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Original/Research Article

The Correlation between Serum Level of Vitamin D and Outcome of Sepsis Patients; a Cross-Sectional Study

Majid Shojaei, Anita Sabzeghabaei, Helia Valaei Barhagh, Soheil Soltani

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e1

Introduction: The effect of vitamin D deficiency in manifestation of sepsis and its role as an important mediator in the immune system has received attention. The present study was done with the aim of evaluating the correlation between serum levels of vitamin D and outcome of sepsis patients.

Methods: The present cross-sectional study was performed on patients over 18 years of age suspected to sepsis presenting to an emergency department during 1 year using non-probability convenience sampling. For all eligible patients, blood sample was drawn for measurement of serum level of vitamin D3 and the correlation of this vitamin with outcomes such as mortality, renal failure, liver failure and etc. was assessed.

Results: 168 patients with the mean age of 70.8 ± 13.3 (43.0 – 93.0) years were studied (56.0% male). Mean serum level of vitamin D3 in the studied patients was 19.03 ± 13.08 (4.0 – 85.0) ng/ml. By considering 20 – 50 ng/ml as the normal range of vitamin D, 61.6% of the patients had vitamin D deficiency. Only age (r=-0.261, p=0.037) and mortality (r=-0.426, p=0.025) showed a significant correlation with mean vitamin D. Sepsis patients with older age and those who died had a lower level of vitamin D. Area under the ROC curve of serum vitamin D level regarding 1-month mortality of the sepsis patients was 0.701 (95%CI: 0.439 – 0.964).

Conclusion: Based on the results of the present study, the prevalence of vitamin D deficiency in sepsis patients presenting to the ED was estimated as 61.6%. A significant and indirect correlation was found between the serum level of vitamin D3 and mortality as well as older age. It seems that consumption of vitamin D supplements might be helpful in decreasing the prevalence of infection, sepsis, and mortality caused by it, especially in older age.

Continuous Education of Basic Life Support (BLS) through Social Media; a Quasi-Experimental Study

Seyyed Mahdi Zia Ziabari, Vahid Monsef Kasmaei, Lida Khoshgozaran, Maryam Shakiba

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e4

Introduction: It is imperative, if not fundamental, for medical students to receive continuing education in Basic life support (BLS). This present study aimed to investigate the effectiveness of continuing education using social media in this regard.

Methods: In this quasi-experimental study, a questionnaire containing 20 items about BLS awareness was completed by the interns who were trained monthly in the emergency medicine training course. Then half of the interns received distant education through Telegram software up to three months, and the other did not receive any further education. Again, both groups completed the questionnaire at the end of the third month.

Results: 100 medical interns with the mean age of 25.05 ± 1.26 years were allocated to two groups of 50 subjects (65.0% female). Two groups were similar regarding the mean age (p = 0.304), gender (p = 0.529), mean awareness score at the beginning of the study (p = 0.916), and average pre-internship exam score (p = 0.080). The mean awareness score of medical interns increased significantly in intervention (11.44 ± 2.37 to 14.88 ± 1.97, p < 0.0001) and control (11.38 ± 3.22 to 12.54 ± 3.04, p < 0.0001) groups at second examination. But mean difference of awareness score, before and after the education, was significantly higher in intervention group (3.44 ± 1.48 versus 1.16 ± 1.51; p < 0.0001).

Conclusion: The increase in the BLS awareness score was significantly higher in medical interns who were continuously educated using Telegram social media software.  

Prevalence of Depression and Personality Disorders in the Beginning and End of Emergency Medicine Residency Program; a Prospective Cross Sectional Study

Farhad Rahmati, Saeed Safari, Behrooz Hashemi, Alireza Baratloo, Roozbeh Khosravi Rad

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e5

Introduction: Emergency medicine physicians are constantly under psychological trauma due to encountering critically ill patients, mortality, and violence, which can negatively affect their mental and physical health. The present study was performed with the aim of determining the rate of depression and personality disorders in first-year emergency medicine residents and comparing it with the time they reach the 3rd year.

Methods: In the present prospective cross-sectional study, emergency medicine residents working in multiple teaching hospitals were included via census method and evaluated regarding the rate of depression and personality disorders using the standard MMPI-2 questionnaire upon admission to the program and graduation and their status regarding the evaluated disorders were compared between the 2 phases of evaluation.

Results: 99 residents with the mean age of 33.93 ± 5.92 years were evaluated. 85 (85.85%) rated their interest in their discipline as moderate to high. The rates of stress (p = 0.020), anxiety (p < 0.001), and hypomania (p = 0.015) had significantly increased during the 3 years and psychasthenia rate had decreased significantly during this time (p = 0.002). Changes in the prevalence of other disorders on the third year compared to the year of admission to emergency medicine program were not significant.

Conclusion: Considering the results of the present study, it seems that paying more attention to mental problems and decreasing environmental stressors of medical residents, especially emergency medicine residents, should be among the priorities of managers and policymakers of this discipline.

Impact of Education on Trauma Patients’ Handover Quality; a Before-After Trial

Ali Shahrami, Masoomeh Nazemi-Rafi, Hamidreza Hatamabadi, Afshin Amini, Mahammad Haji Aghajani

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e7

Introduction: Poor handover and inadequate transmission of clinical information between shifts cause a lot of problems in patient care and result in significant risks for physicians and patients. This study was designed to evaluate the impact of education and application of handover checklist on trauma patients’ handover quality.

Methods: In this before-after trial, handover process of trauma patients in an educational hospital was evaluated before and after education and application of a handover checklist, abbreviated as “WHO MISSED IP?â€, using a questionnaire that consisted of 10 necessary items, which should be delivered during handover of trauma patients. A total score of 10 was considered for each patient handover, the score 10 out of 10 indicating that all 10 important pieces of patient information were correctly delivered.

Results: 52 pre and post-intervention handover sessions were evaluated (438 patients). Prior to intervention, 18% of patients were not delivered to the next shift, most of which were in the night shift handover (p < 0.001). From the pre-intervention to the post-intervention period, significant improvements were detected in all items except for diagnosis and consulting items. The mean duration of handover changed from 1.22 ± 0.24 minutes to 1.58 ± 0.23 minutes after intervention (p < 0.01). In the pre-intervention period, the score equal or greater than 9 was observed in 7.5% of patients, while after intervention, 63.6% of patients had score ≥ 9 regarding complete handover (p < 0.01).

Conclusion: Based on the findings of the present study, teaching handover standards and application of handover checklist could be helpful in improving the quality of information delivery between emergency medicine residents and improve trauma patients’ handover indices.

Introduction: Rapid detection of pneumonia and early initiation of antibiotic therapy are associated with better prognosis in patients. The present study was designed aiming to evaluate the sensitivity of chest ultrasonography performed by emergency medicine specialists in detection of pneumonia and comparing it with plain radiography.

Methods: In the present diagnostic accuracy study, patients presenting to the emergency department with clinical symptoms of lung infection underwent plain radiography, ultrasonography, and computed tomography (CT) scan of chest and the screening performance characteristics of plain radiography and ultrasonography were compared considering CT scan findings as the gold standard.

Results: 280 patients with the mean age of 56.47 ± 19.79 (10 – 92) years were studied (57.1% male). The results of chest CT scan were indicative of infection symptoms being present and confirmed pneumonia diagnosis for all the patients. Out of the 280 cases of pneumonia confirmed via chest CT scan, 17 (6.1%) cases were not detected via ultrasonography and 48 (17.1%) cases were missed by chest radiography (false negative cases). No false positive case was reported by ultrasonography or chest x-ray. Since all of the CT scans were positive, no comment can be made regarding the specificity of the evaluated tests, but sensitivity of ultrasonography and plain radiography were 93.92 (90.28 – 96.31) and 82.85 (77.81 – 86.97), respectively (p = 0.583).

Conclusion: Based on the findings of the present study, although the sensitivity of ultrasonography in detection of pneumonia was significantly higher than chest x-ray, overall the screening performance characteristics of the 2 tests were not significantly different. Therefore, considering characteristics such as safety, low cost, being portable, and being available, ultrasonography seems to be a reasonable tool for screening and diagnosis of patients with pneumonia.

Oral Piracetam vs Betahistine in Outpatient Management of Peripheral Vertigo; a Randomized Clinical Trial

Ali Arhami Dolatabadi, Seyedeh Roghieh Larimi, Arash Safaie

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e9

Introduction: Although vertigo is a common complaint in patients presenting to the emergency department (ED), its ideal treatment is still under debate. This study was conducted to compare oral betahistine and oral piracetam in management of outpatients with peripheral vertigo.

Methods: This was a randomized clinical trial performed on patients who were presented to the EDs of 4 teaching hospitals, with complaint of true vertigo. Patients were randomly allocated to either betahistine or piracetam group and their 7-day outcomes were compared.

Results: 100 cases with the mean age of 54.72 ± 14.09 years were randomly allocated to either group (62.0% female). The two groups were similar regarding age, sex, and intensity of symptom at the time of presenting to the ED. Twelve (24%) patients in piracetam group and 6 (12%) patients in betahistine group experienced adverse events (odds ratio: 2.32, CI 95%: 0.79-6.76; p = 0.125). There were 3 (6%) patients in each group that experienced a recurrence of their symptoms and 2 (4%) patients in each group saw another physician for vertigo.

Conclusion: Oral piracetam is a potentially proper treatment for management of peripheral vertigo and there are few adverse effects associated with it.

Remifentanil versus Propofol/Fentanyl Combination in Procedural Sedation for Dislocated Shoulder Reduction; a Clinical Trial

Vahid Monsef Kasmaee, Seyed Mahdi Zia Zibari, Marjan Aghajani Nargesi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e10

Introduction: Procedural sedation and analgesia (PSA) is a fundamental skill for every emergency physician. This study aimed to compare the PSA characteristics of remifentanil with propofol/fentanyl combination.

Methods: In this double-blind randomized clinical trial, the procedural characteristics and number of failures, as well as adverse events were compared between groups treated with either remifentanil or propofol/fentanyl combination consisting of 15-60 year old patients referring to emergency department following acute anterior shoulder dislocation.

Results: 64 patients were randomly assigned to either remifentanil (32 cases) or propofol/fentanyl, (32 cases) groups. The two groups were similar regarding mean age, sex, and pain severity at the time of presentation to ED. The two regimens had the same efficiency regarding pain management (100% success rate). 22 (68.8%) cases in remifentanil group and 4 (12.5%) cases in propofol/fentanyl group had failed in muscle relaxation (p < 0.001). In the group receiving remifentanil, onset of action (p = 0.043) and recovery time (p < 0.001) were significantly shorter. 10 (31.3%) cases in remifentanil group and 11 (34.4%) cases in the other group experienced adverse events (p =0.790). There was a significant difference between groups regarding the type of adverse events (p = 0.003).

Conclusion: Compared to propofol/fentanyl combination, remifentanil has equal efficiency in pain management, lower success rate in muscle relaxation, significantly higher frequency of apnea, and shorter onset of action and recovery times in PSA for reduction of anterior shoulder dislocation.

Frequency and Causes of Complaints against Emergency Medicine Specialists in Forensic Medicine Files; a Cross-Sectional Study

Hossein Alimohammadi, Hamidreza Hatamabadi, Azita Khodayari, Mahmood Doukhtehchi Zadeh Azimi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e11

Introduction: Complaints against physicians have increased in recent years and one of the specialties facing a relatively high rate of complaints is emergency medicine. Therefore, the present study was designed with the aim of evaluating the frequency and causes of complaints against emergency medicine specialists in forensic medicine cases.

Methods: In the present cross-sectional study, all the existing files in two forensic medicine centers, Tehran, Iran, from 2012 to 2015, in which complaints were filed against emergency medicine specialists, either alone or along with other physicians, were evaluated via census sampling method and their required data were extracted and recorded via a pre-designed checklist.

Results: 151 cases of medical complaints were filed against emergency medicine specialists during the study period. 85 (53.6%) complaints were filed following death of the patients and 66 (43.7%) were filed following an injury or disability. Multiple trauma, stomach ache, and altered level of consciousness were the most common chief complaints among young and old patients upon their ED visit. In 104 (68.9%) cases, the emergency medicine specialists were finally proved innocent. No significant correlation was found between the probability of proving innocent and the physician’s experience (p = 0.92), physician’s sex (p = 0.27), age range of the patient (p = 0.193), or the shift in which the patient had visited the ED (p = 0.32). The rate of proving innocent was significantly higher in complaints against governmental hospitals compared to non-governmental ones (73.6% vs. 61.9%; p= 0.004) and teaching hospitals compared to non-teaching ones (75.8% vs. 54.9%; p = 0.26).

Conclusion: In about 70% of medical complaint cases against emergency medicine specialists, the in charge physician was proved innocent. No significant correlation was found between the probability of proving innocent and physician’s experience, the physician’s sex, the patient’s age range, or the shift in which the patient had presented to the ED.

Effects of Supplementation and Training on Ameliorating Lipid Profiles and Protection against Coronary Artery Disease; an Experimental Study

Reza Vafaee, Hamid Soori, Mehdi Hedayati, Hamid Reza Hatamabadi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e16

Introduction: The use of antioxidants may reduce the harmful effects of radicals during exercise and extreme sports. The Current study aimed to investigate the effect of this supplement on the lipid profiles in exercise-induced muscle injury.

Methods: In this experimental study, 64 Wistar rats were randomly divided into four groups of control, exercise, exercise + Resveratrol (REV) and REV.  After a week of adaptation, endurance and acute exercises were conducted in a motor driven treadmill, followed by using a training protocol in which running speed was gradually elevated until 19 weeks of age. Finally, the levels of cholesterol (CHO), triglycerides (TG), low-density lipoproteins (LDL), high-density lipoproteins (HDL), and very low-density lipoproteins (VLDL) were compared between the groups.

Results: There was no statistically significant difference in CHO plasma level between the studied groups after acute and endurance exercises. There was a significant increase in the level of TG in the exercise group (p = 0.001) and the exercise + REV (p = 0.004) group after acute and endurance exercises. After the implementation of the endurance and acute exercises none of the studied groups had statistically significant changes in HDL plasma level. There was a significant decrease in LDL plasma levels in the exercise (p = 0.007) and the exercise + REV (p = 0.01) groups. After performing endurance protocol, VLDL plasma levels increased significantly in the exercise (p = 0.001) and the exercise+ REV (p = 0.005) groups in comparison with control group.

Conclusions: Based on the findings, there was no difference in the level of CHO and HDL between the training groups, REV and control groups. However, both endurance exercise and acute exercise trainings resulted in an increase in TG and VLDL levels and decrease in LDL level, compared with the control group.

The Most and Least Stressful Prehospital Emergencies from Emergency Medical Techniciansans' View Point; a Cross-Sectional Study

Afshin Khazaei, Maryam Esmaeili, Elham Navab

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e20

Introduction: Exposure to different prehospital emergencies (PE) may have a different impact on Emergency Medical Technicians (EMTs) based on the characteristics and circumstances of the emergency. The present study aimed to prioritize PE types according to their stressfulness as well as their correlation with post traumatic stress disorders (PTSD).

Method: In this cross-sectional study, all EMTs in the Emergency Medical Services (EMS) of Hamadan province were invited to participate, voluntarily. The study questionnaire comprised of two parts: a) personal characteristics and prioritizing PE types in terms of their stressfulness and b) The PTSD checklist. Kruskal-Wallis test was used for examining the relationship between total PTSD score and the most and the least stressful PEs. Multivariate logistic regression was also used to predict the impact of different types of PEs on PTSD.

Results: 259 EMTs with the mean age of 32.79±6.16 years were studied. The total mean score of PTSD on PCL-5 was 21.60±11.45. Also, 20.1% of technicians met the criteria for PTSD. The mean age of technicians who met PTSD criteria was less than that of technicians who did not meet PTSD criteria (28 vs. 33 years, P<0.001). The most and least stressful emergencies were cardiovascular (24.7%) and environmental (26.3%) emergencies, respectively. There was a significant correlation between the most (Kruskal-Wallis=40.92, df=12, p < 0.001) and the least stressful emergencies (Kruskal-Wallis=28.22, df=15, p = 0.02) from EMTs’ viewpoint and PTSD score. Multivariate logistic analysis showed that gynecologic (aOR=2.28, Wald=5.83, p=0.016) and allergic (aOR=0.12, Wald=10.16, p=0.01) emergencies were significant predictive factors of PTSD.

Conclusion: Based on the view point of the studied EMTs, cardiac and environmental emergencies were the most and least stressful emergencies. The frequency of PTSD in this series was about 20% and it significantly correlated with younger age, lower experience, higher number of shifts, non-official employment and EMT degree. Based on multivariate logistic analysis, gynecologic and allergic emergencies were the only significant predictive factors of PTSD.

Quebec Decision Rule in Determining the Need for Radiography in Reduction of Shoulder Dislocation; a Diagnostic Accuracy Study

Ehsan Bolvardi, Behnaz Alizadeh, Mahdi Foroughian, Bita Abbasi, Seyed Reza Habibzadeh, Reza Akhavan

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e21

Introduction: The Quebec Decision Rule (QDR) has been developed for deciding on the necessity of radiography for patients with shoulder dislocation. This study aimed to investigate the diagnostic value of QDR in this regard.

Method: This diagnostic accuracy study was conducted on patients with shoulder dislocation visiting the emergency department. After filling out the QDR-based checklist for all patients, they underwent radiography and the obtained radiography results were compared to QDR-based clinical diagnostic findings.

Results: ‌ 143 patients with the mean age of 32.1±12 years were evaluated (88.8% males). Sensitivity, specificity, and positive and negative predictive values of QDR were 50%, 58.2%, 3.3%, and 97.6%, respectively. The sensitivity and specificity were 100% and 50% in patients >40 years old, and 33.3% and 59.8% in those <40 years old. These indices were 33.3% and 60.4%, respectively, in the male sex and 100% and 40% in the female sex.

Conclusion: ‌ Quebec decision rule holds promise to diagnose concomitant fractures in patients over the age of 40 with 100% sensitivity, thereby reducing the number of radiographies by 50% without causing diagnostic errors. In contrast, this criterion proved inefficient in patients younger than 40. ‌

Value of CA-125 Glycoprotein in Predicting Acute Appendicitis; a Diagnostic Accuracy Study

Mahboub Pouraghaghaei, Kavous Shahsavarinia, Farzad Kakaei, Sevda Gholipour Khalili, Babak Mohammadpour, Payman Moharamzahed, Moloud Balafar

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e24

Introduction: Carcinogen antigen 125 (CA-125) is a glycoprotein antigen, which has shown potentials in predicting peritoneal inflammation. The aim of this study is to determine the value of CA-125 in predicting acute appendicitis (AA).

Methods: This prospective diagnostic accuracy study was conducted on 15 – 70 year-old patients with acute abdominal pain, suspected to AA, referred to emergency department. The serum level of CA-125 was measured for all patients before appendectomy and its screening characteristics in detection of AA case (confirmed by histology findings) were calculated and reported with 95% confidence interval (CI).

Results: 95 patients with the mean age of 31.65 ± 12.9 (15-75) years were studied (54.3% male). Based on the histologic findings, 72 (75.8%) cases were categorized as AA (23 cases as severe). AA and non-AA (NAA) groups were similar regarding the mean age (p = 0.59), mean duration of symptoms (p = 0.08), mean white blood cell (WBC) count (p = 0.37), and mean PMN percentage (p = 0.55).  Mean CA-125 level was 16.5 ± 20.0 U/mL in the AA group and 30.5 ± 6.1 U/mL in the NAA group (p = 0.001). Adjustment of analysis based on gender revealed a significant correlation between CA-125 level and diagnosis of AA only in females (34.23 ± 39 U/mL in NAA versus 20.7 ± 26.7 U/mL in AA, p = 0.012). The area under the ROC curve of CA-125 was 0.62 (95%CI: 0.51 to 0.72). Sensitivity, specificity, NPV, PPV, NLR, and PLR of CA-125 in 16.4 U/mL cut off (best point) were 77.8% (95%CI: 66.4 - 86.7), 50.0% (95%CI: 28.2 - 71.8), 83.6% (95%CI: 76.7 - 88.7), and 40.7% (95%CI: 27.4 - 55.6), 0.44 (95%CI 0.2 - 0.8), and 1.56 (95%CI: 1.0 - 2.4), respectively.

Conclusion: Considering the lower levels of CA-125 in patients with AA compared with NAA cases and also weak screening performance characteristics, it seems that it could not be considered as an accurate screening tool in this regard.

Association of Admission Blood Glucose Level with Major Adverse Cardiac Events in Acute Coronary Syndrome; a Cohort Study

Mostafa Alavi-Moghaddam, Mohammad Parsa-Mahjoub, Robabeh Ghodssi-ghassemabadi, Bita Bitazar

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e26

Introduction: Appropriate management of abnormal admission blood glucose level (ABGL) in acute coronary syndrome (ACS) patients still remains a common issue. This study aims to assess the influence of ABGL on development of 30-day major adverse cardiac events (MACEs) in patients with suspected ACS.

Methods: This is a prospective cohort study based on analysis of data collected from patients suspected to acute coronary syndrome admitted to emergency department. ABGL of patients was measured and its association with development of MACEs (MI, CVA, mortality) within 30 days of follow-up was studied.

Results: 814 participants with the mean age of 61.8 ±13.4 years were studied (58.1% male). MACE endpoints were developed in 166 (39.0%) hyperglycemic, 30 (46.9%) hypoglycemic, and 53 (16.4%) normoglycemic patients (p<0.0001). Mean admission blood glucose level of patients who developed MACE within 30 days was significantly higher than others (210.6±123.4 vs 157.4±86.6mg/dL; p<0.0001; OR: 1.006 (1.005 to 1.008)). There was a significant correlation between male gender (p=0.027), abnormal admission blood glucose level (p<0.001), diabetes (p = 0.001), hypertension (p=0.059), prior CABG (p=0.008), first and second blood troponin levels (p<0.001), first and second abnormal ECGs (p<0.001), and also ECG changes (p<0.001) with developing AMCE. Abnormal ABGL, first and second blood troponin levels, and the history of diabetes were among independent risk factors of developing MACE within 30 days.

Conclusion: It seems that abnormal admission blood glucose level in suspected ACS patients was an independent predictor of major adverse cardiac events within 30 days.

Electrocardiogram Changes as an Independent Predictive Factor of Mortality in Patients with Acute Ischemic Stroke; a Cohort Study

Payman Asadi, Seyyed Mahdi Zia Ziabari, Donya Naghshe Jahan, Arezoo Jafarian Yazdi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e27

Introduction: Various factors such as age and severity of the stroke have been deemed connected with risk of mortality in patients with acute ischemic brain stroke. The present study was performed with the aim of evaluating the role of electrocardiogram (ECG) changes in predicting the outcome of these patients.

Methods: In this cohort study, patients who had presented to the emergency department of a teaching hospital during 1 year and were diagnosed with acute ischemic stroke were evaluated. Demographic data and 12-lead ECG findings of the patients were gathered and their relationship with 1-year mortality was analyzed.

Results: Finally, 546 stroke patients with the mean age of 69.5±12.7 (24 – 100) years were studied (53.3% female). 82.7% of the studied patients had at least one of the evaluated ECG abnormalities. The most common ECG findings included normal sinus rhythm (27.3%), inverted T wave (21.2%), sinus tachycardia (11.7%), atrial fibrillation (AF) (11.5%), and pathologic Q wave (9.9%). In the end, 117 (20.9%) patients died during the 1-year follow-up. Frequencies of non-sinus rhythm (p < 0.0001), inverted T wave (p = 0.0001), AF rhythm (p<0.0001), pathologic Q (p<0.0001), ST segment changes (p = 0.011), and atrioventricular (AV) node block (p = 0.007) were significantly higher in patients who died. ECG changes increased the odds of 1-year mortality of these patients 4 times (Odds ratio = 4.05 with 95% CI: 2.39 - 6.87; p < 0.0001). Additionally, age over 60 years and having a history of cardiac diseases increased the odds of mortality 6 (95% CI: 1.4 – 27.9) and 1.5 (95% CI: 0.9 – 2.1) times, respectively.

Conclusion: Based on the findings of the present study, it seems that along with age and history of cardiac diseases, ECG changes can be considered as an independent predictive factor of mortality in patients with ischemic stroke.

Pre-Hospital Delay and Its Contributing Factors in Patients with ST-Elevation Myocardial Infarction; a Cross sectional Study

Hamidreza Poorhosseini, Mohammad Saadat, Mojtaba Salarifar, Seyedeh Hamideh Mortazavi, Babak Geraiely

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e29

Introduction: The outcome of ST-elevation myocardial infarction (STEMI) is significantly influenced by the total tissue ischemic time. In spite of efforts for reducing the in-hospital delay by full-time provision of primary percutaneous coronary intervention (P-PCI) in the 24/7 program, pre-hospital delay still persists. As a first report in Iran, we aimed to assess the duration of pre-hospital delay and its contributing factors in STEMI patients in the P-PCI era.

Methods: The present cross-sectional study evaluated 2103 STEMI patients who underwent primary PCI from 2016 to 2018. Demographic, personal and socioeconomic factors, index event characteristics, past medical history, pain onset and door times of patients were recorded and independent factors of pre-hospital delay were calculated.

Results: Median (IQR) of pain to door (P2D) time was 279 (120-630) minutes. In multivariate analysis, female gender [Beta=0.064 (95%CI: 0.003-0.125); p=0.038], being uneducated [Beta=0.213 (95%CI: 0.115-0.311); p<0.001], the onset of chest pain between 00:00 to 6:00 [Beta=0.130 (95%CI: 0.058-0.202); p<0.001] or 7:00 to 12:00 [Beta=0.119 (95%CI: 0.049-0.190); p=0.001], self-transportation [Beta=0.098 (95%CI: 0.015-0.181); p=0.020] or referral from another hospital [Beta=0.253 (95%CI: 0.117-0.389); p<0.001], atypical chest pain [Beta=0.170 (95%CI: 0.048-0.293); p=0.006], history of hypertension [Beta=0.052 (95%CI: 0.002-0.102); p=0.041], and opium abuse [Beta=0.076 (95%CI: 0.007-0.146); p=0.031] were associated with a significantly higher log(P2D), while history of CABG was associated with shorter P2D.

Conclusion: Our study showed that P2D is still very high in Iran and revealed the high-risk groups associated with longer P2D. Effective actions should be implemented to increase the public awareness about the symptoms of STEMI, and the importance of immediate appropriate help-seeking.

Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study

Seyyed Mahdi Zia Ziabari, Siamak Rimaz, Afshin Shafaghi, Maryam Shakiba, Zahra Pourkazemi, Elnaz Karimzadeh, Melika Amoukhteh

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e30

Introduction: Finding easily accessible and non-invasive methods for differentiating various sources of gastrointestinal (GI) bleeding before performing endoscopy and colonoscopy is of great interest. The present study was designed with the aim of evaluating the screening performance characteristics of blood urea nitrogen (BUN) to Creatinine (Cr) ratio in this regard.

Methods: The present diagnostic accuracy study was performed on patients with acute GI bleeding presenting to emergency department from 2011 to 2016, in a retrospective manner. BUN/Cr ratio was calculated for all patients and its accuracy in differentiation of upper and lower GI bleedings, confirmed via endoscopy or colonoscopy, was evaluated.

Results: A total of 621 patients with the mean age of 59.49±17.94 (5 – 93) years were studied (60.5% male). Area under the receiver operating characteristic (ROC) curve of BUN/Cr ratio for predicting the source of GI bleeding was 0.63 (95% CI: 0.57 – 0.68). Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of BUN/Cr ratio at 35 cut-off point were 19.63% (95%CI: 16.69 – 23.45), 90.16% (95%CI: 83.11 – 94.88), 89.09 (95%CI: 81.35 – 93.98), 21.53 (95%CI: 18.09 – 25.39), 8.16 (95%CI:4.76 – 13.98), and 3.65 (95%CI: 3.44 – 3.87), respectively.

Conclusion: Considering the relatively proper specificity and positive predictive value of BUN/Cr ratio, in cases that bleeding source cannot be determined using other non-invasive methods, values higher than 35 can predict upper GI bleeding with high probability. However, due to the low sensitivity, values less than 35 are not diagnostic.

Helicopter Emergency Medical Services in 2017 Kermanshah Earthquake; a Qualitative Study

Ali Sahebi, Zohreh Ghomian, Mohammad Sarvar

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e31


Introduction: Becoming aware of experiences, and lessons learned in challenges can help optimize planning and improve efficiency and effectiveness. The present study aimed to address the challenges of helicopter emergency medical services (HEMS) from the viewpoint of the managers involved in HEMS in Kermanshah earthquake.

Methods: This qualitative research was done using the content analysis method. The data were collected by semi-structured interviews.  The study population consisted of directors who participated in management and transfer of injured people in the earthquake-stricken area of Kermanshah. Sampling was purposeful in the first stage and then by the snowballed method.

Results: In the present study, 479 codes were initially extracted regarding participants' perspectives and experiences and after eliminating duplicates, 53 codes were finalized. After analyzing the data, 4 categories and 12 sub-categories were extracted. In this research, lack of integrated management and process-oriented preparedness were the subjects with the highest number of codes.

Conclusion: According to the findings of this study, it is suggested that comprehensive training programs should be implemented for effective management of the air emergency process during disasters such as earthquakes.

Management of Preventable Deaths due to Road Traffic Injuries in Prehospital Phase; a Qualitative Study

Adel Eftekhari, Abbasali DehghaniTafti, Khadijeh Nasiriani, Majid Hajimaghsoudi, Hossein Fallahzadeh, Davoud Khorasani-Zavareh

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e32

Introduction: Prehospital care plays an important role in decreasing the number of deaths due to road traffic injuries (RTIs). This study aimed to identify the challenges of preventable deaths due to RTIs in the prehospital phase based on the attitudes of stakeholders.

Methods: Conventional content analysis of qualitative study was used to analyze the data. The participants were 24 RTI prevention experts from fire-fighting organization, traffic police, the Red Crescent, Emergency Medical Services staff, emergency medicine specialists, and hospital emergency nurses who were selected by means of purposive sampling. Data were collected using unstructured interviews and analyzed by means of data coding, followed by extracting sub-categories, and main categories.

Results: Six main categories were extracted as the major challenges of preventable deaths in RTIs in the prehospital phase including “poor management of the crash scene†with two subcategories of lack of rapid access to the patient and lack of scene safety, “lack of adequate rules and regulations†with two subcategories of lack of protocols and guidelines and lack of clear duties checklists, “poor management of time†with two subcategories of elongated response time at the crash scene and elongated time of victim transport, “low quality of training†with two subcategories of insufficient training of Emergency Medical Services (EMS) staff and inadequate public training, “poor communication and coordination†with two subcategories of poor communication of EMS staff and lack of uniform commandership at the crash scene, and “low quality of victim management†with two subcategories of low quality of clinical care and lack of accurate clinical assessment.

Conclusion: The following measures are necessary to reduce preventable deaths due to RTIs in the prehospital phase: accurate clinical assessment of the victim on the scene, provision of high quality and accurate clinical care, enforcement of legal obligations and using protocols in the field of victim management, coordination of the involved organizations through identifying the duties and responsibilities of each organization, and full management of the crash scene by assigning a unique commander to each unit and creation of the highest level of safety on crash scene.

Early Intubation vs. Supportive Care in Management of Severe Blunt Chest Trauma; a Randomized Trial Study

Mohammad Nasr-Esfahani, Amir Bahador Boroumand, Mohsen Kolahdouzan

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e35

Introduction: Early intubation is one of the critical issues in patients with chest trauma. This study aimed to examine the effect of early intubation on outcomes of patients with severe blunt chest trauma.

Methods: This clinical trial was performed on patients with blunt chest trauma referring to emergency department. Patients were randomly divided to intervention (early intubation) and control (supportive care) groups and the duration of hospitalization, complete recovery rate, laboratory changes, and in hospital mortality were compared between the two groups.

Results: 64 cases were divided into two equal groups of early intubation and control. There were no significant differences between two groups regarding age (p=0.36), sex (p=0.26), type of trauma (p>0.05), and comorbid diseases (p>0.05). The duration of hospitalization in the early intubation group was significantly lower than that of the control group (p = 0.01). 90.6% of those in early intubation group and 68.8% of those in the control group showed complete recovery (p = 0.03). There was no case of mortality in either group. There was a significant difference in venous blood pH between the groups at 6, 12, 18 and 24 hours after intubation (p < 0.05). Also, there was a significant difference in the HCO3 level at 6 and 12 hours after intubation (p <0.05).

Conclusion: Early intubation is better than supportive treatment in patients with severe chest trauma because of a better complete recovery rate, lower duration of hospitalization, and better acid/base situation.

Predictors of Out of Hospital Cardiac Arrest Outcomes in Pre-Hospital Settings; a Retrospective Cross-sectional Study

Elham Navab, Maryam Esmaeili, Nastaran Poorkhorshidi, Rasoul Salimi, Afshin Khazaei, Abbas Mogimbigi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e36

Introduction: Different potential factors can affect the outcomes of Out of Hospital Cardiac Arrest (OHCA). The present study aimed to identify important factors contributing to the Return of Spontaneous Circulation (ROSC) and Survival to Hospital Discharge (SHD) in these patients.

Methods: This cross-sectional study was conducted on all the OHCA patients who underwent Cardiopulmonary Resuscitation (CPR) in emergency medical service (EMS) of Hamadan province during 2016-2017. All the relevant data were retrieved from three sources, according to Utstein’s style. In addition, univariate and multivariate logistic regressions were employed to identify predictive factors of ROSC and SHD using SPSS software, version 20.

Results: Among the 3214 eligible patients whose data were collected, most OHCA patients were female (59.7%) with the mean age of 58 years. Moreover, the majority of OHCAs (77.8%) occurred at home during 8pm-8am (65.1%) and about 26.3% of OHCAs were witnessed, with only 5.1% bystander-initiated CPR. Furthermore, the median ambulance response time and CPR duration were 6.0 and 20 minutes, respectively. Overall, ROSC and SHD success rates were 8.3 and 4.1%, respectively. Bystander CPR was found to be the most effective predicting factor for the success rate of ROSC (AOR=3.26, P<0.001) and SHD (AOR=3.04, P<0.001) after adjusting for the Utstein variables including the patients’ age, gender, cardiac disease history, arrest time, CPR duration, response time, being witnessed, bystander CPR, and endotracheal intubation (ETI).

Conclusion: The overall success rates of ROSC and SHD were 8.3% and 4.1%, respectively. The age, ambulance response time, CPR duration, and cardiac disease history were negatively associated with the outcomes of ROSC and SHD, while being witnessed, bystander CPR, ETI, and initial shockable rhythm were positively related to both of the above-mentioned outcomes.

Introduction: Considering the importance of early diagnosis of diabetic foot ulcers and its complications, this study aimed to evaluate the accuracy of erythrocyte sedimentation rate (ESR), C - reactive protein (CRP), and pro-calcitonin (PCT) in predicting the ulcer class, osteomyelitis, and peripheral arterial disease (PAD).

Methods: This cross-sectional study was performed on 200 consecutive patients suffering from diabetic foot ulcer who were referred to Infectious Disease Ward. The levels of PCT, ESR, and CRP were measured for all patients and the screening performance characteristics of each marker in predicting the ulcer class, osteomyelitis, and PAD was calculated.

Results: The levels of PCT, ESR and CRP were significantly higher in patients with class IV foot ulcer compared to those with class III ulcers (p<0.001). Patients with evidence of osteomyelitis had significantly higher level of PCT, ESR and CRP. The best cutoff points of PCT, ESR and CRP in predicting osteomyelitis were 0.35 ng/ml (86.1% sensitivity, 45.3% specificity), 56.5 mm/hours (95.8% sensitivity, and 50.0% specificity) and 44 mg/ml (90.3% sensitivity, 57.0% specificity), respectively. The presence of PAD was significantly associated with increased levels of the three biomarkers. The best cutoff values for PCT, ESR and CRP in predicting PAD were 0.45 (70.8% sensitivity, 71.7% specificity), 61.5 (83.3% sensitivity, 52.0% specificity) and 49 (83.3% sensitivity, 63.8% specificity), respectively.

Conclusion: Based on the findings of the present study, although the accuracy of PCT, ESR, and CRP in predicting the severity of diabetic foot ulcers was fair, increase in the three parameters can predict the occurrence of osteomyelitis and PAD following diabetic food development with good accuracy and acceptable sensitivity.

Factors with the Highest Impact on Road Traffic Deaths in Iran; an Ecological Study

Alireza Razzaghi, Hamid Soori, Amir Kavousi, Alireza Abadi, Ardeshir Khosravi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e38

Introduction: The largest proportion of road traffic deaths (RTDs) happen in Low and Middle Income Countries (LMICs). The efforts for decreasing RTDs can be successful if there is precise information about its related risk factors. This study aimed to determine economic, population, road, and vehicle factors with the highest impacts on RTDs in Iran.

Methods: This is an ecological study, which has been done using covariates including: the population density, economic growth, urbanization, distance traveled (km) in 100 thousand people, the length of urban roads, the length of rural roads and the Vehicle per 1000 population for each province of Iran in 2015. The covariates considered had been gathered from different sources and to determine which one of the covariates has an effect on RTDs, the Negative Binomial (NB) regression model was used.

Results: The mean number of RTDs per 100000 population was 474 ± 70.59 in 2015. The highest and lowest rates of death belonged to Fars and Qom provinces, respectively. The results of the univariate model showed the population density as the only covariate of RTDs (p=0.001). Also, among other covariates, GDP was the only variable with a p-value equal to 0.2. In the multivariate NB model, it was seen that the population density (p=0.001), and GDP (p=0.02) significantly correlated with RTDs. For a unit (Million Rial) increase in the GDP of the province, the number of deaths decreased by as much as 0.0014. In addition, for a unit increase in population density, the number of deaths went up by as much as 30.

Conclusion: Population density and GDP had positive and negative effects on the number of fatal road traffic injuries, respectively. By considering these factors in presentational and controlling programs on road traffic injuries, it is possible to decrease the RTDs.   

Clinical Characteristics and Associated Factors of Mortality in Febrile Neutropenia Patients; a Cross Sectional Study

Hamidreza Hatamabadi, Ali Arhami Dolatabadi, Ayda Akhavan, Saeed Safari

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e39

Introduction: The duration and severity of neutropenia directly correlate with the incidence of life-threatening infections. This study aimed to evaluate the clinical characteristics and associated factors of mortality in febrile neutropenia patients.

Method: This retrospective cross sectional study was conducted on all febrile neutropenia patients who were admitted to oncology department of two educational hospitals, Tehran, Iran, from 2011 to 2016. Available patients’ data regarding baseline characteristics, treatment, and outcome were collected and analyzed using SPSS 21.

Results: 357 patients with the mean age of 50.9±17.7 years were studied (59.7% female). Mean white blood cell count of the studied patients was 715.1 ± 270.4 (100 – 1400) cells/mm3. The absolute neutrophil count (ANC) of all patients was <500 cells/mm3. The most frequent sources of malignancy in studied patients were gastrointestinal (35.9%), breast (22.4%), and sarcoma (15.7%), respectively. The mean time interval between initiation of treatment in ED and increase of ANC to > 500 cells/mm3 was 2.45 ± 2.1 (1 – 16) days. 186 (52.1%) subjects reached ANC>500 cells/ mm3 after 2-5 days of hospitalization. The rate of hospital mortality was 5.3% (338 (94.7%) survived). The correlation between gender (p = 0.11), temperature (p = 0.123), number of ED visits (p = 0.765), presenting clinical manifestation (p = 0.201), source of malignancy (p= 0.328), presence of metastasis (p = 0.69), positive urine culture (p = 0.45), positive blood culture (p = 0.62), time from last chemotherapy (p = 0.677), and time to reach ANC>500 cells/mm3 (p = 0.739) with mortality was  not significant.

Conclusion: Based on the findings of the present study, the rate of hospital mortality in patients with febrile neutropenia was 5.3%. Older age and lower white blood cell count were among the significant associated factors of mortality in this series.

Relationship between Thrombosis Risk Factors, Clinical Symptoms, and Laboratory Findings with Pulmonary Embolism Diagnosis; a Cross-Sectional Study

Rama Bozorgmehr, Mehdi Pishgahi, Pegah Mohaghegh, Marziye Bayat, Parastou Khodadadi, Ahmadreza Ghafori

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e41

Introduction: Pulmonary embolism (PE) is a potentially life threatening disease, accurate and timely diagnosis of which is still a challenge that physicians face. This study was designed with the aim of evaluating the relationship between thrombosis risk factors, clinical symptoms, and laboratory findings with the presence or absence of PE.

Methods: The present retrospective cross-sectional study was performed on patients with suspected pulmonary embolism who were hospitalized in different departments of Shohadaye Tajrish Hospital, Tehran, Iran, during 1 year. All patients underwent computed tomography pulmonary angiography (CTPA) and then thrombosis risk factors, clinical symptoms, and laboratory findings of confirmed PE cases with CTPA were compared with others.

Results: 188 patients with the mean age of 61.91 ± 18.25 (20 – 101) years were studied (54.8% male). Based on Wells' score, 32 (17.2%) patients were in the low risk group, 145 (78.0%) were in the moderate risk group, and 9 (4.8%) patients were classified in the high risk group for developing PE. CTPA findings confirmed PE diagnosis for 60 (31.7%) patients (6.7% high risk, 75.0% moderate risk, 18.3% low risk). D-dimer test was only ordered for 27 patients, 25 (92.6%) of which were positive. Among the patients with positive D-dimer, 18 (72.0%) cases had negative CTPA. Inactivity (57.4%), hypertension (32.8%), and history of cancer (29.5%) were the most common risk factors of thrombosis in patients with PE. In addition, shortness of breath (60.1%) and tachypnea (11.1%) were the most common clinical findings among patients with PE. There was no significant difference between the patients with PE diagnosis and others regarding mean age (p = 0.560), sex distribution (p = 0.438), and type of thrombosis risk factors (p > 0.05), hospitalization department (p = 0.757), Wells’ score (p = 0.665), electrocardiography findings, or blood gas analyses.

Conclusion: Although attention to thrombosis risk factors, clinical symptoms, and laboratory findings, can be helpful in screening patients with suspected PE, considering the ability of CT scan in confirming or ruling out other possible differential diagnoses, it seems that a revision should be done to lower the threshold of ordering this diagnostic modality for suspected cases.

Association of High Serum Adiponectin with the Risk of Malnutrition and Worse Outcome in Head Trauma Patients; a Cohort study

Mohammed Ibrahim Mohialdeen Gubari, Mohammad Javad Hosseinzadeh-Attar, Mostafa Hosseini, Fadhil Ahmed Mohialdeen, Abdolreza Norouzy

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e43

Introduction: A number of studies have shown the association between serum adiponectin level and the nutritional status. This study aimed to evaluate the relation between serum adiponectin and changes in nutritional status of head trauma patients.

Methods: The current prospective cohort study was carried out on head trauma patients who were hospitalized in ICU of a General Teaching Hospital, Sulaimani, Iraq. Patients were divided into two groups based on their serum adiponectin level during the first 24 hours of admission (<15mg/L and ≥15 mg/L) and malnutrition and nutritional indices were compared between groups 1, 6 and 13 days after admission.

Results: Sixty-four patients with the mean age of 35.97 ± 11.5 years were studied (59.4% male; 57% traffic accidents). The nutritional status of head trauma patients with serum adiponectin ≥15 mg/L significantly deteriorated from day 1 to 13 based on different nutritional status indices. BMI (p = 0.08), LBM (p = 0.002), APM (p = 0.009), and MUAC (p = 0.008) had a significant decreasing trend from day 1 to day 13 in patients with serum adiponectin level ≥ 15 mg/L.  In addition, the number of high risk patients for developing malnutrition based on NUTRIC score (p < 0.001) and the number of severely malnourished cases based on SGA score (p < 0.001) significantly increased from day 1 to 13 in this group. The severity of disease based on APACHE (p < 0.001) and SOFA (p < 0.001) scores increased in the mentioned cases during the follow up period.

Conclusion: Serum adiponectin level ≥ 15 is associated with significant deterioration in nutritional status, increase in the risk of malnutrition, and worsening of the clinical outcome in patients with moderate to severe head trauma in ICU.

One-Month Follow-Up of Patients with Unspecified Abdominal Pain Referring to the Emergency Department; a Cohort Study

Seyed Mohammad Hoseininejad, Reza Jahed, Mohammad Sazgar, Fatemeh Jahanian, Seyed Jaber Mousavi, Syed Hosein Montazer, Touraj Asadi, Hamed Aminiahidashti

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e44

Introduction: About one third of patients referring to emergency department (ED) with abdominal pain, are discharged without a definite diagnosis. This study aimed to investigate the one-month outcome of patients with unspecified abdominal pain.

Methods: This cohort study was conducted on subjects who were evaluated in ED with unspecified abdominal pain and were referred to the gastroenterology clinic and followed for one month. Finally, they were divided into two groups of cases with clear cause of abdominal pain and unclear cause of abdominal pain and patients’ characteristics were compared between the groups.

Results: 150 cases with the mean age of 40.68 ± 18.34 years were studied (53.3% female). After one month, 67 (44.7%) patients still complained of abdominal pain. A definitive cause of abdominal pain was established in 88 (58.7%) cases. There was not any significant difference between groups regarding, sex distribution (p = 012), duration of pain (p = 0.11), history of previous similar pain (p = 0.136), pain radiation (p = 0.737), length of hospital stay (p = 0.51), and presence of anorexia (p = 0.09), nausea and vomiting (p= 0.50), fever (p = 1.0), diarrhea (p = 0.23), and constipation (p = 0.07). There was a significant difference between the groups regarding location of pain (p = 0.017), age (p = 0.001) and history of comorbid diseases (p = 0.046). The predictive factors of finding a clear cause for abdominal pain in one-month follow-up, were leukocytosis (OR: 5.92 (95% CI: 2.62 – 13.39); p < 0.001), age (OR: 2.78 (95% CI: 1.15 – 6.71); p = 0.023), and outpatient follow-up (OR: 1.04 (95% CI: 1.02 – 1.07); p < 0.001).

Conclusion: Approximately, 40% of patients who were discharged with unspecified abdominal pain did not receive a clear diagnosis after one month of follow-up. Older age, leucocytosis in initial evaluations, and outpatient follow-up increased the probability of finding a clear cause for abdominal pain in the mentioned cases.

Value of Ultrasonography in Detection of Diaphragmatic Injuries Following Thoracoabdominal Penetrating Trauma; a Diagnostic Accuracy Study

Ali Sharifi, Amir Kasraianfard, Abdolhamid Chavoshi Khamneh, Soheila Kanani, Mohamedali Aldarraji, Mohammad Ali Seif-Rabiei, Amir Derakhshanfar

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e45

Introduction: Diagnosis of diaphragmatic rupture following thoracoabdominal penetrating trauma is very challenging in asymptomatic patients with stable vital signs. This study aimed to evaluate the diagnostic accuracy of focused assessment with sonography for trauma (FAST) in this regard.

Methods: This cross-sectional study was performed on patients referring to emergency department due to left thoracoabdominal stab wound during 2 years. All patients initially underwent ultrasonography and the screening performance characteristics of FAST in detection of diaphragmatic injuries were calculated, considering the findings of diagnostic laparoscopy as the gold standard test.

Results: Twenty-four patients with the mean age of 33 ± 10.64 years (16-61 years) were studied (100% male). The mean chest wall laceration size was 2.7 ± 2.7 cm (1-10 cm) and the most frequent location of wounds was posterior chest wall (42%) and in the 6th and 7th intercostal space (50%). Diaphragmatic rupture was seen in 4 (16.7%) patients based on diagnostic laparoscopy. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratio of FAST in detection of diaphragmatic raptures were 50% (95% CI: 9.18 – 90.8), 100% (95% CI: 79.9 – 100.0), 100% (95% CI: 19.8 – 100.0), 9.1% (95% CI: 1.5 – 30.6), Infinity, and 0.1 (95% CI: 0.02 – 0.37), respectively. The overall accuracy of FAST in this regard was 75.0% (95% CI: 42.3 – 100.0).

Conclusion: In patients with penetrating trauma to the left thoracoabdominal region, FAST cannot be the definitive alternative to diagnostic laparoscopy to detect diaphragm rupture.

Epidemiologic Characteristics of Patients Admitted to Emergency Department with Dermatological Complaints; a Retrospective Cross sectional Study

Deniz Kilic, ozlem yigit, Taylan Kilic, Cagri Sefa Buyurgan, Ozlem Dicle

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e47

Introduction: Dermatological diseases constitute 5-8% of all emergency department (ED) visits. However, little is known about these patients. The aim of this study is to determine the epidemiologic characteristics of patients admitted to ED with dermatological complaints.

Methods: This is a retrospective cross-sectional study conducted in the ED of a university hospital. Patients over 18 years of age who presented to ED with the following complaints were included in the study: rash, pruritus, and edema sensation in the throat or shortness of breath due to an allergic reaction. Demographics, chief complaints, final diagnoses, triage categories, consultations and hospitalization rates were obtained through computerized database of the hospital. 

Results: 859 patients were included in the final analysis. 511 (59.5%) patients were female and the mean age of patients was 39.03±15 years. The most common complaint and final diagnosis were skin rash with pruritus (50.9%) and urticaria with drug eruptions (84.5%), respectively. Two patients (0.2%) had an emergent triage category. 804 (93.6%) patients were discharged from ED, while 55 (6.4%) received consultations, resulting in 19 (34.5%) hospitalizations.

Conclusion: Most of the patients admitted to ED with dermatological complaints are non-urgent and can be treated as outpatients. However, physicians should be alert for emergent causes, as well.

Use of a Motorlance to Deliver Emergency Medical Services; a Prospective Cross Sectional Study

Korakot Apiratwarakul, Kamonwon Ienghong, Thapanawong Mitsungnern, Praew Kotruchin, Pariwat Phungoen, Vajarabhongsa Bhudhisawasdi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e48

Introduction: Access time to patients with critical or emergent situations outside the hospital is a critical factor that affects both severity of injury and survival. This study aimed to compare the access time to the scene of an emergency situation between a traditional ambulance and motorlance.

Methods: This prospective cross sectional study was conducted on all users of emergency call, Srinagarind Hospital, Thailand, from June to December 2018, who received a registration number from the command center.

Results: 504 emergency-service operations were examined over a six-month period, 252 (50%) of which were carried out by motorlance. The mean activation time for motorlance and ambulance were 0.57 ± 0.22 minutes and 1.11 ± 0.18 minutes, respectively (p<0.001). Mean response time for motorlance was significantly lower (5.57 ± 1.21 versus 7.29 ± 1.32 minutes; p < 0.001). The response times during 6 a.m. to 6 p.m. were 5.26 ± 1.11 minutes for motorlance and 7.15 ± 1.39 minutes for ambulance (p < 0.001). These measures for night time (6 p.m. to 6 a.m.) were 5.58 ± 1.21 minutes and 8.01 ± 1.30 minutes, respectively (p < 0.001). The mean automated external defibrillator (AED) waiting time for motorlance and ambulance were 5.26 ± 2.36 minutes and 9.24 ± 3.30 minutes, respectively (p = 0.012). The survival rate of patients after AED use in motorlance and ambulance was 80% versus 37.5%; p<0.001.

Conclusion: Emergency service delivery by motorlance had lower mean activation time, response time, AED time, and mortality rate of cardiac arrest patients compared to ambulance. It seems that motorlance could be considered as an effective and applicable device in emergency medical service delivery, especially in crowded cities with heavy traffic.

Diagnostic Accuracy of Ultrasonography in Diagnosis of Metatarsal Bone Fracture; a Cross Sectional Study

Mohsen Ebrahimi, Seyed Reza Habibzadeh, Syyed Reza Ahmadi, Samaneh Khajeh Nasiri, Mohammad Majid Kaveh, Mahdi Foroughian

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e49

Introduction: Metatarsus is one of the most common sites in the sole of foot bones fractures. The aim of this study was to determine the diagnostic accuracy of ultrasound in diagnosis of metatarsal bone fractures following foot trauma.

Methods: This cross-sectional study was carried out on patients with blunt foot trauma admitted to emergency department of a hospital in Mashhad, Iran from January to September 2016. All patients were evaluated with bedside ultrasound for the presence of first to fifth metatarsal fractures and screening performance characteristics of ultrasonography in detection of metatarsal fractures were calculated considering foot radiography as the reference test.

Results: The study was conducted on 102 patients with a mean age of 35.14±14.32 years (56.8% male). The most common signs of trauma in physical examination were pain and tenderness (100%), swelling (96.1%), ecchymosis (14.7%) and deformity (1.9%). Sensitivity, specificity, and positive and negative likelihood ratio of ultrasonography in detection of metatarsal bone fracture were 96.7% (95% CI: 0.83-0.99), 84.5% (95% CI: 0.73-0.92), 73.1% (95% CI: 0.57-0.85), and 98.3% (95% CI: 0.91-0.99), respectively. The overall accuracy of ultrasonography was 0.906 (95% CI: 0.844 – 0.969) based on area under the receiver operating characteristic (ROC) curve.

Conclusion: Considering the excellent diagnostic accuracy, ultrasonography can be used as an alternative means in diagnosis of metatarsal bone fractures.

Risk Factors of Suicide Death Based on Psychological Autopsy Method; a Case-Control Study

Nafee Rasouli, Seyed Kazem Malakouti, Mohsen Rezaeian, Seyed Mehdi Saberi, Marzie Nojomi, Diego De Leo, Abbas Ramezani-Farani

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e50

Introduction: Investigation in each community can contribute to understanding the key factors involved in suicide death and its prevention. The present study aimed to investigate suicide death risk factors based on psychological autopsy method.

Methods: The present case-control study was conducted from April to September 2017, in Tehran, Iran, to compare two groups of people; those who died by suicide and controls (over the age of 18 years). Data were collected by one interviewer via Structured Clinical Interviews (SCID-I), questionnaires used in the SUPREMISS study, and the Dickman impulsivity scale.

Results: Each group consisted of 40 individuals. There was no significant difference between the case and control groups in terms of all demographic variables except for the level of education (p = 0.06)  and occupational status (p = 0.009). The frequency of previous history of suicide attempt (p = 0.001), family history of suicide (p = 0.003), DSM IV Axis I disorders (p = 0.006), and substance and alcohol consumption (p = 0.01) were significantly higher in the case group. The most commonly diagnosed disorders included MDD (45%) and substance use disorders (30%), respectively. The most common methods used in suicide included hanging (32.5%), and Aluminum phosphide poisoning (32.5%) known as rice tablet. The strongest predictor of suicide death was the deceased person's Previous history of suicide attempt (OR= 9.3; p = 0.04), smoking (OR= 6.4; p = 0.006), unemployment (OR= 5; p = 0.02), and DSM IV axis I disorders (OR= 3.8; p = 0.04).

Conclusion: Previous suicide attempt, smoking, unemployment, and suffering from at least one mental disorder were the significant predictors of suicide death. Among mental disorders, major depressive disorder and substance use disorder were the most prevalent mental health problems.

Point of Care Ultrasound in Detection of Brain Hemorrhage and Skull Fracture Following Pediatric Head Trauma; a Diagnostic Accuracy Study

Maryam Masaeli, Mojtaba Chahardoli, Sepehr Azizi, Babak Shekarchi, Foroogh Sabzghabaei, Nima Shekar Riz Fomani, Mehdi Azarmnia, Mahdis Abedi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e53

Introduction: Head trauma is a common reason for emergency department visits worldwide; many of which involve young children. Currently, the standard imaging test for head trauma patients is Noncontrasted Computed tomography, even though it employs ionizing radiation. We sought to determine if head ultrasound, as a fast and safe modality, can guide diagnosis and treatment of children in emergency settings.  

Methods: In this cross-sectional study, head CT-scans and emergency head ultrasounds were performed on head trauma children referred to the emergency departments of Firouzgar and Besat Hospitals, Tehran, Iran, from September 2018 to May 2019. The findings of the two modality were separately evaluated, and used to estimate US diagnostic accuracy statistics.

Results: 538 patients with the mean age of 5.6 +- 4.9 (0-18) years were studied (54.8% male). Sensitivity and specificity of bedside sonography in detection of hemorrhage below the age of 2 were 85.71 (42.13-99.64) and 97.99 (94.23-99.58).Between 2 and 6 years old 80.00 (51.91-95.67) and 97.97 (94.88-99.44), and above the age of 6 were 46.67 (21.27-73.41) and 92.90 (87.66-96.40), respectively. For diagnosing skull fractures, sensitivity and specificity were 92.31 (84.01-97.12) and 95.87 (93.62-97.50), respectively. Cohen’s kappa coefficient varied greatly for different findings from 0.363 to 0.825, indicating different agreement rates for each.

Conclusion: Based on our findings, emergency ultrasound can play a greater role in the initial management of head trauma children especially as a triage test or in disasters.



Validation of SUSPEKT Score in Predicting One-month Mortality of Patients with Hemorrhagic Stroke; a Diagnostic Accuracy Study

Hamid Kariman, Hamidreza Hatamabadi, Majid Shojaee, Farhad Asarzadegan, Simin Saljughi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e56

Introduction: Predicting the outcome of patients with intracranial hemorrhage (ICH) is the area of interest for in charge physicians as well as patients and their associates. This study aimed to evaluate the accuracy of SUSPEKT score in predicting one-month outcome of patients with hemorrhagic stroke.

Methods: This prospective cross sectional study was conducted on > 18 years old patients with non-traumatic supra-tentorial ICH admitted to emergency department, from February 2017 to January 2018. SUSPEKT score was measured for each patient and its screening performance characteristics in prediction of one-month mortality were calculated.

Results: 169 cases with the mean age of 63.09± 15.45 (21 – 96) years were studied (56.8% male). After one month follow up 47 (27.8%) cases had died, 30 (17.7%) cases were bed ridden, and 72 (42.6%) could walk without help or with a cane. Non-survived patients had significantly larger intra-ventricular hemorrhage (IVH) (p < 0.001) and hematoma (p < 0.001) volume, higher serum glucose (p < 0.001) and blood pressure (p = 0.028), higher frequency of IVH (p < 0.001), and higher WBC count (p = 0.037). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SUSPEKT score at the 65 cut point were 82.97% (95% CI: 68.65% – 91.86%), 74.59% (95% CI: 65.76% – 81.84%), 55.71% (95% CI: 43.38% – 67.40%), and 91.91% (95% CI: 84.23% – 96.16%), respectively.

Conclusion: Total accuracy of SUSPEKT score in predicting one-month mortality of non- traumatic ICH patients is in good range and it has 82% sensitivity and 92% NPV in this regard. It seems that we need further studies before applying the score in routine practice.

PIRO, SOFA and MEDS Scores in Predicting One-Month Mortality of Sepsis Patients; a Diagnostic Accuracy Study

Ali Vafaei, Kamran Heydari, Seyed-Saeed Hashemi-Nazari, Neda Izadi, Hassan Hassan Zadeh

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e59

Introduction: Different scoring systems based on clinical and laboratory findings are designed for prediction of short-term mortality of patients with severe sepsis and septic shock. This study aimed to compare the screening performance characteristics of PIRO, SOFA and MEDS Scores in predicting one-month mortality of sepsis patients.

Methods: This diagnostic accuracy study was performed on septic shock and severe sepsis patients referring to emergency department of Loghmane Hakim Hospital, Tehran, Iran, from 2017 to 2018. The performance of MEDS, SOFA, and PIRO models in predicting 30-day mortality of patients was evaluated using discrimination and calibration indices.

Results: 200 patients with the mean age of 71.03±15.59 years were studied (61% male). During the 30 days, 66 patients died (mortality rate=33%). The area under the ROC curve of PIRO, MEDS, and SOFA scores were 0.83 (95% CI=0.78-0.89), 0.94 (95% CI=0.91-0.97) and 0.87 (95% CI=0.81-0.92), respectively. Based on Brier, BrierScaled and Nagelkerke’s R2 ofthe models, the best performance in predicting one-month mortality belonged to MEDS score. C-statistic showed that MEDS score had the highest value in the differentiation between the survived and non-survived cases.

Conclusion: This study showed that MEDS score performs better than PIRO and SOFA scores in predicting one-month mortality of patients with severe sepsis and septic shock.

Characteristics of Traumatic Urogenital Injuries in Emergency Department; a 10-year Cross-sectional Study

Babak Javanmard, Morteza Fallah karkan, Mohammadreza Razzaghi, Anahita Ansari Djafari, Saleh ghiasy, Behzad Lotfi, Reza Vafaee

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e63

Introduction: Urogenital system injuries (UGIs) are seen in 10% of adult cases with multiple trauma. Although UGIs are rarely life threatening, they can cause major long-term morbidities. This study aimed to evaluate the characteristics of traumatic UGIs in patients who were referred to emergency department following multiple traumas. 

Methods: This retrospective cross-sectional study was conducted on multiple trauma patients who were presented to emergency department during a 10-year period (2008-2017). All patients with kidney, ureter, bladder, urethra, or external genitalia injuries were studied. The patients’ data were extracted from their clinical profiles.

Results: Out of the 13598 admitted patients in our trauma center, UGIs were seen in 267 (1.9%) cases. The mean age of patients with UGIs was 27.3 ± 6.1 years (74.15% male).  The highest incidence of UGI was seen in those aged between 21 and 30 years (39.7%) and motorcycle accidents (49%) was the most frequent cause of trauma. 221 patients had an unstable situation and were emergently transferred to operation room (13.57% with traumatic kidney injury). The most common injured sites of urogenital system were kidney with 155 (58%) cases, followed by external genitalia with 91 (34.1%) cases. 77.5% of cases were managed conservatively and the rest (22.5%) underwent surgical procedures.

Conclusion: UGIs comprise a low percentage (2%) of traumatic injuries, which are mostly caused by blunt trauma due to road traffic accidents. Kidney is the most common injured organ and UGIs mostly happen in young ages.

Association of Clinical Signs and Symptoms with Abnormal Urinalysis Findings of Blunt Trauma Patients; a Cross-Sectional Study

Bahram Zarmehri, Ayeh Shouman, Elham Pishbin, Niaz-Mohammad Jafari Chokan, Mona Najaf Najafi, Seyed Reza Habibzadeh, Esmaeil Rayat Dost, Mahdi Foroughian

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e64

Introduction: Urinalysis (UA) is performed routinely as a diagnostic screening test for trauma patients in most centers. This study aimed to examine the relationship between patients’ clinical signs and symptoms with UA findings. Methods: This cross-sectional study was carried out on multiple trauma patients between 18 to 65 years old, who were referred to the Emergency Department. UA was performed for all patients and its association with clinical signs and symptoms (pain, tenderness, abrasion, ecchymosis, hematoma, etc.) in abdomen, back, flank, and inferior hemi-thorax was evaluated.Results: 640 patients with the mean age of 39.8 ± 11.2 years were studied (65.0% males). 271 (42.4%) cases had associated injuries and 554 (86.6%) cases had at least one sign or symptom of trauma in abdomen, back, flank or inferior hemi-thorax. 146 (22.8%) patients had negative UA. Among cases with positive UA, 364 (56.9%) cases had microscopic hematuria with RBC < 25/HPF, 60 (9.4%) had microscopic hematuria with RBC ≥ 25/HPF and 70 (10.9%) had gross hematuria. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria (p <0.001). Symptomatic patients who had signs in the abdomen, back or inferior hemi-thorax mainly had microscopic hematuria with RBC < 25/HPF, but those with signs in the flank, mainly had microscopic hematuria with RBC ≥ 25/HPF (p<0.001). Patients with pain, tenderness, abrasion, and ecchymosis in flank had a higher risk of positive UA findings (figure 2; p <0.001).

Conclusion: Based on the findings of the present study, patients with any findings of pain, tenderness, abrasion, or ecchymosis in flank had higher risk of abnormal UA and perhaps urogenital injuries. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria.

Epiemiologic Features and Hospitalization Cost of Burn Injuries in Iran Based on National Burn Registry; a Cross-sectional Study

Reza Rezaee, Khalil Alimohamadzadeh, Seyed-Mojtaba Hosseini

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e65

Introduction: Burn is one of the most common causes of injury in the world. The aim of this study was to determine the epidemiologic features and cost of hospitalization associated with burn injuries in Iran.

Methods: In this cross-sectional study, the data related to hospitalized burn cases in 2017 were obtained from the office of curative affairs in the Ministry of Health and Medical Education of Iran and analyzed regarding the epidemiologic features and hospitalization costs.

Results: 35933 hospitalized burn patients, from the beginning to the end of 2017, with  the mean age of 29.37 ± 21.41 (1 – 99) years were studied (59.4% male). Scald burns (49.4%) were the most prevalent type of burns and 30.3% of burns occurred in spring. The most frequent severity of burn injury was second-degree burns (69.3%) with 1-20 percent involvement of body's surface area (74.7%). Frequency of scald burn was higher in females, while the frequency of flame was higher in males. Total hospitalization cost of studied cases was 66910.22 $.  In male patients, the highest average direct cost was related to electrical burns; while in females, the highest average direct cost was related to chemical burns. Higher degrees and percentages of burn injuries required a more costly treatment.

Conclusions: Burn injuries most frequently happened in males, ages < 10 years, spring season, and with scald and flame. The most frequent injuries were second-degree burns with 1% – 20%  body surface involvement. The highest direct hospitalization cost was related to chemical and electrical burns. There was a direct correlation between the degree and percentage of burn and the hospitalization costs.

Improving the Quality of Care of Women in the Emergency Department: A survey of battered women

Brieana Rodriguez, Madalyn Mandich

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e68

Study Objectives: Domestic Violence (DV) is a problem defined as physical, sexual, and/or mental abuse used by one person in a relationship in order to gain control over the other. Over 10 million in the US will experience DV, and 34% will seek medical care for their injuries. The Joint Commission, the American College of Emergency Physicians, and the US Preventive Services Task Force strongly encourage screening for DV. However, only 30% of women who present to the Emergency Department (ED) are screened. To gain better understanding of patient screening and treatment in the ED, we conducted a pilot survey of DV patients in a shelter, seen in an ED.


Methods: The survey was conducted during the women's initial visit to Sojourner Family Peace Center in Milwaukee, WI. It includes 22 questions measuring responses of women’s encounters with screening and treatment for DV in the ED. 


Results: Sojourner collected 24 surveys over 7 months. Thirteen women presented for treatment of injuries related or not related to abuse. Problems with abuse-related care they received were identified. For example, 31% of women presenting with obvious signs of abuse, such as human bite wounds or head injury, were not screened. Four of 11 women were screened with family or law enforcement present. Nine of 11 were screened by a nurse, social worker, or police officer, not a physician. Four women felt rushed by healthcare professionals and that they did not genuinely care. Most noticeably, women were not screened at all.


Conclusion: We gained valuable insight on interactions between healthcare personnel and DV victims. DV screening must be done with no family present. Removing law enforcement from rooms is noted to make women feel more comfortable. If a family member is adamant about remaining with the patient, the patient can be removed for a blood draw or sensitive exam to attain privacy. Standardizing screening could aid in making DV victims feel less rushed and more at ease. The courageous women sharing personal stories help pave the way to better treatment for future victims of DV presenting to the ED.


Problem-Based versus Lecture-Based Method in Pre-hospital Trauma Life Support Training; a Pre-test Post-test Study

Masoumeh Falaki, Rouzbeh Rajaei Ghafouri, Samad Shams Vahdati

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e70

Introduction: Pre-hospital trauma life support (PHTLS) training is necessary for all emergency medical services (EMS) personnel to increase their efficacy and skills. This study aimed to compare two methods of problem-based learning (PBL) and lecture-based learning (LBL) for PHTLS training courses of EMS personnel. 

Methods: In this pre-post-test study, 144 male EMS staff members were divided into two groups of PBL (n=72) and LBL (n=72). Both groups received four sessions of PHTLS training based on 8th edition of PHTLS guideline. The participants’ knowledge and skills were evaluated before and three months after training and the two groups were compared in this regard.  

Results: The mean knowledge score (63.59±13.43 to 81.08±4.66; p<0.001) and mean skills score (58.85±19.74 to 99.07±25.02; p<0.001) of participants had significantly improved after the training courses. Both groups had similar scores before intervention, but PBL group had significantly higher scores in knowledge (p<0.001) and skills (p<0.001) after intervention. There was also a significantly higher change in knowledge (p<0.01) and skills (p<0.001) in PBL group compared to LBL group.

Conclusions: PHTLS training improves EMS personnel’s knowledge and skill in managing trauma patients. PBL was more effective than LBL.

Review Article

A Comparison between the Ability of Revised Trauma Score and Kampala Trauma Score in Predicting Mortality; a Meta-Analysis

Shahram Manoochehry, Masoud Vafabin, Saeid Bitaraf, Ali Amiri

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e6

Introduction: Describing injury severity in trauma patients is vital. In some recent articles the Revised Trauma Score (RTS) and Kampala Trauma Score (KTS) have been suggested as easily performed and feasible triage tools which can be used in resource-limited settings. The present meta-analysis was performed to evaluate and compare the accuracy of the RTS and KTS in predicting mortality in low-and middle income countries (LMICs).

Methods: Two investigators searched the Web of Science, Embase, and Medline databases and the articles which their exact number of true-positive, true-negative, false-positive, and false-negative results could be extracted were selected. Sensitivity and subgroup analysis were performed using Stata software version 14 to determine the factor(s) affecting the accuracy of the RTS and KTS in predicting mortality and source(s) of heterogeneity.

Results: The heterogeneity was high (I2 > 80%) among 11 relevant studies (total n = 20,631). While the sensitivity of the KTS (0.88) was slightly higher than RTS (0.82), the specificity, diagnostic odds ratio, negative likelihood ratio, and positive likelihood ratio of the KTS (0.73, 20, 0.16, 3.30, respectively) were lower than those of the RTS (0.91, 45, 0.20, 8.90, respectively). The area under the summary-receiver operator characteristic curve for KTS and RTS was 0.88 and 0.93, respectively.

Conclusion: However, regarding accuracy and performance, RTS was better than KTS for distinguishing between mortality and survival; both of them are beneficial trauma scoring tools which can be used in LMICs. Further studies are required to specify the appropriate choice of the RTS or KTS regarding the type of injury and different conditions of the patient.

Obstetric Triage Scales; a Narrative Review

Farzaneh Rashidi Fakari, Masoumeh Simbar, Shahrzad Zadeh Modares, Hamid Alavi Majd

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e13

Introduction: The growing demand for high-quality obstetric care and treatment has led to the advent and development of a field known as obstetric triage. The present review study aimed to examine the development of tools and criteria for obstetric triage services.

Methods: In this narrative review, two authors searched for related articles using the keywords of “obstetric triage, gynecology triage, perinatal Triage, maternity triage, midwifery triage†AND “tool, index, scale, questionnaire, systemâ€. With Persian and English language limitation, searches were performed in Scopus, Google Scholar, Scientific Information Database, ProQuest, Medline, Embase and Web of Science databases for articles published from 2000 to 2018.

Results: Out of the 289 articles reviewed in this study, 8 articles met the eligibility criteria. Out of these 8 articles, 6 were dedicated to introducing a tool designed and only 2 introduced an obstetric triage system. The obstetric triage tools and systems covered included Emergency Severity Index (ESI), Obstetric Triage Acuity Scale (OTAS), Birmingham symptom specific obstetric triage system (BSOTS), Maternal Fetal Triage Index (MFTI), Florida Hospital Obstetric Triage Acuity Tool, self-assessment questionnaire for gynecologic emergencies (SAQ-GE) and Perinatal Emergency Team Response Assessment (PETRA). Overall, the validity and reliability of the studied method were investigated and found to be acceptable in only 5 of the reviewed studies.

Conclusion: The review showed the lack of consensus on how to devise a single standardized tool or system for obstetric triage. The comparison of different obstetric triage tools and systems demonstrated the need for a standardized and widely-approved system with high validity and reliability and standard definitions for obstetric triage to determine the right priority and waiting times of obstetric care services.

History and Structure of the Fourth Leading Emergency Medical Service in the World; a Review Article

khosro shakeri, Mehdi Jafari, Hamidreza Khankeh, Hesam Seyedin

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e17

Over forty-three years have passed since the foundation of pre-hospital emergency care system in Iran. Considering the changes that have taken place in recent years in pre-hospital emergency and limited studies in this area, the present review aimed to describe the history, organizational structure, combination of workforce, dispatch system, medical direction and innovations in the pre-hospital system of Iran.  The present paper also discusses the strengths and weaknesses of the current system.

Serum and cerebrospinal fluid levels of S-100B is a biomarker for spinal cord injury; a systematic review and meta-analysis

Gholamreza Faridaalee, Fatemeh Keyghobadi Khajeh

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e19

Introduction: There is controversy regarding the value of serum or cerebrospinal fluid (CSF) levels of S100 calcium-binding protein B (S-100B) in spinal cord injury (SCI). For reaching a general conclusion, the present meta-analysis was designed aiming to evaluate the value of serum and CSF levels of S-100B protein in detecting the presence of SCI in animal studies.

Methods: An extensive search was performed in Medline, Embase, Scopus and Web of science databases. Screening articles, summarizing them and entering data to checklist and quality assessment of the mentioned articles were done by 2 independent reviewers. Data were analyzed and a pooled standardized mean difference (SMD) and 95% confidence interval (95% CI) were presented.

Results: Finally, the data of 7 articles were included in the meta-analysis. Serum level of S-100B had increased as a result of SCI. During the first 6 hours after injury, the level of this protein was very high (SMD=3.8; 95% CI: 2.6 to 5.1; p<0.0001), but as time passed the serum level of the protein had decreased (SMD=0.4; 95% CI: -1.2 to 2.0; p=0.65). In addition, CSF level of the mentioned protein was very high during the initial 6 hours after injury (SMD: 5.8; 95% CI: 3.6 to 8.0), and this elevated level was still observed until 12 hours after injury (SMD: 6.5; 95% CI: 3.7 to 9.3; p<0.0001).

Conclusion: The results of the present systematic review and meta-analysis show that measuring the level of S-100Î’ protein in serum and CSF has a potential value in diagnosis of SCI in animal models. This biomarker increases during the initial 6 hours following injury and remains high until 24 hours after that. However, more than 24 hours after the injury, serum level of this protein returns to the level of animals without SCI.

Applications of Machine Learning Approaches in Emergency Medicine; a Review Article

Negin Shafaf, Hamed Malek

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e34

Using artificial intelligence and machine learning techniques in different medical fields, especially emergency medicine is rapidly growing. In this paper, studies conducted in the recent years on using artificial intelligence in emergency medicine have been collected and assessed. These studies belonged to three categories: prediction and detection of disease; prediction of need for admission, discharge and also mortality; and machine learning based triage systems. In each of these categories, the most important studies have been chosen and accuracy and results of the algorithms have been briefly evaluated by mentioning machine learning techniques and used datasets.

Outcomes of Crowding in Emergency Departments; a Systematic Review

Hamid Reza Rasouli, Ali Aliakbar Esfahani, Mohammad Nobakht, Mohsen Eskandari, Sardollah Mahmoodi, Hassan Goodarzi, Mohsen Abbasi Farajzadeh

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e52

Introduction: Emergency Department (ED) crowding is a global public health phenomenon affecting access and quality of care. In this study, we seek to conduct a systematic review concerning the challenges and outcomes of ED crowding.

Methods: This systematic review utilized original research articles published from 1st January 2007, to 1st January 2019. Relevant articles from the PubMed (MEDLINE), EMBASE, and Google scholar databases were extracted using predesigned keywords. Following the PRISMA guidelines, two reviewers independently evaluated the quality of the studies using Critical Appraisal Skills Programme for cohort studies and qualitative studies, and Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument for studies.

Results:  Out of the total of 73 articles in the final record, we excluded 15 of them because of poor quality. This systematic review synthesized the reports of 58 original articles. The outcomes of multiple individual patients and healthcare-related challenges are comprehensively assessed.

Conclusions: ED crowding affects individual patients, healthcare systems and communities at large. The negative influences of crowding on healthcare service delivery result in delayed service delivery, poor quality care, and inefficiency; all negatively affecting the emergency patients' healthcare outcomes, in turn.

Pre-hospital pain management; a systematic review of proposed guidelines

Mahmoud Yousefifard, Shaghayegh Askarian-Amiri, Arian Madani Neishaboori, Mostafa Sadeghi, Peyman Saberian, Alireza Baratloo

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e55

Introduction: A standard guideline concerning pre-hospital pain management is still a matter of discussion. Therefore, the current umbrella review is determined to perform a comprehensive search in databases and Grey literature and collect and summarize the guidelines and protocols dealing with prehospital pain management.       

Methods: In the present study, all of the available guidelines and protocols concerning pre-hospital pain management were reviewed. Presented guidelines are from 2010 up to present, as the majority of guidelines are considered old and become renewed after 10 years. Finally, the development quality of each guideline was evaluated using AGREE II instrument.

Results: The search conducted in databases and non-indexed protocols resulted in inclusion of 12 pre-hospital pain management guidelines. The time interval of the guidelines was from 2010 to 2019. Four guidelines were designed for pain management in trauma patients and other guidelines were presented for all of the clinical conditions associated with pain. All of the 12 included guidelines presented pain management instructions in adults. Pain management in children was reported in 10 guidelines. All of the guidelines persisted on a standard method for pain evaluation. Pain management was categorized in three groups; mild, moderate and severe pain. Most of the guidelines recommend paracetamol as an optional treatment for management of mild pain in both adults and children. In management of moderate and severe pain, fentanyl and morphine were suggested for both adults and children. In most of the treatment guidelines fentanyl is the optional choice for children.

Conclusion: The present umbrella review has summarized the current evidence in pre-hospital pain management for the first time via investigation of guidelines and protocols related to the matter. Based on the obtained evidence, no guideline is yet presented concerning opioid-free management of moderate and severe pain. The evidence is insufficient for using non opioid medications such as ketamine.

The Preparedness of Hospital Emergency Departments for Responding to Disasters in Iran; a Systematic Review and Meta-Analysis

Mosayeb Kazemzadeh, Elham Shafiei, Katayoun Jahangiri, Kosar Yousefi, Ali Sahebi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e58

Introduction: Hospitals are the most important infrastructures of any society. The hospital emergency department is one of the most important wards of hospitals in response to disasters. The purpose of this study was to evaluate the preparedness of hospital emergency departments in response to disasters in Iran via a systematic review and meta-analysis.

Methods: This study was a systematic review and meta-analysis. The literature search was conducted in the national and international databases including SID, Magiran, Irandoc, Google scholar, Medline, Scopus, and ISI. Valid Persian and English keywords were used to extract articles related to the preparedness of hospital emergency departments in response to disasters. The STROBE checklist was used to evaluate the quality of the articles, and the I2 index was used to assess heterogeneity among the studies. Statistical analyses were conducted using STATA14 software.

Results: In this study, 185 articles were initially recruited. Meta-analysis was finally performed on 4 articles selected based on inclusion criteria. The analysis included a total of 51 hospitals in Iran. According to our results, the mean preparedness of hospital emergency departments in response to disasters was calculated as 54.64% (95% CI = 41.15-68.13, I2 = 0.0%; p = 0.727).

Conclusion: The results of this study showed that the average level of preparedness of hospital emergency departments in Iran to respond to disasters was moderate to high. Therefore, planning and actions should be considered based on the guidelines and accreditation standards to enhance the preparedness of hospital emergency departments in response to disasters.

Ultrasonography in Detection of Renal Calculi in Children; a Systematic Review and Meta-analysis

Mojtaba Fazel, Mohammed I M Gubari, Mahmoud Yousefifard, Mostafa Hosseini

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e66

Introduction: Although numerous studies have been done to evaluate the diagnostic value of ultrasonography in diagnosis of renal calculi in children, there is still no consensus. Therefore, in the present systematic review and meta-analysis, we aimed to evaluate the diagnostic accuracy of ultrasonography in identifying renal stones in children.

Methods: A comprehensive search of the electronic databases including Medline, Embase, Scopus and Web of Science was conducted up to July 2019. Diagnostic accuracy studies in children were included. Data was summarized and pooled. Area under the curve (AUC), sensitivity, specificity, diagnostic score and diagnostic odds ratio were reported with 95% confidence interval (95% CI).

Results: Data from 7 articles were included. Pooled analysis showed that the area under the curve of ultrasonography in diagnosis of pediatric renal calculi was 0.94 (95% CI: 0.92 to 0.96). The sensitivity and specificity of this diagnostic modality were 0.80 (95% CI: 0.70 to 0.87) and 1.00 (95% CI: 0.84 to 1.00), respectively. Diagnostic score and diagnostic odds ratio of ultrasonography in detection of renal calculi were 110.32 (95% CI: 2.88 to 19.76) and 82362.41 (95% CI: 17.80 to 3.8 × 108), respectively.

Conclusion: Overall, the low level of evidence indicates that sensitivity and specificity of ultrasonography in detecting renal calculi in children are 80% and 100%, respectively. However, due to the serious limitations of the included studies, well-designed prospective diagnostic accuracy studies are recommended for future studies.

Brief Report

Association of Lymphopenia with Short Term Outcomes of Sepsis Patients; a Brief Report

Hojat Sheikh Motahar Vahedi, Aida Bagheri, Amirhosein Jahanshir, Javad Seyedhosseini, Elnaz Vahidi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e14

Introduction: Studies have claimed that low lymphocyte count is independently correlated with 28-day survival of sepsis patients. Therefore, this study aimed to evaluate the value of lymphopenia in predicting the short-term outcome of sepsis patients.

Methods: This cross-sectional study was performed on sepsis patients referred to the emergency department during an 8-month period and relationship of lymphopenia with 28-day mortality and probability of septic shock and readmission due to sepsis was assessed.

Results: 124 cases with the mean age of 66.12 ± 15.82 (21-90) years were studied (54.8% male). 81 (65.3%) cases had lymphopenia (59.3% male). Lymphopenic patients had a significantly higher mean age (p = 0.003), higher need for ICU admission (p < 0.001), higher prevalence of 28-day septic shock (p < 0.001), higher 28-day mortality (p < 0.001), higher probability of readmission due to sepsis (p = 0.048), and higher SOFA score (p < 0.001). During 28 days of follow up, 57 (46%) patients were expired. They had a higher prevalence of septic shock (p < 0.001) and higher SOFA score (p < 0.001). Multivariate analysis showed that septic shock (OR=364.6; 95% CI: 26.3 to 5051.7; p = 0.001) and lymphopenia (OR=19.2; 95% CI: 1.7 to 211.3; p = 0.016) were the independent predictors of 28-day mortality.

Conclusions: Based on the findings, lymphopenia was independently associated with higher 28-day mortality and lymphopenic patients were older than the control group and had a significantly higher need for ICU admission, higher probability of 28-day septic shock and readmission due to sepsis, and higher SOFA score.

The Role of Pre-Hospital Telecardiology in Reducing the Coronary Reperfusion Time; a Brief Report

Peyman Saberian, Nader Tavakoli, Tayeb Ramim, Parisa Hasani Sharamin, Elham Shams, Alireza Baratloo

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e15

Objective: The determination of pre-hospital triage based on electrocardiogram and telecardiology in shortening the initial angioplasty time in patients with ST segment elevation myocardial infarction (STEMI) treated with PCI.

Methods: This cross-sectional study was conducted from September 2015 to January 2018 in six hospitals equipped with 24-hour angioplasty facilities in Tehran, Iran. Patients referred to the hospital with a diagnosis of STEMI by Emergency Medical Services (EMS) and undergoing primary angioplasty in the equipped centers were included. Patients were divided into two groups: 1) Patients who were transferred to Cath Lab after electrocardiography (ECG) and telecardiology by EMS (EMS247 group); 2) Patients who did not have ECG and telecardiology in the ambulance and were transferred to the emergency department.

Results: A total of 1205 people with the mean age of 58.99 ± 12.33 years (19-95 years) entered the study of whom 996 (82.65%) were male. Of these, 841 (69.8%) patients were transmitted via EMS, who have a 12-lead ECG carried out in the ambulance and after consultation with the cardiologist emphasizing the need for direct transmission to the angioplasty for PPCI. In the study, time interval of Symptom-to-device in the EMS247 group was less than the EMS routine group (P = 0.001). There was a similar finding about the time interval of First medical contact (FMC) to device. Mean differences of interval time in two groups were 100.4 and 22.5 min for symptom-to-Device and FMC-to-Device, respectively.

Conclusions: It is likely that the use of telecardiology in prehospital triage plays an important role in reducing time of PPCI for patients with acute myocardial infarction with ST segment elevation.

Seizure Prevalence and Its Related Factors in Tramadol Intoxication; a Brief Report

Asrin Babahajian, Payam Khomand, Farhad Manoochehri, Roozbeh Fakhimi, Behrooz Ahsan, Mohiadin Amjadian, vahid yousefinejad

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e28

Introduction: Seizure is known to be a serious complication of tramadol consumption even in its therapeutic doses. The aim of this study was to determine the prevalence of seizure and its related factors in tramadol intoxicated patients referred to emergency department (ED).

Methods: In this cross-sectional study, all individuals, admitted to ED following tramadol intoxication were divided into two groups based on the presence or absence of seizures. Demographic data as well as clinical, electroencephalogram and imaging findings were compared between the two groups using SPSS software version 22.

Results: 167 patients with the median age of 23 (13-45) years were studied (85% male). Seizure was seen in 97 (58.0%) cases. Risk of seizure had increased 3.7 times in patients with a history of seizure (OR: 3.71 Cl 95%: 1.17 - 11.76). Tramadol dose was significantly higher in patients who had seizure more than once (Median: 2800 IQR: 1800-4000), compared to those who had one seizure episode (Median: 850 IQR: 1800-400) (p <0.0001).

Conclusion: Based on the findings of this study, history of seizure increased the risk of seizure in patients taking tramadol, and the increase in dose correlated with a significant increase in seizure frequency.

Atropine Challenge Test in Screening the Organophosphorus Poisoning Cases with Atypical Presentation; a Brief Report

Shahin Shadnia, Nasim Zamani, Sara Nikpour, Ali Saffaei, Mohammad Reza Farnia

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e46

Introduction: Atropine is not recommended in organophosphorus (OPs) poisoning cases without any obvious clinical signs. This study aimed to evaluate the clinical utility of Atropine challenge test in screening OPs poisoning cases with atypical presentation.

Methods: In this prospective cross sectional study, after primary supportive care, patients with atypical pretentions of OPs poisoning underwent Atropine challenge test (1 mg intravenously) and demographic parameters, clinical presentations, and serum level of cholinesterase enzyme were compared between cases with positive and negative test results.

Results: 20 patients with the mean age of 47.60 ± 13.25 years were studied. The mean time since exposure and initial symptoms was 6.17 ± 2.99 hours. The most common clinical presentations were tachycardia (55%) and flushing (35%). The atropine challenge test was positive in 3 (15.00%) cases. The two groups were the same regarding gender distribution (p = 0.582), mean age (p = 0.957), clinical presentation (p > 0.05), and mean PR interval (p = 0.729). The level of cholinesterase was 220.00 ± 15.52 U/mL and 332.17 ± 143.99 U/mL in patients with positive and negative Atropine challenge test, respectively (p = 0.006).

Conclusion: Patients with positive Atropine challenge test had a significantly lower level of serum cholinesterase and response to Atropine in their therapeutic management. Hence, Atropine challenge test could be considered as a useful clinical test in the setting of acute OPs poising.

Incidental Findings of Computed Tomography Angiography in Patients Suspected to Pulmonary Embolism; a Brief Report

Mustafa Korkut, cihan bedel, Kürsat Erman, Serkan Yüksel

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e60

Introduction: Computed tomography pulmonary angiography (CTPA)  scans are increasingly used in emergency department (ED). Therefore, the observation of incidental findings (IFs) has also increased. This study aimed to evaluate the frequency of IFs in patients who underwent  CTPA.

Methods: All consecutive patients that underwent CTPA scanning for pulmonary embolism (PE) rule out between January  2017 and June  2018  were analysed. Incidental findings were divided into and reported in three categories: group 1 potentially life-threatening, group 2 required follow up, and group 3 with limited clinical significance.

Results: 151 cases with the mean age of  61.2 ± 17.6 years were studied (54.3% female). PE was documented in 77 cases (50.9%). 448 IFs were detected (3 IFs were found per patient). 60 (13.3%) IFs were classified as group 1, 180 (40.1%) as group 2, and 208 (46.6%) as group 3. Cardiomegaly was the most frequent finding in group 1 (n=32), followed by aortic aneurysm (n=13). In group 2, pleural effusion (n=58) and pneumonia (n=36) were the most frequent incidental findings. Lung structure changes (n=92) and thoracic bone related findings (n=43) were the most common IFs observed in group 3.

Conclusion: IFs were detected in the majority of patients that underwent CTPA. Most of these findings do not require follow-up or treatment. However, more than 50% of cases may require further diagnostic evaluation (40.1%) or immediate treatment (13.3%). 

Developing a Checklist for Cardiopulmonary Resuscitation (CPR) Quality Control in Emergency Department; a Qualitative Study

Mohammad Afzalimoghaddam, Ehsan Karimialavijeh, Gholamreza Zakipour, Hadi Mirfazaelian, Amir Nejati, Pooya Payandemehr

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e61

Introduction: Monitoring the quality of cardiopulmonary resuscitation (CPR) could help in achieving favorable outcomes, decreasing mortality, and preventing post-CPR neurologic sequels. This study aimed to generate a user-friendly checklist for CPR quality control in emergency department (ED).

Method: A qualitative study was performed between January and December 2018. In the first step, two emergency medicine specialists searched currently available databases and extracted the factors related to CPR quality. Afterward, two sessions of focus group discussions were held. The participants included four emergency medicine specialists, two ED managers, one anesthesiologist, and one cardiologist. Subsequently, 20 medical specialists, consisting of 10 emergency medicine specialists, six anesthesiologists, and four cardiologists, were invited to a Delphi panel in order to rate the extracted items from the prior group discussions.

Results: During the two rounds of focus group discussions, 38 items related to the quality of CPR were identified. A Delphi panel evaluated the items; 31 items with at least 75% agreement were selected. These 31 items were included in the final checklist and after a pilot study and adjustment of its content they were sorted in 10 categories as follows: 1. chest compression, 2. airway, 3. bag-mask ventilation, 4. cardiac monitoring, 5. defibrillation, 6. intravenous (IV) drug delivery, 7. Medications, 8. Advanced airway, 9. CPR sequence, and 10. Reversible causes.

Conclusion: Our study provides a checklist for monitoring the quality of CPR in ED, but it is still necessary to include other factors related to the ED environment on this checklist.

Case Report

Kikuchi-Fujimoto Disease in an Iranian Woman; a Rare but Important Cause of Lymphadenopathy

Mana Baziboroun, Masomeh Bayani, Ghodsieh Kamrani, Shahab Saeedi, Majid Sharbatdaran

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e3

Kikuchi-Fujimoto Disease (KFD), is a rare and self-limited condition of histiocytic necrotizing lymphadenitis, which typically presents as fever and lymphadenopathy. We describe a case of KFD in an Iranian woman. Due to low incidence and high importance, awareness of this disease is necessary for clinicians for early diagnosis and appropriate treatment. A 26-year-old woman was admitted to our hospital with a 3-week history of fever and lymphadenopathy. On physical examination, she had three separate enlarged lymph nodes on the right side of her neck. In laboratory tests that were carried out, she had mild anemia and an increase in C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR) and lactate dehydrogenase (LDH) level, while other tests were normal. Ultasound (U/S) guided core needle lymph node biopsy was performed and based on the histological finding, diagnosis of Kikuchi-Fujimoto disease was made. The patient was managed supportively and with prednisolone. She symptomatically improved and was discharged with no follow up. Although the incidence of KFD is rare, it must be considered as a differential diagnosis of lymphadenopathy especially in tuberculosis-endemic areas like our country-Iran. Moreover, it is necessary that physicians are aware of this disease in order to minimize unnecessary evaluation and toxic treatment.

Conservative Management of Asymptomatic Pneumoperitoneum; Report of Two Cases

Leila Alizadeh, Mahdieh Shakeri-Darzekonani, Amin Sadrazar, Masoud Nouri-Vaskeh, Sedigheh Basirjafari

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e12

Peptic ulcer disease is a common gastrointestinal disorder has been reduced in recent years due to effective new treatments. Peptic ulcer perforation is an emergent life-threatening condition causes pneumoperitoneum and septic shock. It often requires surgical procedures. We describe two cases of peptic ulcer perforation with only mild discomfort on the epigastric region since several months ago. The patients treated with high dose proton pump inhibitor and conservative actions without surgical procedures. Weekly follow up the cases showed that the clinical condition of patients remains stable without any new signs and symptoms. This report showed noninvasive treatment can be effective alone, in some cases with mild symptoms.

Stress Cardiomyopathy (Takotsubo syndrome) Following Accidental Methadone Poisoning; Report of Two Pediatric Cases

Khatereh Dehghani, Mohammad Shojaie, Amir Hossein Pourdavood, Mohammad Khajouei

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e22

Methadone poisoning has become more common in the pediatric population due to extensive use of methadone maintenance therapy (MMT). It is associated with decreased level of consciousness, coma, respiratory distress and cardiac intoxication. The cardiac complications have been reported to be QT prolongation, torsade de pointes, coronary artery disease, arrhythmia, stress cardiomyopathy and death. We herein report two pediatric patients with accidental methadone poisoning who developed stress cardiomyopathy and cardiac failure. The first case was a 4-yaer-old girl and the second one was an 18-month-old girl both being accidentally poisoned with methadone syrup and were brought with decreased level of consciousness. Both were diagnosed to suffer from congestive heart failure based on echocardiography. However, the first case passed away despite appropriate treatment, while the second one survived the condition and was discharged with good condition and was symptom free at 6-month follow-up.

Pulmonary Edema Following Intrathecal Fluorescein Injection; a Case Report

Faranak Behnaz, Masih Ebrahimy Dehkordy, Hamidreza Azizi Faresani, Mohammadreza Shahmohammadi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e18

Intrathecal Fluorescein has been used widely for detection of cerebrospinal fluid (CSF) leakage. After administration of fluorescein many serious complications may happen. Pulmonary edema is one of the most serious complications that require emergency responses. In this study, we report a complicated case of pulmonary edema following Intrathecal fluorescein injection.

Hepatic Artery Aneurysms as a Rare but Important Cause of Abdominal Pain; a Case Series

Hamidreza Haghighatkhah, Morteza Sanei Taheri, Seyed Mohammadhadi Kharazi, Maryam Zamini, Sahar Rabani Khorasgani, Zahra Jahangiri Zarkani

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e25

Hepatic artery aneurysm (HAA) is the common visceral aneurysms with the highest reported rate of rupture. The clinical manifestations depending on the size of the aneurysm include epigastric pain, obstruction of biliary tract, rupture and death. Imaging modalities like computed tomography (CT) scan and CT-angiography have a valuable role in the early detection of HHAs. Complications and selecting appropriate treatments depending on the size and location of the aneurysms. This article aimed to report clinical presentation, imaging finding and treatment of some patients presenting with HAAs to emergency department.

Caffeine Intoxication in Pregnancy: Report of a case

Tsuyoshi Nojima, Hiromichi Naito, Yoshinori Kosaki, Takaaki Osako, Kimiaki Tanaka, Atsuo Murata, Atsunori Nakao

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e67

Although fatalities due to caffeine intoxication are uncommon,a caffeine overdose may cause profound toxicity, resulting in tachycardia, arrhythmia, convulsions, vomiting, coma, and possibly death. In particular, high caffeine consumption while pregnant can cause increased fetal catecholamine levels, which could lead to increased fetal heart rate and placental vasoconstriction and impair fetal oxygenation. Therefore, caffeine intoxication in pregnant women should be treated immediately. Herein, we present a 33-year-old pregnant woman who was treated in our department afteringesting 4000mg of caffeine in an attempt to commit suicide. We successfully treated our patient, and she delivered a healthy baby at 38 weeks.


Inhalational Toxicity of Aluminum Phosphide as an Ongoing Concern; a Report of Two Cases

Azam Shafahi, Babak Mostafazadeh, Bita Dadpour

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e69

Acute aluminium phosphide (ALP) poisoning is an extremely lethal poisoning. Ingestion is usually suicidal in intent, uncommonly accidental and rarely homicidal. Unfortunately, the absence of a specific antidote results in very high mortality and the key to successful treatment is in rapid decontamination and institution of resuscitative measures.

Phosphine gas is highly toxic, and fatality is expected even several hours after continuous exposure.  However, intensive supportive treatments may be lifesaving in some cases. Here, two cases of accidental inhalation intoxication with ALP are reported. One patient was discharged and another suffered cardiac arrest during treatment.

Photo Quiz

A 92-Year-Old Man with Abdominal Pain Following Intractable Vomiting; a Photo Quiz

Chin-Chu Wu, Aming Chor-Ming Lin

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e42

A 92-year-old man with hypertension, chronic obstructive pulmonary disease (COPD), peptic ulcer disease and dementia presented to the emergency department with a 2-day history of abdominal pain in the left upper quadrant, distention, dry cough and intractable vomiting. On physical examination, the patient had epigastric tenderness and bowel sounds were reduced.


Tissue hypoxia is a key factor for cell death after acute myocardial infarction (MI). It seems that increase in the relative oxygen pressure in inhaled air can be an effective treatment option for treating acute MI. However, contradicting findings and results have been published regarding using oxygen therapy in patients with acute MI (1, 2). Some researchers have believed that generation of free radicals, induction of oxidative stress, and damage to cell membrane are among side effects of O2 consumption (3, 4). It has been shown that O2 therapy can increase microvascular resistance, result in a decrease in coronary blood flow and cardiac output, and bring about numerous negative effects such as increase in the risk of arrhythmia and cellular damage (4).

With great interest we have read the paper “Pregnancy Screening before Diagnostic Radiography in Emergency Department; an Educational Review†by A.I. Abushouk et al. (1). We agree with the authors that unnecessary fetal radiation exposure should be avoided and that pregnancy screening can be a means to accomplish this. However, in their paper the authors suggest in several instances that radiological imaging during pregnancy can lead to teratogenic effects. In the Abstract it is stated: “Radiation exposure during pregnancy may have serious teratogenic effects to the fetus. Therefore, checking the pregnancy status before imaging women of child bearing age can protect against these effects.â€, and in the Introduction: “Therefore, checking the pregnancy status before imaging women of child bearing age can protect against radiation teratogenic effects.â€

The Rate of Catheter-Related Infections using Metal Coated Central Venous Catheters; a Letter to Editor

Seyed Hossein Ardehali, Mona Jahangirian, Alireza Fatemi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e33

Blood infections due to intravenous catheters make up about 10\% -- 15\% of hospital infections (1). In 2009, Centers for Disease Control and Prevention (CDC) reported the rate of blood infections related with using central venous catheter in the intensive care unit (ICU) to be 1.65 in 1000 catheters per day (2). Mortality due to infections related to central venous catheters has been reported to be between 12\% and 25\% in different studies. These infections have increased the duration of hospitalization by 12 days (3, 4). Different approaches have been proposed for reducing these infections, among these approaches using aseptic methods, preventive antibiotics, disposable tools, and training the staff can be pointed out (5-7). Among the methods considered in this regard is using catheters coated with antiseptic agents, antibiotics, and metals such as silver and platinum (8). Some studies have suggested using these methods for reducing the mentioned infections and their consequences; however, their use is not currently agreed upon and their effect on reducing the infections caused by intravenous tools is still being studied.

The Role of Foley Catheter Coated with Gold, Silver, and Palladium in Decreasing Urinary Tract Infections in the Intensive Care Unit; a Letter to Editor

Seyed Hossein Ardehali, Maryam Sedaghatmanesh, Alireza Fatemi

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e40

Urinary tract infections (UTIs) are among the most common hospital-acquired infections, which are caused by urinary catheterization in most cases (1, 2). These infections, like other hospital-acquired infections, elongate the duration of hospitalization and can act as a depot for antibiotic-resistant bacteria. For each day that the catheter remains in the urinary tract, the probability of UTI increases by 3% to 7% (3). In 2011, the Centers for Disease Control and Prevention (CDC) reported the rate of catheter-related UTI in the intensive care unit (ICU) as 1.2 to 4.5 cases per 1000 catheters per day and the mortality rate related to these infections has been estimated to be about 15% (4).

Compression Test for Diagnosis of Phalangeal Fracture; a Letter to Editor

Naser Mohamad Karimi, Faeze Zeinali.N

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e51

Physical examination is the most important procedure for examining traumatized patients and ruling out possible bone fractures. Edema, deformity, ecchymosis, tenderness on trauma location, and limited bone movement are among the signs of fracture. The diagnosis is documented by plain radiography. The number of false positive cases in this test increase in the presence of soft tissue injury along with bone damage.

In this case, a great number of X-rays will be taken daily and many patients will be exposed to radiation, unnecessarily (1). The question to be fully answered is whether all cases of trauma and pain require radiographs or not?

A Polyvinyl Chloride Eraser as a Surface Marker for Computed Tomography in Emergency Imaging; a Letter to Editor

Yuya Murakami, Taihei Yamada, Hiromichi Naito

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e54

In the wake of recent progress in computed tomography (CT) enabling to obtain high quality images within five minutes, CT scan has been widely used in emergency diagnostic radiology and is considered best suited for detection of pathologies, as well as assessing the location and extent of lesions in the emergency department.

Emergency physicians often require confirmation of surface bruises or wounds coexisting with pathology on CT scan. Alternatively, they may want to confirm the presence or absence of pathology in the painful lesion. The use of an appropriate surface marker on the skin surface of the painful lesion may enable them to identify areas of interest and safely reduce radiation exposure.

Screening of Trauma Patients in Need of Knee Radiography by Triage Nurses and Using Ottawa Knee Rule; a Letter to Editor

Samad Shams Vahdati, Alireza Ala, Zhila Samani, Sasan Ghazanfar Ahari, Mohammad Mirza-Aghazadeh-Attari

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e57

In some clinical guidelines, emergency triage nurses request radiographies according to the clinical decision-making priorities. While some studies have suggested that nurses are not as accurate as doctors in assessing major complications of trauma to the knee, it is thought that they are as capable in detecting minor traumas and inconsequential episodes (1). Many studies have shown that the cost of treatment and the waiting period for patients in the emergency department decrease without missing fractures when traumas are initially assessed by a certified nurse. Routinely, a clinical criteria termed Ottawa Knee Rule is utilized to determine if a patient is in need of a knee radiography or not (2, 3). According to this guideline, if a patient with suspected knee trauma meets any of the following criteria, he or she should undergo imaging modalities: Age above 55 years, tenderness at head of fibula, isolated tenderness of patella, inability to flex the knee more than 90°, and inability to bear weight (4).

The Value of Ultrasonography in determining Pupillary Light Reflex in Patients with Traumatic Ocular Injuries; a Letter to Editor

Hamid Mirjalili, Ali Raee Ezzabadi, Yeganeh Yazdiyousefi, Mohammad Ali Jafari Nadoshan

Archives of Academic Emergency Medicine, Vol. 7 No. 1 (2019), 11 November 2018 , Page e62

Pupillary light reflex (PLR) measurement is one of the frequent physical examinations used by emergency physicians for assessment of brain stem function and monitoring of intracranial pressure (1, 2). PLR could be abnormal due to various causes such as optic nerve damage, oculomotor nerve damage, brain stem lesion, and using central nervous system depressant drugs, such as barbiturates.