diagnosis of pneumothorax was made for the patient and a left thoracostomy tube was inserted; however, massive air leak was noted and the clinical symptoms did not improve. Computed tomography scan of the chest in the mediastinal window showeda doubtful pathology, crumpled laminated membrane.</p> Ahmad Shirinzadeh-Dastgiri Ali Saberi Mohammad Vakili Sayed Mahdi Marashi Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-09 2022-04-09 10 1 e24 e24 10.22037/aaem.v10i1.1513 A 27-year-old Female Patient with Acute nausea/vomiting and Pelvic pain; a Photo Quiz <p>A 27-year-old female patient, G2P1, presented to the emergency department (ED) with acute onset nausea, vomiting, and mild chronic abdominopelvic pain. Physical examination revealed bilateral lower quadrant tenderness without rebound, guarding, or rigidity, and vital signs were within normal limits. Electrolytes, complete blood count, and liver and kidney function tests were normal. A pregnancy test was negative, and urinalysis did not reveal any abnormalities. No free fluid was observed in the abdominal ultrasound, and the ovaries and other intra-abdominal structures were found to be normal. The patient underwent intravenous contrast-enhanced abdomiopelvic computed tomography (CT) scan.</p> Murat Ozsarac Yusuf Yurumez Onur Karakayalı Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-04-24 2022-04-24 10 1 e29 e29 10.22037/aaem.v10i1.1508 An Overview of Published Articles in Archives of Academic Emergency Medicine in 2021 <p><strong><em>Archives of Academic Emergency Medicine</em></strong> has published 70 articles in 2021, which have been authored by more than three hundred researchers from various countries, including but not limited to the United States, Australia, India, Japan, Thailand, Iraq, Pakistan, France, Greece, and Iran. In this editorial, we intend to&nbsp;provide an overview of our publications in 2021, 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.</p> Mehrnoosh Yazdanbakhsh Somayeh Saghaei Dehkordi Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-02-27 2022-02-27 10 1 e18 e18 10.22037/aaem.v10i1.1555 Advance Without Cut and Retrograde Removal of Embedded Fishhook; Introducing a Novel Technique <p>Removing embedded fishhook without causing further tissue damage from the barbed nature of the hook is a challenge in emergency department (ED). The four most commonly used techniques include advance and cut, string-yank, needle cover, and retrograde removal. This study aims to describe a modified push- through technique without cutting the barb, namely advance without cut and retrograde removal, as an effective technique of successful removal of fishhooks. There is no risk of additional injury to patients and healthcare staff, and the technique does not need tools that are not generally readily available in EDs.</p> Abdolghader Pakniyat Kourosh Akhbari Fatemeh Radfar Copyright (c) 2021 Archives of Academic Emergency Medicine 2022-01-01 2022-01-01 10 1 e2 e2 10.22037/aaem.v10i1.1403 Intravenous Lipid Emulsion for treating Tramadol-Induced Seizures: Surprising but Worth Considering for Future Studies; a Letter to Editor <p>None</p> Bruno Megarbane Ahmed S. Gouda Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-02-09 2022-02-09 10 1 e14 e14 10.22037/aaem.v10i1.1541 Video Laryngoscopy in Emergency Airway Management - a Paradigm Shift from ‘I’ to ‘We’; a Letter to Editor <p>Emergency medicine has evolved as a speciality but airway management is still a challenge. Traditionally, direct laryngoscopy (DL) is used for intubation with maneuvers to directly visualize the vocal cords. Most tracheal intubations in the emergency department (ED) are done on an emergent basis and enhancing the technicalities of intubation can be life-saving. Video laryngoscopy (VL) is available in the emrgenyc department and can help reduce the intubation failure rate; hence, it has been recommended for maintaining airways in obese patients.</p> Sadaf Sheikh Faisal Shamim Copyright (c) 2022 Archives of Academic Emergency Medicine 2022-03-20 2022-03-20 10 1 e22 e22 10.22037/aaem.v10i1.1474