Original/Research Article

Effect of Positive End-Expiratory Pressure on Central Venous Pressure in Patients under Mechanical Ventilation

Majid Shojaee, Anita Sabzghabaei, Hossein Alimohammadi, Hojjat Derakhshanfar, Afshin Amini, Bahareh Esmailzadeh

EMERGENCY , Vol. 5 No. 1 (2017), , Page e1

Introduction: Finding the probable governing pattern of PEEP and CVP changes is an area of interest for in-charge physicians and researchers. Therefore, the present study was designed with the aim of evaluating the relationship between the mentioned pressures. Methods: In this quasi-experimental study, patients under mechanical ventilation were evaluated with the aim of assessing the effect of PEEP change on CVP. Non-trauma patients, over 18 years of age, who were under mechanical ventilation and had stable hemodynamics, with inserted CV line were entered. After gathering demographic data, patients underwent 0, 5, and 10 cmH2O PEEPs and the respective CVPs of the mentioned points were recorded. The relationship of CVP and PEEP in different cut points were measured using SPSS 21.0 statistical software. Results: 60 patients with the mean age of 73.95 ± 11.58 years were evaluated (68.3% male). The most frequent cause of ICU admission was sepsis with 45.0%. 5 cmH2O increase in PEEP led to 2.47 ± 1.53 mean difference in CVP level. If the PEEP baseline is 0 at the time of 5 cmH2O increase, it leads to a higher raise in CVP compared to when the baseline is 5 cmH2O (2.47 ± 1.53 vs. 1.57 ± 1.07; p = 0.039). The relationship between CVP and 5 cmH2O (p = 0.279), and 10 cmH2O (p = 0.292) PEEP changes were not dependent on the baseline level of CVP. Conclusion: The findings of this study revealed the direct relationship between PEEP and CVP. Approximately, a 5 cmH2O increase in PEEP will be associated with about 2.5 cmH2O raise in CVP. When applying a 5 cmH2O PEEP increase, if the baseline PEEP is 0, it leads to a significantly higher raise in CVP compared to when it is 5 cmH2O (2.5 vs. 1.6). It seems that sex, history of cardiac failure, baseline CVP level, and hypertension do not have a significant effect in this regard.

Ketorolac versus Magnesium Sulfate in Migraine Headache Pain Management; a Preliminary Study

Hossein Delavar Kasmaei, Marzieh Amiri, Ahmed Negida, Samaneh Hajimollarabi, Nastaransadat Mahdavi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e2

Introduction: Migraine is a common cause of emergency department (ED) visits. To date, there is no recommended drug of choice for pain management of these patients. In the present study, we aimed to evaluate the effectiveness of ketorolac and magnesium sulfate in this regard. Methods: This is a cross-sectional study performed on all 18 - 60 year-old patients, visiting two different EDs with complaint of moderate to severe migraine headache. Patients were treated with 30 mg ketorolac in one hospital and 1 gram magnesium sulfate in the other. Pain scores were assessed on arrival, 1 and 2 hours after drugs administration and quality of pain management was compared between two groups using SPSS 22. Results: 70 patients with the mean age of 36.4 ± 11.4 years were enrolled (51.4% male). The two groups were similar regarding baseline characteristics (p > 0.05). The improvement in pain score in magnesium sulfate group was greater than Ketorolac group after both one hour (6 vs 3; p < 0.001) and two hours (7 vs 5; p < 0.001). Conclusion: It seems that both ketorolac and magnesium sulfate are significantly effective in pain control of patients with migraine headache presenting to the emergency department. Magnesium sulfate was superior to ketorolac both one and two hours after drug administration.

Epidemiology and Related Risk Factors of Preterm Labor as an Obstetrics Emergency

Ali Asghar Halimi Asl, Saeed Safari, Mohsen Parvareshi Hamrah

EMERGENCY , Vol. 5 No. 1 (2017), , Page e3

Introduction: Preterm birth is still a major health problem throughout the world, which results in 75% of neonatal mortality. Preterm labor not only inflicts financial and emotional distress, it may also lead to permanent disability. The present study was conducted to determine the related risk factors and preventive measures of preterm labor.

Methods: This retrospective cross-sectional study assessed all preterm labors, as well as an equal number of term labors, during seven years, at an educational hospital. Probable risk factors of preterm labor were collected using medical profiles of participants by the aid of a pre-designed checklist. Significant related factors of preterm labor were used for multivariate logistic regression analysis with SPSS 21.0.

Result: 810 cases with the mean age of 28.33 ± 6.1 years were evaluated (48.7% preterm). Multipartite; fetal anomaly; prenatal care; smoking; not consuming folic acid and iron supplements; in vitro fertilization; history of infertility, caesarian section, trauma,  systemic disease, and hypertension; amniotic fluid leak; rupture of membranes; cephalic presentation; vaginal bleeding; placenta decolman; oligohydramnios; pre-eclampsia; chorioamnionitis; uterine abnormalities; cervical insufficiency; intercourse during the previous week; short time since last delivery; and mother’s weight significantly correlated with preterm labor.

Conclusion: Based on the results of the present study, intercourse during the previous week, multipartite, short time from last delivery, preeclampsia, fetal anomaly, rupture of membranes, hypertension, and amniotic fluid leak, respectively, were risk factors for preterm labor. On the other hand, iron consumption, cephalic presentation, systematic disease, history of caesarian section, prenatal care, and mother’s weight could be considered as protective factors.

Comparison of APACHE II and SAPS II Scoring Systems in Prediction of Critically ill Patients’ Outcome

Hamed Aminiahidashti, Farzad Bozorgi, Seyyed Hosein Montazer, Majid Baboli, Abolfazl Firouzian

EMERGENCY , Vol. 5 No. 1 (2017), , Page e4

Introduction: Using physiologic scoring systems for identifying high-risk patients for mortality has been considered recently. This study was designed to evaluate the values of Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiologic Score (SAPS II) models in prediction of 1-month mortality of critically ill patients.

Methods: The present prospective cross sectional study was performed on critically ill patients presented to emergency department during 6 months. Data required for calculation of the scores were gathered and performance of the models in prediction of 1-month mortality were assessed using STATA software 11.0.

Results: 82 critically ill patients with the mean age of 53.45 ± 20.37 years were included (65.9% male). Their mortality rate was 48%. Mean SAPS II (p < 0.0001) and APACHE II (p = 0.0007) scores were significantly higher in dead patients. Area under the ROC curve of SAPS II and APACHE II for prediction of mortality were 0.75 (95% CI: 0.64 - 0.86) and 0.72 (95% CI: 0.60 - 0.83), respectively (p = 0.24). The slope and intercept of SAPS II were 1.02 and 0.04, respectively. In addition, these values were 0.92 and 0.09 for APACHE II, respectively.

Conclusion: The findings of the present study showed that APACHE II and SAPS II had similar value in predicting 1-month mortality of patients. Discriminatory powers of the mentioned models were acceptable but their calibration had some amount of lack of fit, which reveals that APACHE II and SAPS II are partially perfect.

20-Day Trend of Serum Potassium Changes in Bam Earthquake Victims with Crush Syndrome; a Cross-sectional Study

Saeed Safari, Iraj Najafi, Mostafa Hosseini, Alireza Baratloo, Mahmoud Yousefifard, Hamidreza Mohammadi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e5

Introduction: Many of those who survive following an earthquake die in the next phase due to preventable and treatable medical conditions such as hyperkalemia. The present study aimed to evaluate the trend of potassium changes in crush syndrome patients of Bam earthquake. Methods: In this retrospective cross-sectional study, using the database of Bam earthquake victims, which were developed by Iranian Society of Nephrology following Bam earthquake, Iran, 2003, the 20-day trend of potassium changes in > 15 years old crush syndrome patients was evaluated. Results: 135 crush syndrome patients with the mean age of 29.9 ± 9.91 years were evaluated (56.3% male). Mean potassium concentration during the first 3 days of admission was 5.6 ± 1.3 mEq/L. On the day of admission, 43.1% (95% CI: 34.0 - 52.2) had normal potassium concentration, 3.4% (95% CI: 0.1 - 6.8) had hypokalemia, and 53.4% (44.3 - 62.6) had hyperkalemia. During 20-day follow-up, 62.3% (95% CI: 66.7-71.9) of the patients had normal potassium. While, 11.5% (95% CI: 9.7-13.3) had hypokalemia and 19.2% (95% CI: 17.0-21.5) had hyperkalemia. As the days of hospitalization increased, prevalence of hyperkalemia decreased while hypokalemia increased. On the 17th day 21.2% (95% CI: 2.2-39.9) had hypokalemia and 10.5% (95% CI: 0.1 – 24.7) had hyperkalemia. Conclusion: Findings of the present study showed that following urine alkalinization and fluid resuscitation, the prevalence of hyperkalemia reduced, but hypokalemia developed. It seems that the correction of serum potassium level should be accompanied by precise monitoring of intake and output of the patient and prescription of reasonable amount of intravenous fluid.

Introduction: In addition to the annual mortality rate, unintentional home injury may result in temporary or
permanent disability and requires medical attention and continuous care in millions of children. This study
aimed to explore features and risk factors of these injuries. Methods: In this cross-sectional study, demographic
variables and epidemiologic pattern of home injuries among children under 5 years of age were collected via a
population-based survey in sevenmain cities of Khuzestan province, southwest Iran, during September 2011 to
December 2012. Developing a risk stratification model, independent risk factors of unintentional home injury
were determined and put to multivariate logistic regression analysis. Results: 2693 children with the mean age
of 27.36 § 15.55 months (1 to 60) were evaluated (50.9% boy). 827 (30.7%) cases had a history of at least one
home injury occurrence since birth to study time. The most common injury mechanisms were burning with 291
(38.4%) cases, falling with 214 (28.3%) and poisoning with 66 (8.7%) cases, respectively. The independent risk
factors of unintentional home injury were age ¸ 24 month (p<0.001), residency in Ahvaz city (p<0.001), mother’s
illiteracy (p<0.014), ethnicity (p<0.001), private housing (p=0.01), birthweight (p<0.001), and being the first child
(p=0. 01). Sensitivity, specificity, and area under the ROC curve of the model designed by multivariate analysis
were 53.5%, 84.8%, and 0.75 (95% CI: 0.73- 0.77; P < 0.001, figure 1), respectively. Conclusion: According to
the findings of this study, 30.7% of the studied children were injured at least once since birth. Burning, falling,
poisoning, swallowing objects, choking, and biting were the main home injury mechanisms. Age ¸ 24 months,
being the first child, living in a private house, being a resident of Ahvaz city, and having an illiterate mother were
found to be risk factors of home injury.

Trends of Serum Electrolyte Changes in Crush syndrome patients of Bam Earthquake; a Cross sectional Study

Saeed Safari, Mehdi Eshaghzade, Iraj Najafi, Alireza Baratloo, Behrooz Hashemi, Mohammad Mehdi Forouzanfar, Farhad Rahmati

EMERGENCY , Vol. 5 No. 1 (2017), , Page e7

Introduction: Electrolyte imbalances are very common among crushed earthquake victims but there is not
enough data regarding their trend of changes. The present study was designed to evaluate the trend of changes
in sodium, calcium, and phosphorus ions among crush syndrome patients. Methods: In this retrospective
cross-sectional study, using the database of Bam earthquake victims, which was developed by Iranian Society of
Nephrology following Bam earthquake, Iran, 2003, the 10-day trend of sodium, calcium, and phosphorus ions
changes in > 15 years old crush syndrome patients was evaluated. Results: 118 patients with the mean age of
25.6 § 6.9 yearswere studied (57.3 male). On the first day of admission, 52.5% (95% CI: 42.7 - 62.3) of the patients
had hyponatremia, which reached 43.9% (95% CI: 28.5 - 59.3) on day 10. 100.0% of patients were hypocalcemic
on admission and serum calcium level did not change dramatically during the 10 days of hospitalization. The
prevalence of hyperphosphatemia on the first day was 90.5% (95% CI: 81.5 - 99.5) and on the 10th day of hospitalization
66.7% (95% CI: 48.5 - 84.8) of the patients were still affected. Conclusion: The results of the present
study shows the 52.5%prevalence of hyponatremia, 100% hypocalcemia, and 90.5% hyperphosphatemia among
crush syndrome patients of Bam earthquake victims on the first day of admission. Evaluation of 10-day trend
shows a slow decreasing pattern of these imbalances as after 10 days, 43.9% still remain hyponatremic, 92.3%
hypocalcemic, and 66.7% hypophosphatemic.

Introduction: Designing a tool that can differentiate those at risk of child abuse with great diagnostic accuracy
is of great interest. The present study was designed to evaluate the diagnostic accuracy of Escape instrument
in triage of at risk cases of child abuse presenting to emergency department (ED). Methods: The present diagnostic
accuracy study performed on 6120 of the children under 16 years old presented to ED during 3 years,
using convenience sampling. Confirmation by the child abuse team (pediatrician, a socialworker, and a forensic
physician) was considered as the gold standard. Screening performance characteristics of Escape were calculated
using STATA 21. Results: 6120 children with the mean age of 2.19 § 1.12 years were screened (52.7% girls).
137 children were suspected victims of child abuse. Based on child abuse team opinion, 35 (0.5%) children were
confirmed victims of child abuse. Sensitivity, specificity, positive and negative likelihood ratio and positive and
negative predictive values of this test with 95% CI were 100 (87.6 – 100), 98.3 (97.9 – 98.6), 25.5 (18.6 – 33.8), 100
(99.9 – 100), 0.34 (0.25 – 0.46), and 0 (0 – NAN), respectively. Area under the ROC curve was 99.2 (98.9 – 99.4).
Conclusion: It seems that Escape is a suitable screening instrument for detection of at risk cases of child abuse
presenting to ED. Based on the results of the present study, the accuracy of this screening tool is 99.2%, which is
in the excellent range.

The Relation of Q Angle and Anthropometric Measures with Ankle Sprain; a Case-control study

Hamid Zamani Moghadam, Seyed Taha Hoseini, Amir Masoud Hashemian, Mohammad Davood Sharif

EMERGENCY , Vol. 5 No. 1 (2017), , Page e9

Introduction: Since most studies on ankle sprain are medical and sports-related and not much epidemiologic and etiologic data from the general population exist in this field, the present study evaluates the relationship between Q angle and anthropometric measures with ankle sprain in the general population.

Methods: In the present case-control study, all of the patients over 18 years age presenting to emergency departments (ED) of two educational Hospitals, complaining from ankle sprain, were evaluated during more than 1 year. A checklist consisting of demographic data, height, weight, body mass index (BMI), and history of ankle sprain, as well as degree of Q angle was filled for all participants. The correlation of mentioned variables with incidence of ankle sprain was calculated using SPSS 22.

Results: 300 patients with ankle sprain were evaluated (53.5% male). Mean age of the patients was 37.03 ± 14.20 years. Mean weight, height, and BMI were 71.71 ± 11.26 (43 – 114), 168.74 ± 8.63 (143 – 190) and 25.14 ± 3.19 (18.41 – 38.95), respectively. Mean Q angle of the patients was 12.78 ± 3.19 degrees (5 – 23). There was a significant correlation between weight (p < 0.001), BMI (p = 0.001), history of sprain (r: 0.26, p < 0.001) and Q angle (p = 0.002) with incidence of ankle sprain. In addition, there was a significant statistical correlation between weight (p = 0.031), BMI (p = 0.020) and Q angle (p = 0.004) with history of ankle sprain. In patients with a history of ankle sprain, Q angle was wider by about 2 degrees.

Conclusion: It seems that the prevalence of ankle sprain directly correlates with high weight, BMI, and Q angle and is more prevalent in those with a history of sprain. Although the findings of the present study show a statistically significant correlation between these factors and ankle sprain, the correlation is not clinically significant.

Introduction: Globally, it is estimated that around 5.8 million people die annually as result of injuries, which causes 10% of all deaths and 16% of disability adjusted life years lost worldwide. This study aimed to determine the epidemiology of injuries in emergency departments in Iran.

Method: This cross sectional study was carried out using national injury surveillance data registry from 21 March 2009 to 20 March 2014.

Results: 7,176,344 patients with the mean age of 27.5 ± 17.8 years were registered to 657 EDs (70.6% male). Road Traffic Crash (RTC) was the most common cause of injury (31.0%) followed by hit (28.2%) and fall (10.1%). While roads were the commonest place of injuries, 34.0% of patients have been injured at home. More than 90% of injuries were unintentional. Assault and suicide attempt were causes of injury in 5.6% and 3.9% of patients, respectively.


This paper addresses where prevention measures are most urgently needed and offers insights which could be useful for injury prevention programs in Iran and other developing countries.

Introduction: Acute coronary syndrome accounts for more than 15% of the chest pains. Recently, Hess et al. developed North American Chest Pain Rule (NACPR) to identify very low-risk patients who can be safely discharged from emergency department (ED). The present study aimed to validate this rule in EDs of two academic hospitals.

Methods: A prospective diagnostic accuracy study was conducted on consecutive patients 24 years of age and older presenting to the ED with the chief complaint of acute chest pain, during March 2013 to June 2013. Chest pain characteristics, cardiac history, electrocardiogram findings, and cardiac biomarker measurement of patients were collected and screening performance characteristics of NACPR with 95% confidence interval were calculated using SPSS 21.

Results: From 400 eligible patients with completed follow up, 69 (17.25 %) developed myocardial infarction, 121 (30.25%) underwent coronary revascularization, and 4 (2%) died because of cardiac or unidentifiable causes. By using NACPR, 34 (8.50%) of all the patients could be considered very low- risk and discharged after a brief ED assessment. Among these patients, none developed above-mentioned adverse outcomes within 30 days. Sensitivity, specificity, positive prediction value, and negative prediction value of the rule were 100% (95% CI: 87.35 - 100.00), 45.35 (95% CI: 40.19 - 50.61), 14.52 (95% CI: 10.40 – 19.85), and 100 (95% CI: 97.18 - 100.00), respectively.

Conclusions: The present multicenter study showed that NACPR is a good screening tool for early discharge of patients with very low-risk chest pain from ED.

Introduction: Pain is the most common complaint of patients referring to emergency department (ED). Considering
the importance of pain management in ED, this study aimed to investigate the efficacy and feasibility of
ultrasound-guided nerve blocks in this setting. Methods: 46 patients who came to the ED with injured extremities
were enrolled in the study and received either femoral, axillary or sciatic nerve block depending on their
site of injury (1.5 mg Bupivacaine per kg of patient’s weight). Patients were asked about their level of pain before
and after receiving the nerve block based on numerical rating scale. The difference between pre and post block
pain severity was measured. Both patients and physicians were asked about their satisfaction with the nerve
block in 5 tiered Likert scale. Results: 46 patients with the mean age of 37.5 § 12.5 years (8-82 years) received
ultrasound-guided nerve block (84.8% male). 6 Sciatic, 25 axillary, and 15 femoral nerve blocks were performed.
Mean pain severity on NRS score at the time of admission was 8.1 § 1.4, which reduced to 2.04 § 2.06 after block.
25 (54.3%) patients were highly satisfied (Likert scale 5), 15 (32.6%) were satisfied (Likert scale 4), 3 (6.5%) were
neutral and had no opinion (Likert scale 3), 1 (2.1%) was not satisfied (Likert scale 2), and 2 (4.3%) were highly
unsatisfied (Likert scale 1). There was no significant difference among the satisfaction scores within the three
block locations (p = 0.8). There was no significant difference in physicians level of satisfaction between the three
block locations either (p = 0.9). 1 (2.1%) case of agitation and tachycardia and 1 (2.1%) case of vomiting were
observed after the procedure. Conclusion: Ultrasound-guided nerve block of extremities is a safe and effective
method that can be used for pain management in the ED. It results in high levels of satisfaction among both
patients and physicians.

Introduction: Deep vein thrombosis (DVT) is a major cause of morbidity and mortality in intensive care unit (ICU) patients despite use of prophylactic anticoagulant therapy. The aim of the present study was to determine the incidence of DVT among medical and surgical ICU patients.

Methods: In this cross sectional study, patients older than 18 years who were hospitalized in the ICU of Imam Hossein educational Hospital, Tehran, Iran, for ≥ 2 days, during August 2008 to July 2011 were evaluated regarding DVT incidence. Demographic data, comorbidities, acute physiology and chronic health evaluation (APACHE) II scores, ICU length of stay, type of DVT prophylaxis, and patient outcomes were analyzed using SPSS 19.

Results: Out of the 1387 reviewed patient files, 500 (36.04%) patients had been classified as potential DVT cases. DVT occurred in 3.5% of them with the mean age of 60 ± 18 years (62.5% male) and mortality rate of 27.1%. Significant independent risk factors of DVT incidence were age (p = 0.02) and length of ICU stay (p = 0.01).

Conclusion: The results of this study showed the 3.5% incidence of DVT in ICU admitted patients. Longer ICU stay and older age were independent risk factors of DVT development.

Smartphones and Medical Apps in the Practice of Emergency Medicine in Iran

Amirhosein Jahanshir, Ehsan Karimialavijeh, Hojjat Sheikh Motahar Vahedi, Mehdi Momeni

EMERGENCY , Vol. 5 No. 1 (2017), , Page e14

Introduction: Medical applications help physicians to make more rapid and evidence based decisions that may provide better patient care. This study aimed to determine the extent to which smart phones and medical applications are integrated in the emergency department daily practice.

Method: In a cross sectional study, a modified standard questionnaire (Payne et al.) consisting of demographic data and information regarding quality and quantity of smartphone and medical app utilization was sent to emergency-medicine residents and interns twice (two weeks apart), in January 2015. The questionnaire was put online using open access "Web-form Module" and the address of the web page was e-mailed along with a cover letter explaining the survey. Finally, responses were analyzed using descriptive statistics and SPSS 22 software.

Results: 65 cases participated (response rate 86%). The mean age of interns and residents were 25.03 ± 1.13 and 30.27 ± 4.68 years, respectively (p < 0.001). There was no significant difference between interns and residents in owning a smartphone (p = 0.5). Android was more popular than IOS (67.7% against 25.8%) and the most popular medical apps were Medscape and UpToDate, respectively. 38 (61.3%) of the respondents were using their apps more than once a day and mostly for drug information. English (83.9%), Persian (12.9%), and other languages (3.2%) were preferred languages for designing a medical software among the participants, respectively.

Conclusion: The findings of present study showed that smartphones are very popular among Iranian interns and residents in emergency department and a substantial number of them own a smartphone and are using medical apps regularly in their clinical practice. 

Ability of Ultrasonography in Detection of Different Extremity Bone Fractures; a Case Series Study

Farzad Bozorgi, Massoud Shayesteh Azar, Seyed Hossein Montazer, Aroona Chabra, Seyed Farshad Heidari, Alireza Khalilian

EMERGENCY , Vol. 5 No. 1 (2017), , Page e15

Introduction: Despite radiography being the gold standard in evaluation of orthopedic injuries, using bedside
ultrasonography has several potential supremacies such as avoiding exposure to ionizing radiation, availability
in pre-hospital settings, being extensively accessible, and ability to be used on the bedside. The aim of the
present study is to evaluate the diagnostic accuracy of ultrasonography in detection of extremity bone fractures.
Methods: This study is a case series study, which was prospectively conducted on multiple blunt trauma patients,
who were 18 years old or older, had stable hemodynamic, Glasgow coma scale 15, and signs or symptoms
of a possible extremity bone fracture. After initial assessment, ultrasonography of suspected bones was performed
by a trained emergency medicine resident and prevalence of true positive and false negative findings
were calculated compared to plain radiology. Results: 108 patients with the mean age of 44.6 § 20.4 years were
studied (67.6% male). Analysis was done on 158 sites of fracture, which were confirmed with plain radiography.
91 (57.6%) cases were suspected to have upper extremity fracture(s) and 67 (42.4%) to have lower ones.
The most frequent site of injuries were forearm (36.7%) in upper limbs and leg (27.8%) in lower limbs. Prevalence
of true positive and false negative cases for fractures detected by ultrasonography were 59 (64.8%) and 32
(35.52%) for upper and 49 (73.1%) and 18 (26.9%) for lower extremities, respectively. In addition, prevalence of
true positive and false negative detected cases for intra-articular fractures were 24 (48%) and 26 (52%), respectively.
Conclusion: The present study shows the moderate sensitivity (68.3%) of ultrasonography in detection
of different extremity bone fractures. Ultrasonography showed the best sensitivity in detection of femur (100%)
and humerus (76.2%) fractures, respectively. It had low sensitivity in detection of in intra-articular fractures.

Introduction: Although significant development in the field of medicine is achieved, sepsis is still a major issue threatening humans’ lives. This study was aimed to audit the management of severe sepsis and septic shock patients in emergency department (ED) according to the present standard guidelines.

Method: This is a prospective audit on approaching adult septic patients who were admitted to ED. The audit checklist was created based on the protocols of Surviving Sepsis Campaign and British Royal College recommendations. The mean knowledge score and the compliance rate of studied measures regarding standard protocols were calculated using SPSS version 21.

Results: 30 emergency medicine residents were audited (63.3% male). The mean knowledge score of studied residents regarding standard guidelines were 5.07 ± 1.78 (IQR = 2) in pre education and 8.17 ± 1.31 (IQR = 85) in post education phase (p < 0.001). There was excellent compliance with standard in 4 (22%) studied measures, good in 2 (11%), fair in 1 (6%), weak in 2 (11%), and poor in 9 (50%). 64% of poor compliance measures correlated to therapeutic factors. After training, score of 5 measures including checking vital signs in < 20 minute, central vein pressure measurement in < 1 hour, blood culture request, administration of vasopressor agents, and high flow O2 therapy were improved clinically, but not statistically.

Conclusion: The protocol adherence in management of severe sepsis and septic shock for urine output measurement, central venous pressure monitoring, administration of inotrope agents, blood transfusion, intravenous antibiotic and hydration therapy, and high flow O2 delivery were disappointingly low. It seems training workshops and implementation of Clinical audit can improve residents’ adherence to current standard guidelines regarding severe sepsis and septic shock.

The Prevalence of Personality Disorders among Emergency Nurses Based on MMPI-2 Questionnaire; a Cross-sectional Study

Parvin Kashani, Sahar Mirbaha, Mohammad Mehdi Forouzanfar, Farahnaz Meschi, Alireza Baratloo

EMERGENCY , Vol. 5 No. 1 (2017), , Page e17

Introduction: The prevalence of behavioral disorders is substantially higher in stressful working environments such as emergency departments. The present study aimed to evaluate the prevalence of personality disorders among emergency nurses.

Methods: In the present epidemiologic study, the prevalence of personality disorders among emergency nurses of three educational hospitals, Tehran, Iran, were evaluated based on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) test. After the questionnaires were filled, data were entered to a special software for MMPI-2 test and the final result was interpreted based on the opinion of a clinical psychologist. Findings were reported using descriptive statistics.

Results: 102 emergency nurses with the mean age of 30.2 ± 5.6 years were enrolled (100% female; 100% with master’s degree in nursing). The mean working time and experience of studied nurses were 210.8 ± 47.9 hours/month (130-370) and 4.1 ± 3.6 years (1-20), respectively. 32 (31.4%) cases showed symptoms of personality disorders The most common personality disorder detected in this study was somatization with 8.8%, hysteria with 6.9% prevalence, and pollyannaish with 4.9%. Among the studied factors only recent history of unpleasant event has significant correlation with existence of personality disorders (p = 0.015).

Conclusion: The present study showed that somatization, hysteria, and pollyannaish were the most common personality disorders among the emergency nurses. History of an unpleasant event in the past year was the only effective factor in existence of personality disorders in the studied nurses.

Introduction: In cases with potential diagnosis of ischemic chest pain, screening high risk patients for adverse outcomes would be very helpful. The present study was designed aiming to determine the diagnostic accuracy of thrombolysis in myocardial infarction (TIMI) score in Patients with potential diagnosis of ischemic chest pain.

Method: This diagnostic accuracy study was designed to evaluate the screening performance characteristics of TIMI score in predicting 30-day outcomes of mortality, myocardial infarction (MI), and need for revascularization in patients presenting to ED with complaint of typical chest pain and diagnosis of unstable angina or Non-ST elevation MI.

Results: 901 patients with the mean age of 58.17 ± 15.00 years (19-90) were studied (52.9% male). Mean TIMI score of the studied patients was 0.97 ± 0.93 (0-5) and the highest frequency of the score belonged to 0 to 2 with 37.2%, 35.3%, and 21.4%, respectively. In total, 170 (18.8%) patients experienced the outcomes evaluated in this study. Total sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of TIMI score were 20 (95% CI: 17 – 24), 99 (95% CI: 97 – 100), 98 (95% CI: 93 – 100), 42 (95% CI: 39 – 46), 58 (95% CI: 14 – 229), and 1.3 (95% CI: 1.2 – 1.4), respectively. Area under the ROC curve of this system for prediction of 30-day mortality, MI, and need for revascularization were 0.51 (95% CI: 0.47 – 0.55), 0.58 (95% CI: 0.54 – 0.62) and 0.56 (95% CI: 0.52 – 0.60), respectively.

Conclusion: Based on the findings of the present study, it seems that TIMI score has a high specificity in predicting 30-day adverse outcomes of mortality, MI, and need for revascularization following acute coronary syndrome. However, since its sensitivity, negative predictive value, and negative likelihood ratio are low, it cannot be used as a proper screening tool for ruling out low risk patients in ED.

Screening Characteristics of Bedside Ultrasonography in Confirming Endotracheal Tube Placement; a Diagnostic Accuracy Study

Hamid Zamani Moghadam, Mohamad Davood Sharifi, Hasan Rajabi, Mojtaba Mousavi Bazaz, Ali Alamdaran, Niazmohammad Jafari, Seyed Amir Masoud Hashemian, Morteza Talebi Deloei

EMERGENCY , Vol. 5 No. 1 (2017), , Page e19

Introduction: Confirmation of proper endotracheal tube placement is one of the most important and lifesaving issues of tracheal intubation. The present study was aimed to evaluate the accuracy of tracheal ultrasonography by emergency residents in this regard.  

Method: This was a prospective, cross sectional study for evaluating the diagnostic accuracy of ultrasonography in endotracheal tube placement confirmation compared to a combination of 4 clinical confirmation methods of chest and epigastric auscultation, direct laryngoscopy, aspiration of the tube, and pulse oximetry (as reference test).

Results: 150 patients with the mean age of 58.52 ± 1.73 years were included (56.6% male). Sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio of tracheal ultrasonography in endotracheal tube confirmation were 96 (95% CI: 92-99), 88 (95% CI: 62-97), 98 (95% CI: 94-99), 78 (95% CI: 53-93), 64 (95% CI: 16-255), and 0.2 (95% CI: 0.1-0.6), respectively.

Conclusion: The present study showed that tracheal ultrasonography by trained emergency medicine residents had excellent sensitivity (>90%) and good specificity (80-90) for confirming endotracheal tube placement. Therefore, it seems that ultrasonography is a proper screening tool in determining endotracheal tube placement.

Doing Pre-operative Investigations in Emergency Department; a Clinical Audit

Muhammad Salman Rafiq, Maria Rafiq, Muhammad Imran Rafiq, Seema Gul Salman, Sania Hafeez

EMERGENCY , Vol. 5 No. 1 (2017), , Page e20

Introduction: Pre-operative investigations for emergency surgical patients differ between centers. Following established guidelines can reduce unnecessary investigation, cost of treatment and hospital stay. The present audit was carried out to evaluate the condition of doing pre-operative investigations for three common surgical emergencies compared to National Institute for Health and Care Excellence (NICE) guidelines and local criteria.Methods: A retrospective clinical audit of acute-appendicitis, abscess and hernia patients admitted to the emergency department was carried out over a one-year period from July 2014 to July 2015. Data of laboratory investigations, their indication, cost and duration of hospital stay was collected and compared with NICE-guidelines.Results: A total of 201 patients were admitted to the emergency department during the audit period. These included 77(38.3%) cases of acute-appendicitis, 112 (55.7%) cases of abscesses, and 12 (6%) cases of hernia. Investigations not indicated by NICE-guidelines included 42 (20.9%) full blood counts, 29 (14.4%) random blood sugars, 26 (12.9%) urea tests, 4 (2%) chest x-rays, 13 (6.5%) electrocardiographs, and 58 (28.9%) urine analyses. These cost 25,675 Rupees (245.46 Dollars) in unnecessary investigation costs and 65.7 days of additional hospital stay.Conclusions: Unnecessary investigations for emergency surgical patients can be reduced by following NICE-guidelines. This will reduce workload on emergency services, treatment costs and the length of hospital stay.

Predictive Factors of Poor Outcome in Road Traffic Injures; a Retrospective Cohort Study

Hamid Reza Hatamabadi, Majid Shojaee, Parvin Kashani, Mohammad Mehdi Forouzanfar, Dorrin Aghajani Nargesi, Mohammad Reza Amini Esfahani

EMERGENCY , Vol. 5 No. 1 (2017), , Page e21

Introduction: Road traffic injuries (RTI) are among the most important health problems worldwide as they cause more than 1.2 million deaths and 50 million injuries each year. Therefore, the present study aims to evaluate the outcome and aftermath of RTI in those who were injured and hospitalized due to a traffic accident.

Methods: In the present retrospective cohort study with a one-year follow-up, data were extracted from the profiles of the RTI hospitalized patients. Outcome of the patients was evaluated at the time of discharge and 1-year later including their living state, presence of a disability or complete recovery.

Results: 1471 patients were studied (mean age of 32.8±17.0; 80.3% male). 571 (38.8%) had mild disability, 684 (46.5%) moderate disability, and 85 (5.8%) had severe disability at the time of discharge. In the end, 53 (3.6%) died. In the 1-year follow-up, 194 (13.2%) had mild disability, 43 (2.9%) had moderate disability, 9 (0.6%) had severe disability, and 7 (0.5%) were in a vegetative state. Presence of an underlying disease (p=0.03), loss of consciousness for more than 24 hours (p=0.04), spinal injury (p=0.002), presence of multiple trauma (p=0.01), increased ISS (p<0.001), need for ventilator (p<0.001), and organ injuries during hospitalization (p<0.001) are independent factors that increase the risk of poor outcome in RTI patients.

Conclusion: Based on the results of the present study, underlying illnesses, loss of consciousness for more than 24 hours, spinal injury, multiple trauma, increased ISS, need for ventilator, and organ injuries during hospitalization were independent factors that increased the probability of poor outcome in RTI injuries.

Introduction: Diagnostic values reported for ultrasonographic screening of acute appendicitis vary widely and are dependent on the operator’s skill, patient’s gender, weight, etc. The present study aimed to evaluate the effect of operator skill on the diagnostic accuracy of ultrasonography in detection of appendicitis by comparing the results of ultrasonography done by radiologists and emergency physicians.

Methods: This prospective diagnostic accuracy was carried out on patients suspected to acute appendicitis presenting to EDs of 2 hospitals. After the initial clinical examinations, all the patients underwent ultrasonography for appendicitis by emergency physician and radiologist, respectively. The final diagnosis of appendicitis was based on either pathology report or 48-hour follow-up. Screening performance characteristics of appendix ultrasonography by emergency physician and radiologist were compared using STATA 11.0 software.

Results: 108 patients with the mean age of 23.91 ± 7.46 years were studied (61.1% male). Appendicitis was confirmed for 37 (34.26%) cases. Cohen's kappa coefficient between ultrasonography by the radiologist and emergency physician in diagnosis of acute appendicitis was 0.51 (95% CI: 0.35 – 0.76). Area under the ROC curve of ultrasonography in appendicitis diagnosis was 0.78 (95% CI: 0.69 – 0.86) for emergency physician and 0.88 (95% CI: 0.81 – 0.94) for radiologist (p = 0.052). Sensitivity and specificity of ultrasonography by radiologist and emergency physician in appendicitis diagnosis were 83.87% (95% CI: 67.32 – 93.23), 91.5% (95% CI: 81.89 – 96.52), 72.97% (95% CI: 55.61 – 85.63), and 83.10% (95% CI: 71.94 – 90.59), respectively.

Conclusion: Findings of the present study showed that the diagnostic accuracy of ultrasonography carried out by radiologist (89%) is a little better compared to that of emergency physician (80%) in diagnosis of appendicitis, but none are excellent.  

Mushroom Poisoning in the Northeast of Iran; a Retrospective 6-Year Epidemiologic Study

Bita Dadpour, Shahrad Tajoddini, Maliheh Rajabi, Reza Afshari

EMERGENCY , Vol. 5 No. 1 (2017), , Page e23

Introduction: Toxic mushrooms are distributed across the globe with over 5000 species. Among them, 100 species are responsible for most of the cases of mushroom poisoning. This study aimed to evaluate the epidemiologic pattern of mushroom poisoning among patients referred to the main toxicology center of Mashhad province located in North-east of Iran.

Method: This cross-sectional study was conducted on patients with final diagnosis of mushroom poisoning referred to the toxicology center of Mashhad, Iran, from February 2005 to 2011. Patients’ demographic characteristics, clinical presentations, laboratory findings, outcomes, and therapeutic measures were collected using a predesigned checklist and searching patient’s profile.

Results: 32 cases with the mean age of 24.6 ± 16.7 years were presented to the toxicology center following mushroom poisoning (59% female). Mushroom poisoning accounted for 0.1% of all admitted cases. The mean time elapsed from consumption to referral to poisoning department was 61.9 ± 49.4 hours. 19 (59%) cases were discharged with complete recovery, 7 (22%) expired, and 6 (19%) cases left hospital against medical advice. Mushroom poisoning mortality accounted for 1.5% of deceased cases in the studied center. There was significant relationship between mortality rate and higher values of INR (p = 0.035), PT (p = 0.011) and PTT (p = 0.003). Likewise, there was significant relationship between the need for mechanical ventilation and higher values of INR (p = 0.035), PT (p = 0.006) and PTT (p = 0.014). The relationships between the need for ICU admission, mechanical ventilation, and mortality rate with the rise of hepatic transaminases and serum bilirubin were not significant.

Conclusion: Based on the findings, the prevalence of mushroom poisoning among patients referred to Mashhad toxicology center was very low (0.1%), but with a high mortality rate of 22%. Nausea and vomiting were the most common early symptoms of intoxication and higher values of coagulation profile were correlated with poor outcome.

Introduction: Very severe head trauma cases, defined as Glasgow Coma Scale (GCS) scores of less than 6, have a higher mortality rate and poorer outcome. The purpose of this study was to recognize factors associated with survival and 6-month favorable outcome of very severe head trauma patients presenting to emergency department. Methods: In this historical cohort study, the authors retrospectively reviewed medical records of head trauma patients who were admitted to the emergency department with post-resuscitation GCS scores of less than 6. Both univariate and multivariate analyses were used to test the association between various parameters with survival and 6-month outcome. Results: 103 cases with the mean age of 39 ± 16.5 years were studied (80% male). The overall survival rate was 41.7% and the rate of 6-month favorable outcome was 28.2%. In multivariate analysis, brisk pupil light reaction on admission and patent basal cistern on brain computed tomography (CT) scan were significant factors associated with both survival (OR 5.20, 95% CI 1.57-17.246, p = 0.007 and OR 3.65, 95% CI 1.22-10.91, p=0.02 respectively) and favorable outcome (OR 4.07, 95% CI 1.35-12.24, p=0.01 and OR 3.54, 95% CI 1.22-10.26, p 0.02), respectively. Conclusion: Based on the results of present study, the survival rate of patients with very severe head trauma (GCS < 6) was 41.7%. The strong predictors of survival and 6-month favorable outcome of these patients were brisk pupillary reactivity and patent cistern on brain CT scan. It seems that very severe head trauma patients still have a reasonable chance to survive and aggressive management should be continued.

The Effect of Magnesium Sulfate on Renal Colic Pain Relief; a Randomized Clinical Trial

Abolfazl Jokar, Ali Cyrus, Maryam Babaei, Majid Taheri, Amir Almasi-Hashiani, Ezatollah Behzadinia, Arash Yazdanbakhsh

EMERGENCY , Vol. 5 No. 1 (2017), , Page e25

Introduction: Renal colic can be managed by preventing the contraction movements of ureter muscles. By reducing acetylcholine in the nerve terminals, magnesium sulfate could be effective in this regard. The aim of this study is to investigate the effect of magnesium sulfate on acute renal colic pain relief. Method: The present study was a double-blind clinical trial in which the patients suffering from acute renal colic were randomly divided into 2 groups of who either received standard protocol (intravenous infusion of 0.1 mg/Kg morphine sulfate, 30 mg of Ketorolac, and 100 ml normal saline as placebo/15 minutes) or standard protocol plus 15 mg/Kg of intravenous magnesium sulfate 50%/100 ml normal saline/15 minutes. Severity of patients’ pain was measured by visual analogue scale (VAS) at baseline, and 30 and 60 minutes after infusion. The collected data were analyzed using STATA statistical software. Results: 100 cases were randomly allocated to intervention or control group. The two groups were similar in baseline pain score and demographic characteristics. At 30 and 60 minutes, mean pain score was less in the intervention group compared to the control group. Moreover, the difference between the two groups was statistically significant regarding the additional amount of morphine, suggesting that the intervention group needed less additional morphine than the control group. Conclusion: The results of this study showed that Magnesium sulfate can be used as an adjunct drug in treatment of patients suffering from renal colic. It not only alleviates the pain in the patients, but also diminishes the need for pain medications.

Introduction: Ventilator-associated pneumonia (VAP) is one of the most common hospital infections and a side effect of lengthy stay in intensive care unit (ICU). Considering the ever-changing pattern of common pathogens in infectious diseases and the raise in prevalence of hospital infections, the present study was designed aiming to determine the prevalence of VAP and its bacterial causes. Methods: In this cross-sectional study, the medical profiles of all the patients under mechanical ventilation, who had no symptoms of pneumonia at the time of intubation and developed new infiltration in chest radiography after 48 hours under mechanical ventilation along with at least 2 of the symptoms including fever, hypothermia, leukocytosis, leukopenia, or purulent discharge from the lungs, were evaluated. Demographic data, clinical and laboratory findings, and final outcome of the patients were extracted from the patient’s clinical profile and reported using SPSS version 20 and descriptive statistics.Results: 518 patients with the mean age of 62.3 ± 20.8 years were evaluated (50.9% female). Mean time interval between intubation and showing symptoms was 10.89 ± 12.27 days. Purulent discharges (100%), leukocytosis (71.9%), fever (49.1%), hypothermia (12.3%), and leukopenia (8.8%) were the most common clinical and laboratory symptoms and acinetobacter baumannii (31.58%) and klebsiella pneumoniae (29.82%) were the most common germs growing in sputum cultures. 19 (33.3%) cases of pan drug resistance (PDR) and 10 (17.5%) cases of extensive drug resistance (XDR) were seen. Mortality due to VAP was 78.9% and there was no significant correlation between age (p = 0.841), sex (p = 0.473), ICU admission (p = 0.777), duration of hospitalization (p = 0.254), leukocytosis (p = 0.790), leukopenia (p = 0.952), fever (p = 0.171), hypothermia (p = 0.639), type of culture (p = 0.282), and type of antibiotic resistance (p = 0.066) with mortality. Conclusion: Prevalence of VAP and its associated mortality were 11% and 78.9%, respectively. The most common symptoms and signs were purulent discharge, leukocytosis, and fever. Acinetobacter baumannii and klebsiella pneumoniae were the most common germs in sputum cultures with 50% resistance to commonly used antibiotics.

Introduction: Doing Chest X Ray (CXR) for all trauma patients is not efficient and cost effective due to its low diagnostic value. The present study was designed aiming to evaluate the diagnostic accuracy of thoracic injury rule out criteria (TIRC) in prediction of traumatic intra-thoracic injuries and need for CXR. Method: The present study is a prospective cross-sectional study that has been carried out to evaluate the accuracy of TIRC model in screening blunt multiple trauma patients in need of CXR for ruling out intra-thoracic injuries. Results: 1518 patients with the mean age of 33.53 ± 15.42 years were enrolled (80.4% male). The most common mechanisms of trauma were motor car accident (78.8%) and falling (13.6%). Area under the ROC curve, sensitivity, and specificity of model in detection of traumatic thoracic injuries was 0.95 (95% CI: 0.93 – 0.97), 100 (95% CI: 87.0 – 100), and 80.1 (95% CI: 78.0 – 82.1), respectively. Brier score for TIRC was 0.02 and its scaled reliability was 0.0002. Conclusion: Findings of the present study showed that TIRC has high accuracy in prediction of traumatic intra-thoracic injuries and screening patients in need of CXR. 

Introduction: Evaluation of students’ learning in clinical education system is one of the most important and challenging issues that facilities in this field have been facing. The present study aimed to evaluate the role of feedback during evaluation in increasing emergency medicine residents’ clinical skills.

Method: The present experimental study was performed on all second year emergency medicine residents of two educational hospitals, Tehran, Iran, with switching replications design and before-after method. They were randomly allocated to two groups (with or without feedback) and evaluated three times regarding chest ultrasonography for trauma patients, using direct observation of procedural skills (DOPS) and valid and reliable checklist. Data were analyzed using SPSS 20.

Results: 30 emergency medicine residents with the mean age of 36.63 ± 30.30 years were allocated to two equal groups (56.7% male). Studied groups were similar regarding the baseline characteristics. In both groups, obtained scores showed a significant increase from the first to the third evaluation (p < 0.001). Mean scores of first and second evaluations were 10.24 ± 0.77, 17.73 ± 0.46 in feedback receivers and 9.73 ± 0.77 and 12.13 ± 0.47 in others (p < 0.001). Mean third score after switching groups were 18.53 ± 0.22 in feedback receivers and 18.99 ± 0.22 in others (p = 0.213).

Conclusion: Based on the findings of the present study, giving feedback after evaluating the second year emergency medicine residents regarding chest ultrasonography for trauma patients, led to a significant improvement in their scores in future evaluations and consequently their skill.

Intravenous Amiodarone versus Digoxin in Atrial Fibrillation Rate Control; a Clinical Trial

Majid Shojaee, Bahareh Feizi, Reza Miri, Jalil Etemadi, Amir Hossein Feizi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e29

Introduction: Treatment of rapid ventricular response arterial fibrillation (rapid AF) varies depending on the decision of the in-charge physician, condition of the patient, availability of the drug, and the treatment protocol of the hospital. The present study was designed aiming to compare IV digoxin and amiodarone in controlling the heart rate of patients presenting to emergency department with rapid AF and relative contraindication for first line drug in this regard.

Method: In the present clinical trial, patients presented to the ED with rapid AF and relative contraindication for calcium channel blockers and beta-blockers were treated with either IV amiodarone or IV digoxin and compared regarding success rate and complication using SPSS version 22. P < 0.05 was considered as statistically significant.

Results: 84 patients were randomly allocated to either amiodarone or digoxin treatment groups of 42 (53.6% male). The mean age of the studied patients was 61.8 ± 11.14 years (38 - 79). No significant difference was present regarding baseline characteristics. The rate of treatment failure was 21.4% (9 cases) in amiodarone and 59.5% (25 cases) in digoxin groups (p < 0.001). The mean onset of action was 56.66 ± 39.52 minutes (10 - 180) in amiodarone receivers and 135.38 ± 110.41 minutes (25 - 540) in digoxin group (p < 0.001). None of the patients showed any adverse outcomes of hypotension, bradycardia, and rhythm control.

Conclusion: Based on the findings of the present study, rapid AF patients with relative contraindication for calcium channel blockers or beta-blockers who had received amiodarone experienced both higher (about 2 times) treatment success and a more rapid (about 2.5 times) response compared to those who received IV digoxin.

Rapid Acute Physiology Score versus Rapid Emergency Medicine Score in Trauma Outcome Prediction; a Comparative Study

Babak Nakhjavan-Shahraki, Masoud Baikpour, Mahmoud Yousefifard, Zahra Sadat Nikseresht, Samaneh Abiri, Jalaledin Mirzay Razaz, Gholamreza Faridaalaee, Mahboob Pouraghae, Sahar Shirzadegan, Mostafa Hosseini

EMERGENCY , Vol. 5 No. 1 (2017), , Page e30

Introduction: Rapid acute physiology score (RAPS) and rapid emergency medicine score (REMS) are two physiologic models for measuring injury severity in emergency settings. The present study was designed to compare the two models in outcome prediction of trauma patients presenting to emergency department (ED).

Methods: In this prospective cross-sectional study, the two models of RAPS and REMS were compared regarding prediction of mortality and poor outcome (severe disability based on Glasgow outcome scale) of trauma patients presenting to the EDs of 5 educational hospitals in Iran (Tehran, Tabriz, Urmia, Jahrom and Ilam) from May to October 2016. The discriminatory power and calibration of the models were calculated and compared using STATA 11.

Results: 2148 patients with the mean age of 39.50±17.27 years were studied (75.56% males). The area under the curve of REMS and RAPS in predicting in-hospital mortality were calculated to be 0.93 (95% CI: 0.92-0.95) and 0.899 (95% CI: 0.86-0.93), respectively (p=0.02). These measures were 0.92 (95% CI: 0.90-0.94) and 0.86 (95% CI: 0.83-0.90), respectively, regarding poor outcome (p=0.001). The optimum cut-off point in predicting outcome was found to be 3 for REMS model and 2 for RAPS model. The sensitivity and specificity of REMS and RAPS in the mentioned cut offs were 95.93 vs. 85.37 and 77.63 vs. 83.51, respectively, in predicting mortality. Calibration and overall performance of the two models were acceptable.

Conclusion: The present study showed that adding age and level of arterial oxygen saturation to the variables included in RAPS model can increase its predictive value. Therefore, it seems that REMS could be used for predicting mortality and poor outcome of trauma patients in emergency settings

Worthing Physiological Score vs Revised Trauma Score in Outcome Prediction of Trauma patients; a Comparative Study

Babak Nakhjavan-Shahraki, Mahmoud Yousefifard, Mohammad Javad Hajighanbari, Masoud Baikpour, Jalaledin Mirzay Razaz, Mehdi Yaseri, Kavous Shahsavari, Fatemeh Mahdizadeh, Mostafa Hosseini

EMERGENCY , Vol. 5 No. 1 (2017), , Page e31

Introduction: Awareness about the outcome of trauma patients in the emergency department (ED) has become a topic of interest. Accordingly, the present study aimed to compare the rapid trauma score (RTS) and worthing physiological scoring system (WPSS) in predicting in-hospital mortality and poor outcome of trauma patients.

Methods: In this comparative study trauma patients brought to five EDs in different cities of Iran during the year 2016 were included. After data collection, discriminatory power and calibration of the models were assessed and compared using STATA 11.

Results: 2148 patients with the mean age of 39.50±17.27 years were included (75.56% males). The AUC of RTS and WPSS models for prediction of mortality were 0.86 (95% CI: 0.82-0.90) and 0.91 (95% CI: 0.87-0.94), respectively (p=0.006). RTS had a sensitivity of 71.54 (95% CI: 62.59-79.13) and a specificity of 97.38 (95% CI: 96.56-98.01) in prediction of mortality. These measures for the WPSS were 87.80 (95% CI: 80.38-92.78) and 83.45 (95% CI: 81.75-85.04), respectively. The AUC of RTS and WPSS in predicting poor outcome were 0.81 (95% CI: 0.77-0.85) and 0.89 (95% CI: 0.85-0.92), respectively (p<0.0001).

Conclusion: The findings showed a higher prognostic value for the WPSS model in predicting mortality and severe disabilities in trauma patients compared to the RTS model.  Both models had good overall performance in prediction of mortality and poor outcome.

Early vs Late Coronary Angiography and Intervention Following Thrombolytic Therapy; a Cohort Study

Bahareh Feizi, Shahram Taghdisi, Jalil Etemadi, Amir Hossein Feizi, Setareh Asgarzadeh, Sepideh Kamal

EMERGENCY , Vol. 5 No. 1 (2017), , Page e32

Introduction: The precise time of using percutaneous coronary intervention (PCI) after fibrinolytic therapy for maximum efficiency and minimum side effects is still undetermined. Therefore, the present study was designed to compare the outcome of myocardial infarction (MI) patients who underwent surgical intervention (angiography and PCI) within 48 hours of thrombolytic therapy or after that.

Methods: The present study is a prospective cohort study aiming to compare the occurrence of no-reflow phenomenon, unstable angina, bleeding during intervention, and one month major adverse cardiac outcomes (recurrent MI, need for repeating surgical intervention, and mortality) between MI patents undergoing surgical intervention within the first 48 hours of or after 48 hours of thrombolytic therapy.

Results: 90 patients with the mean age of 54.97 ± 10.54 were studied (86.67% male). 50 (56%) patients underwent surgical intervention within 48 hours and 40 (44%) after that. The 2 groups were not significantly different regarding baseline characteristics. No-reflow phenomenon in the < 48 hours group was about twice the > 48 hours group (OR = 0.35; 95% confidence interval: 0.14 – 0.92; p = 0.03), other outcomes were not significantly different. No case of mortality was seen in the 1 month follow up.

Conclusion: Based on the results of the present study, it seems that no-reflow phenomenon rate is significantly lower in patients undergoing surgical intervention after 48 hours of fibrinolytic therapy. The difference between the two groups regarding prevalence of major adverse cardiac outcomes was not statistically significant.

Comparing the Quality and Complications of Tube Thoracostomy by Emergency Medicine and Surgery Residents; a Cohort Study

Parvin Kashani, Sepideh Harati, Ali Shirafkan, Alireza Amirbeigi, Hamid Reza Hatamabadi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e33

Introduction: Tube thoracostomy complications depend on the operator’s skill, patients’ general condition and the place in which the procedure is done. The present study aimed to compare the quality and complications of tube thoracostomy carried out by emergency medicine residents (EMRs) and surgery residents (SRs).

Methods: This cohort study was conducted on 18-60 years old trauma patients in need of tube thoracostomy presenting to two academic emergency departments. Quality of tube placement and its subsequent complications until tube removal were compared between SRs and EMRs using SPSS 20.

Results: 72 patients with the mean age of 37.1±14.1 years were studied (86.1% male). 23 (63.8%) cases were complicated in SRs and 22 (61.1%) cases in EMRs group (total= 62.5%). Chest drain dislodgement (22.2% in SRs vs. 22.2% EMRs; p>0.99), drainage failure (19.4% in SRs vs. 16.7% EMRs; p=0.50), and surgical site infection (11.1% in SRs vs. 19.4% EMRs; p=0.25) were among the most common observed complications. The overall odds ratio of complication development was 0.89 (95% CI: 0.35-2.25, p = 0.814) for SRs and 1.12 (95% CI: 0.28-4.53, p = 0.867) for EMRs.

Conclusion: The findings of the present study showed no significant difference between SRs and EMRs regarding quality of tube thoracostomy placement and its subsequent complications for trauma patients. The rate of complications were interestingly high (>60%) for both groups.

Introduction: Screening of patients with anterior abdominal penetrating trauma in need for laparotomy is an important issue in management of these cases. This study aimed to compare the accuracy of abdominal wall ultrasonography (AWU) and local wound exploration (LWE) in this regard.

Methods: This diagnostic accuracy study was conducted on ≥ 18 year-old patients presenting to emergency department with anterior abdominal stab wound and stable hemodynamics, to compare the characteristics of AWU and LWE in screening of patients in need of laparotomy.

Results: 50 cases with the mean age of 28.44 ± 7.14 years were included (80% male). Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve of AWU were 70.58 (95% CI: 44.04 – 88.62), 93.33 (95% CI: 76.49 – 98.83), and 81.96 (95% CI: 69.91 – 94.01), respectively. These measures were 88.23 (62.25 – 97.93), 93.33 (76.49 – 98.83), and 90.78 (95% CI: 81.67 – 99.89) for LWE, respectively. The difference in overall accuracy of the two methods was not statistically significant (p = 0.0641).

Conclusion: Based on the findings of the present study, AWU and LWE had the same specificity but different sensitivities in screening of anterior abdominal stab wound patients in need of laparotomy. The overall accuracy of LWE was slightly higher (91.48% versus 85.1%).

Methylprednisolone vs Dexamethasone in Management of COPD Exacerbation; a Randomized Clinical Trial

Mohammad Emami Ardestani, Elham Kalantari, Vajihe Samaiy, Keramat Taherian

EMERGENCY , Vol. 5 No. 1 (2017), , Page e35

Introduction: Corticosteroids are routinely used in management of chronic obstructive pulmonary disease (COPD) exacerbation. The main purpose of present study was to compare the efficacy of methyl prednisolone (MP) and dexamethasone (DXM) for this purpose.

Methods: Adult COPD patients entered the present clinical trial. All patients received standard treatment on admission and were then divided into 2 groups of intravenous MP and DXM. Patients were asked to rate their shortness of breath; sputum volume and viscosity; dyspnea; cough; and general wellbeing on a 0-5 scale. Baseline parameters such as O2 saturation, arterial blood gas parameters, and white blood cell (WBC) count were compared on admission and day 7 and 14 of therapy using SPSS 22.

Results: 68 patients were randomly allocated to 2 groups of 34 (82.4% male). The baseline characteristics of the two groups were similar (p < 0.05). Comparison of treatment outcomes for the 7th day showed a significant difference between the 2 groups only regarding cough (p = 0.047), HCO3 (p < 0.001), and O2 saturation (p = 0.042). On day 14 the 2 groups were different only regarding cough (p = 0.048) and sputum viscosity (p = 0.011). There was a significant difference between the two groups regarding trend of changes in dyspnea (p = 0.02; DXM >> MP) and cough (p = 0.035; MP >> DXM). There were no significant differences between the two medications regarding side effects on 7th and 14th day after treatment.

Conclusion: It seems that MP and DXM have similar efficacy and side effects in treatment of COPD exacerbation and selecting drug of choice would better be based on the most prominent symptoms of patients on admission.

Determinants of prolonged length of stay in the emergency department: A mixed method study from Iran

Mohammad Hosseininejad, Hamed Aminiahidashti, Seyede Masoume Pashaei, Iraj Goli Khatir, Seyed Hosein Montazer, Farzad Bozorgi, Fahime Mahmoudi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e53

Introduction: Timeliness has been considered as a key domain in quality of emergency department (ED) care and delay in care providing is influential determinants of patient’s outcomes. The present study, aimed to evaluate the determinants of prolonged ED length of stay (LOS).

Methods: In this cross-sectional study, using adopted version of the latest form for external evaluation and accreditation of EDs introduced by Iranian Ministry of Health, determinants of prolonged LOS were evaluated in the ED of an educational Hospital. Using SPSS 11, multivariate binary logistic regression was applied to estimate adjusted odds ratios (OR) for determining factors associated with prolonged LOS.

Results: 162 (10.2%) cases with prolonged LOS were detected. Based on univariate analysis, female gender (OR: 1.42, 95% CI: 1.14-1.75, p = 0.001), older age (OR: 1.05, 95% CI: 1.02-1.08, p < 0.0001), admission on evening shifts (OR: 4.0; 95% CI: 1.84-8.68, p < 0.001), triage level I (OR: 1.76, 95% CI: 1.21-2.57, p = 0.003), lack of insurance support (OR: 1.56, 95% CI: 1.12-2.19, p = 0.010), higher number of ordered para-clinical tests (OR: 1.23, 95% CI: 1.11-1.37, p = 0.016), and disposition time > 6 hours (OR, 0.13, p < 0.0001), were significant risk factors of prolonged LOS.

Conclusion: Older age, lack of insurance support, disposition time > 6 hours due to complexity of patients’ complaint, and the necessity of repeated para-clinical measures were the most important reasons for failed provision of timely services. From the view point of ED personnel, a small part of prolonged LOS in ED was concerned with defective ED workflow, while, the most important cause of such delays was the delayed response of the consultancy services.

Nerve Stimulator versus Ultrasound-Guided Femoral Nerve Block; a Randomized Clinical Trial

Arash Forouzan, Kambiz Masoumi, Hasan Motamed, Mohammad Reza Gousheh, Akram Rohani

EMERGENCY , Vol. 5 No. 1 (2017), , Page e54

Introduction: Pain control is the most important issue in emergency department management of patients with femoral bone fractures. The present study aimed to compare the procedural features of ultrasonography and nerve stimulator guided femoral nerve block in this regard.

Method: In this randomized clinical trial, patients with proximal femoral fractures presenting to emergency department were randomly divided into two groups of ultrasonography or nerve stimulator guided femoral block and compared regarding success rate, procedural time, block time, and need for rescue doses of morphine sulfate, using SPSS 20.

Results: 50 patients were randomly divided into two groups of 25 (60% male). The mean age of studied patients was 35.14 ± 12.95 years (19 – 69). The two groups were similar regarding age (p= 0.788), sex (p = 0.564), and initial pain severity (p = 0.513). In 2 cases of nerve stimulator guided block, loss of pinprick sensation did not happen within 30 minutes of injection (success rate: 92%; p = 0.490). Ultrasonography guided nerve block cases had significantly lower procedural time (8.06 ± 1.92 vs 13.60 ± 4.56 minutes; p < 0.001) and lower need for rescue doses of opioid (2.68 ± 0.74 vs 5.28 ± 1.88 minutes; p < 0.001).

Conclusion: Ultrasonography and nerve stimulator guided femoral block had the same success rate and block duration. However, the ultrasonography guided group had lower procedure time and lower need for rescue doses of morphine sulfate. Therefore, ultrasonography guided femoral block could be considered as an available, safe, rapid, and efficient method for pain management of femoral fracture in emergency department. 

Epidemiologic Features and Outcomes of Caustic Ingestions; a 10-Year Cross-Sectional Study

Athena Alipour Faz, Fahimeh Arsan, Maryam Peyvandi, Mahbobeh Oroei, Omid Shafagh, Maryam Yousefi, Hassan Peyvandi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e56

Introduction: Caustic ingestions are among the most prevalent causes of toxic exposure. The present 10-year survey aimed to evaluate the epidemiologic features and outcomes of caustic ingestion cases presenting to emergency department.

Methods: This is a retrospective cross-sectional study on patients who were admitted to a referral toxicology center during 2004 to 2014, following caustic ingestion. Baseline characteristics, presenting chief complaint, severity of mucosal injury, complications, imaging and laboratory findings as well as outcomes (need for ICU admission, need for surgery, mortality) were recorded, reviewing patients’ medical profile, and analyzed using SPSS 22.

Results: 348 patients with mean age of 37.76 ± 17.62 years were studied (55.6% male). The mean amount of ingested caustic agent was 106.69 ± 100.24 mL (59.2 % intentional). Intentional ingestions (p < 0.0001), acidic substance (p = 0.054), and higher volume of ingestion (p = 0.021) were significantly associated with higher severity of mucosal damage. 28 (8%) cases had died, 53 (15.2%) were admitted to ICU, and 115 (33%) cases underwent surgery.

Conclusion: It seems that, suicidal intention, higher grade of mucosal injury, higher volume of ingestion, lower level of consciousness, lower serum pH, and higher respiratory rate are among the most important predictors of need for ICU admission, need for surgery, and mortality.

The Pattern of Pre-hospital Medical Service Delivery in Iran; a Cross Sectional Study

Mashyaneh Haddadi, Mohammad Sarvar, Hamid Soori, Elaheh Ainy

EMERGENCY , Vol. 5 No. 1 (2017), , Page e57

Introduction: Pre-hospital emergency systems provide service by Franco-German and Anglo American models. This study was carried out to compare the Iranian emergency medical service (EMS) with the two models regarding timing and equipment. Methods: In this cross sectional study, response time, scene time, and transport time to hospital as well as ambulance equipment of five hundred thousand Tehran EMS recorded missions, during one year, were compared with Franco-German and Anglo American models, trying to determine the pattern of EMS delivery in Iran.  Results: The mean response time, scene time, and transport time to hospital were 15.00 ±10.88, 18 ±11.48, and 15.00 ±11.20 minutes, respectively. The mean response time (p<0.035), scene time (p<0.033), and transport time to hospital (p<0.015) were more than the standard time. Percentage of ambulances quipped with automated external defibrillator (45%, p<0.001), ventilator (2%, p<0.001), disposable splint (0%, p<0.001), and wheelchair (0%, p<0.001) were very far from standards. Conclusion: The pattern of EMS delivery in Iran was a combination of Anglo American and Franco-German system.

Prevalence and Associated Factors of Acute Traumatic Coagulopathy; a Cross Sectional Study

Hojjat Derakhshanfar, Ali Vafaei, Ali Tabatabaey, Shamila Noori

EMERGENCY , Vol. 5 No. 1 (2017), , Page e58

Introduction: Acute traumatic coagulopathy (ATC) is defined as having evidence of coagulopathy in patients with severe trauma. The aim of this preliminary study was to assess the prevalence and associated factors of ATC in severely traumatic patients presenting to emergency department (ED). Methods: In this retrospective cross sectional study, all patients with severe traumatic injury and available coagulation profile, presenting to the EDs of two major trauma centers in Tehran, Iran, during one year, were studied. Rate of ATC was determined and the associations with various variables as well as outcome were analyzed using SPSS 21. Results: 246 patients with the mean age of 36.57±17.11 years were included (88.2% male). The mean injury severity score (ISS) was 21.83 ± 7.37 (16 – 54). Patients were resuscitated with 676.83 ± 452.02 (0 – 1500) ml intravenous fluid before arriving at the ED. The maximum and minimum frequencies of ATC were 31.3% based on PTT > 36s and 2.4% based on PT > 18s, respectively. There was a significant association between the occurrence of ATC (PT ratio > 1.2) and ISS > 23 (p = 0.001), abdominal abbreviated injury score (AIS) > 3 (p = 0.003), base deficit > 4 (p = 0.019), pulse rate > 90/minute (p = 0.041), and pH < 7.30 (p = 0.043). Conclusion: The frequency of ATC in the present series varied from 2.4% to 31.3% based on different ATC definitions. Abdominal AIS > 3 and base deficit > 4 were among the significant independent factors related to ATC occurrence based on stepwise logistic regression analysis. 

Introduction: Endoscopy is an invasive procedure and finding noninvasive alternative tools in detection of probable upper gastrointestinal (GI) tract injuries following caustic ingestion is an area of interest. The present study aimed to evaluate the screening performance characteristics of thoraco-abdominal computed tomography (CT) scan in this regard.

Methods: This prospective cross sectional study was conducted on patients presenting to emergency department following acute caustic ingestion. The findings of CT scan and endoscopy regarding the presence of upper GI tract damage were compared and screening performance characteristics of CT scan were calculated using MedCalc software.

Results: 34 patients with the mean age of 35.38±13.72 years were studied (58.8% male). The agreement rate between CT scan and endoscopy regarding the grade of esophageal and gastric injuries was moderate (K= 0.38; p = 0.001) and fair (K= 0.17; p = 0.038), respectively. The sensitivity and specificity of CT scan in detection of esophageal damage were 96.29) 79.11- 99.80) and 57.14 (20.23 - 88.19), respectively. These measures were 89.65 (71.50 - 97.28) and 40.00 (7.25 - 82.95), respectively for gastric damage. The area under the ROC curve of CT scan in detection of esophageal and gastric damages was 0.76 (95% CI: 0.52 – 1.00) and 0.64 (95% CI: 0.35 – 0.94), respectively.

Conclusion: Based on the findings of the present study, CT scan could be considered as a sensitive tool in ruling out upper gastrointestinal mucosal injuries following acute caustic ingestions. However, the correlation between endoscopy and CT scan findings regarding the grading of injury is not high enough to eliminate the need for endoscopy. 

Relationship between Dyspnea Descriptors and Underlying Causes of the Symptom; a Cross-sectional Study

Seyyed Mohammad Ali Sajadi, Alireza Majidi, Fahimeh Abdollahimajd, Fatemeh Jalali

EMERGENCY , Vol. 5 No. 1 (2017), , Page e62

Introduction: History taking and physical examination help clinicians identify the patient’s problem and effectively treat it. This study aimed to evaluate the descriptors of dyspnea in patients presenting to emergency department (ED) with asthma, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Method: This cross-sectional study was conducted on all patients presenting to ED with chief complaint of dyspnea, during 2 years. The patients were asked to describe their dyspnea by choosing three items from the valid and reliable questionnaire or articulating their sensation. The relationship between dyspnea descriptors and underlying cause of symptom was evaluated using SPSS version 16. Results: 312 patients with the mean age of 60.96±17.01 years were evaluated (53.2% male). Most of the patients were > 65 years old (48.7%) and had basic level of education (76.9%).  "My breath doesn’t go out all the way" with 83.1%, “My chest feels tight " with 45.8%, and "I feel that my airway is obstructed" with 40.7%, were the most frequent dyspnea descriptors in asthma patients. "My breathing requires work" with 46.3%, "I feel that I am suffocating" with 31.5%, and "My breath doesn’t go out all the way" with 29.6%, were the most frequent dyspnea descriptors in COPD patients. "My breathing is heavy" with 74.4%, "A hunger for more air” with 24.4%, and "I cannot get enough air" with 23.2%, were the most frequent dyspnea descriptors in CHF patients. Except for “My breath does not go in all the way”, there was significant correlation between studied dyspnea descriptors and underlying disease (p = 0.001 for all analyses). Conclusion: It seems that dyspnea descriptors along with other findings from history and physical examination could be helpful in differentiating the causes of the symptom in patients presenting to ED suffering from dyspnea.



Diagnostic Accuracy of Quick Stick for Identifying Traumatic Patients in Need of Tetanus Prophylaxis; a Cross-sectional Study

Iraj Golikhatir, Seyed Hossein Montazer, Nabiollah Bagheri, Fatemeh Jahanian, Farzad Bozorgi, Seyed Mohammad Hosseininejad, Hamed Aminiahidashti

EMERGENCY , Vol. 5 No. 1 (2017), , Page e66

Introduction: Based on the existing studies, measuring serum level of immunoglobulin for making decisions regarding prescription of tetanus prophylaxis seems logical and cost effective. Therefore, the present study was done with the aim of evaluating the diagnostic accuracy of tetanus quick stick (TQS) in comparison with ELISA method in this regard.

Methods: The present diagnostic accuracy study was carried out on trauma patients presenting to emergency department, who were in need of receiving tetanus prophylaxis due to dirty wounds or injuries. Patients’ blood was evaluated regarding presence of anti-tetanus antibody via TQS and ELISA methods and screening performance characteristics of TQS in identifying the cases in need of receiving prophylaxis was calculated compared to ELISA as the reference test.

Results: 148 patients with the mean age of 34.58 ± 15.86 years (4-86) were studied (87.8% male). Agreement rate between the results of TQS and ELISA was 0.78 based on calculation of kappa coefficient. Sensitivity, specificity and area under the ROC curve of TQS were estimated to be 100 (95% CI: 96.50 – 100), 66.66 (95% CI: 38.68 – 86.01), and 0.83 (95% CI: 0.68 – 0.98), respectively. If TQS was used, the cost of treatment regarding use of tetabulin could have a 91.7% reduction.

Conclusion: Based on the findings of the present study, TQS has good diagnostic accuracy in comparison with ELISA and considering its 100% sensitivity and negative predictive value in cases with dirty wound, it can be considered as a reliable tool for screening patients that do not need to receive anti-tetanus prophylaxis.

Intravenous Lidocaine versus Morphine Sulfate in Pain Management for Extremity Fractures; a Clinical Trial

Arash Forouzan, Hassan Barzegari, Hassan Motamed, Ali Khavanin, Hamideh Shiri

EMERGENCY , Vol. 5 No. 1 (2017), , Page e68

Introduction: Considering the existing contradictions regarding effectiveness of intravenous (IV) lidocaine, especially in emergency department (ED), the present study was designed to compare the analgesic effect of IV lidocaine and morphine sulfate in pain management for extremity bone fractures. Method: In this triple blind clinical trial, 15 to 65 year-old patients with extremity fractures and in need of pain management were randomly allocated to either IV lidocaine or morphine sulfate group and were compared regarding severity of pain 5, 10, 15, 20, 25, and 30 minutes after infusion via intention to treat analysis.  The absolute risk reduction, number needed to treat and relative risk of IV lidocaine after 30 minutes were 0.40 (95%CI: 0.25 – 0.64), 7 (95%CI: 3.7 – 23.1), and 20.71 (95%CI: 10.91 – 30.51), respectively. Results: 280 patients with the mean age of 32.50 ± 12.77 years were randomly divided into 2 equal groups of 140 (73.9% male). The 2 groups had similar baseline characteristics. 15 minutes after injection success rate was 49.28% in lidocaine and 33.57% in morphine sulfate group (p = 0.011), and after 30 minutes it reached 85.71% and 65.00%, respectively (p < 0.001). Conclusion: Based on the results of the present study, IV lidocaine could be considered as a reasonable alternative choice for pain management in ED. 

Blood Lead Levels in Asymptomatic Opium Addict Patients; a Case Control Study

Kazem Ghaemi, Atefeh Ghoreishi, Navid Rabiee, Samira Alinejad, Esmaeil Farzaneh, Alireza Amirabadi Zadeh, Mohammad Abdollahi, Omid Mehrpour

EMERGENCY , Vol. 5 No. 1 (2017), , Page e69

Introduction: One of the newest non-occupational sources of lead contamination is drug addiction, which has recently been addressed as a major source of lead poisoning in some countries. The present study aimed to investigate the blood lead level (BLL) of asymptomatic opium addicts.

Methods: This case-control study was conducted during a one-year period to compare BLL of three groups consisting of opium addicts, patients under methadone maintenance therapy (MMT), and healthy individuals.

Results: 99 participants with the mean age of 55.43±12.83 years were studied in three groups of 33 cases (53.5% male). The mean lead level in opium addicts, MMT and control groups were 80.30 ± 6.03 μg/L, 67.94 ± 4.42 μg/L, and 57.30±4.77 μg/L, respectively (p=0.008). There was no significant difference in BLL between MMT and healthy individuals (p=0.433) and also between opium addicts and MMT individuals (p=0.271).Oral opium abusers had significantly higher lead levels (p = 0.036). There was a significant correlation between BLL and duration of drug abuse in opium addict cases (r=0.398, p=0.022). The odds ratio of having BLL ≥ 100 in oral opium users was 2.1 (95% CI: 0.92 - 4.61; p = 0.43).

Conclusion:  Based on the result of present study, when compared to healthy individuals, opium addicts, especially those who took substance orally had significantly higher levels of blood lead, and their odds of having BLL ≥ 100 was two times. Therefore, screening for BLL in opium addicts, particularly those with non-specific complaints, could be useful.

Introduction: Esophagogastroduodenoscopy (EGD) is currently considered as the primary method of determining the degree of mucosal injury following caustic ingestion. The present study aimed to evaluate the screening performance characteristics of EGD in predicting the depth of gastrointestinal mucosal injuries following caustic ingestion.

Methods: Adult patients who were referred to emergency department due to ingestion of corrosive materials, over a 7-year period, were enrolled to this diagnostic accuracy study. Sensitivity, specificity, positive and negative predictive values as well as negative and positive likelihood ratios of EGD in predicting the depth of mucosal injury was calculated using pathologic findings as the gold standard.

Results: 54 cases with the mean age of 35 ± 11.2 years were enrolled (59.25% male). Primary endoscopic results defined 28 (51.85%) cases as second grade and 26 (48.14%) as third grade of mucosal injury. On the other hand, pathologic findings reported 21 (38.88%) patients as first grade, 14 (25.92%) as second, and 19 patients (35.18%) as third grade. Sensitivity and specificity of endoscopy for determining grade II tissue injury were 50.00 (23.04-76.96) and 47.50 (31.51-63.87), respectively. These measures were 100.00 (82.35-100) and 80.00 (63.06-91.56), respectively for grade III. Accuracy of EGD was 87.03% for grade III and 48.14% for grade II.

Conclusion: Based on the findings of the present study, endoscopic grading of caustic related mucosal injury based on the Zargar’s classification has good accuracy in predicting grade III (87%) and fail accuracy in grade II injuries (48%). It seems that we should be cautious in planning treatment for these patients solely based on endoscopic results. 

The Relationship of ST Segment Changes in Lead aVR with Outcomes after Myocardial Infarction; a Cross Sectional Study

Mohammad Reza Beyranvand, Mohammad Assadpour Piranfar, Mohammadreza Mobini, Mehdi Pishgahi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e73

Introduction: Among the 12 leads studied in electrocardiography (ECG), lead aVR can be considered as the most forgotten part of it since no attention is paid to it as the mirror image of other leads. Therefore, the present study has been designed with the aim of evaluating the prevalence of ST segment changes in lead aVR and its relationship with the outcome of these patients.

Methods: In this retrospective cross sectional study medical profiles of patients who had presented to emergency department with the final diagnosis of myocardial infarction (MI) in a 4-year period were evaluated regarding changes of ST segment in lead aVR and its relationship with in-hospital mortality, the number of vessels involved, infarct location and cardiac ejection fraction.

Results: 288 patients with the mean age of 59.00 ± 13.14 (18 – 91) were evaluated (79.2% male). 168 (58.3%) patients had the mentioned changes (79.2% male). There was no significant relationship between presence of ST changes in lead aVR with infarct location (p = 0.976), number of vessels involved (p = 0.269) and ejection fraction on admission (p = 0.801). However, ST elevation ≥ 1 mv in lead aVR had a significant relationship with mortality (Odds = 7.72, 95% CI: 3.07 – 19.42, p < 0.001). Sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios of ST elevation ≥ 1 for prediction of in-hospital mortality were 41.66 (95% CI: 22.79 – 63.05), 91.53 (95% CI: 87.29 – 94.50), 31.25 (95% CI: 16.74 – 50.13), 94.44 (95% CI: 90.65 – 96.81), 0.45 (95% CI: 0.25 – 0.79), and 0.05 (95% CI: 0.03 – 0.09), respectively.

Conclusion: Based on the results of the present study, the prevalence of ST segment changes in lead aVR was estimated to be 58.3%. There was no significant relationship between these changes and the number of vessels involved in angiography, infarct location and cardiac ejection fraction. However, presence of ST elevation ≥ 1 in lead aVR was associated with 8 times increase in in-hospital mortality risk.

Introduction: Central venous catheterization (CVC) is a commonly performed procedure in critically ill patients of emergency department. This study was designed to compare the diagnostic accuracy of saline flush with CXR in confirmation of above-the-diaphragm CVC placement. Methods: This prospective cross sectional study was conducted on adult patients in need of CVC placement in emergency department. Placement Confirmation was performed with saline flush method and CXR, then chest computed tomography (CT) was performed as the gold standard. The screening performance characteristics of the two methods were calculated and compared using SPSS 21 and STATA 11. Results: 103 cases with the mean age of 57.18±9.3 (35 -80) years were studied (52.4% male). The mean duration of procedure was 2.5±1.24 in saline flush and 32.11±5.52 minutes in CXR method (P<0.001(. The area under the ROC curves for saline flush and CXR in confirmation of CVC placement were 0.90 (95%CI: 0.70 – 0.100) and 0.80 (95%CI: 0.55 – 0.100), respectively (p = 0.317). The sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of  saline flush were 80%, 100%, 100, 98.9%, Infinity, and 0.01, respectively. These measures were 60%, 100%, 100%, 98%, Infinity, and 0.02 for CXR, respectively. Conclusion: It seems that saline flush method could be considered as a safe, rapid, and accurate bedside method for CVC placement confirmation in emergency department.

Perspectives of Patient Handover among Paramedics and Emergency Department Members; a Qualitative Study

Majid Najafi Kalyani, Zheila Fereidouni, Raheleh Sabet Sarvestani, Zahra Hadian Shirazi, Ali Taghinezhad

EMERGENCY , Vol. 5 No. 1 (2017), , Page e76

Introduction: Improving patient handover is currently considered as a patient safety goal and one of the top five WHO priorities. So, the aim of this study was to explore the perspectives of patient handover among paramedics and emergency department staff. Methods: This is a descriptive exploratory study with a qualitative content analysis approach. Twenty five paramedics and emergency department staff were selected through purposeful sampling. The data were collected through semi-structured interviews in 2015 and Qualitative Content Analysis was used to analyze the data. Result: One main theme and two major categories emerged through the data analysis. In general, data analysis indicated that patient handover is a sophisticated process, which is an encounter between two separate peninsulas with different extrinsic (different environments and different equipment) and intrinsic factors (different manpower and different expectations). Conclusion: Designing an appropriate environment, providing adequate equipment, recruiting appropriate manpower, and clarifying the expectations are some strategies for improving patient handover conditions.

Demographics of Scorpion Sting in Iran; a Cross Sectional Study

Babak Mahshidfar, Hamed Basir Ghafouri, Mohammad Reza Yasinzadeh, Mani Mofidi, Mahdi Rezai, Davood Farsi, Saeed Abbasi, Peyman Hafezimoghadam

EMERGENCY , Vol. 5 No. 1 (2017), , Page e77

Introduction: Scorpion sting is an important public health problem in some countries, including Iran. This study aimed to describe the demographics of a large number of these victims in some endemic areas of Iran.

Methods: This cross-sectional study evaluated baseline characteristics, clinical findings, management, and disposition of scorpion stung cases in 26 cities of 4 provinces in the southwest quarter of Iran, during one year.

 Results: 3008 cases of scorpion sting with mean age of 27.07 ± 16.58 years were studied (51.3% female). The mean time from sting to hospital was 1.89 ± 1.04 hours. No first aid measures had been taken in 96.6% of cases. Lower (39.5%) and upper (35.7%) extremities were stung most frequently. Midnight to 6:00 am was the period of time most of stings occurred (34.2%). Local pain (77.2%) and erythema (63.5) were among the most common signs and symptoms. 2026 (67.3%) victims had been discharged; 326 (10.8%) were admitted or referred to other hospitals and 5 (0.2%) cases died.

Conclusion: It seems that demographic characteristics of scorpion sting in Iran are not so different from those reported from other sites of the world, as signs and symptoms of local and systemic envenomations. Victims, companions, and healthcare providers perform many futile and maybe harmful measures and there is a need to educate all about all of these details.

Introduction: Falling is reported to be the most common cause of mortality due to trauma in individuals over the age of 75 years. The present study is designed with the aim of determining the demographics of fall-related trauma among the elderly presenting to emergency department (ED). Methods: The present prospective cross-sectional study was carried out on all elderly patients ≥ 60 years old presenting to ED of a major referral trauma center in North West of Iran during 1 year. Demographic data, location and height of falling, duration of hospitalization, trauma severity and in-hospital outcome of the patients were gathered and reported via descriptive statistics. Results: 228 patients with the mean age of 70.96 ± 5.2 years were studied (53.9% female). Most patients were in the 66-70 years age range (32.6%) and had a history of hypertension (22.3%), who had visited following a fall inside the house (69.3%), due to slipping (73.7%), and from a height equal to or less than 2m (71.9%). 6 (2.6%) patients died in the hospital. Mean trauma severity of patients based on ISS, RTS, and TRISS were 10.65 ± 3.95 (3-19), 7.84 ±.21 (1.4-14.5) and 1.66 ±1.31 (-1.49-3.82), respectively. Regarding need for hospitalization, only ISS shows a significant difference between outpatients and inpatients (p = 0.023). Patients who died had a significantly higher trauma severity based on ISS (p < 0.0001) and RTS (p < 0.0001). Conclusion: Based on the findings of the present study, slipping and syncope are the most common causes of  falling in the studied elderly that had mostly happened inside the house and from a height less than 2m. Therefore, most patients were in the mild to moderate range of trauma severity. ISS and RTS were significantly higher in the 6 (2.6%) patients who died.

Intranasal Lidocaine for Primary Headache Management in Emergency Department; a Clinical Trial

Hassan Barzegari, Hassan Motamed, Behrad Ziapour, Majid Hajimohammadi, Mina Kadkhodazadeh

EMERGENCY , Vol. 5 No. 1 (2017), , Page e79

Introduction: Most of the headache cases only require pain management in emergency department (ED). The present study aimed to evaluate the efficacy of intranasal lidocaine in this regard. Method: In this clinical trial, adult patients with primary headache were randomly treated with 7.5 mg intravenous (IV) chlorpromazine and 1 ml intranasal lidocaine 2% (treatment) or normal saline 0.9% (placebo), and were compared 5, 15, and 30 minutes later regarding success rate using SPSS 21. Result: 100 patients were assigned to either treatment or placebo group. Number needed to treat of intranasal lidocaine at 5, 15, and 30 minutes were 4 (95% CI: 2.2 – 6.6), 3 (95% CI: 1.7 – 3.5), and 4 (95% CI: 2.3 – 15.9), respectively. These measures for absolute risk reduction were 30 (95% CI: 15.2 – 44.8), 44 (95% CI: 28.7 – 59.3), and 26 percent (95% CI: 6.3 – 44.3), respectively. Pain relapse occurred in 16% of treatment and 11% of control group within 1 hour of treatment (p = 0.402). Conclusion: It seems that, intranasal lidocaine along with IV chlorpromazine could result in more successful and faster management of primary headaches in ED. 

Characteristics of Methadone Intoxicated Children Presenting to Emergency Department; a Cross Sectional Study

Parvin Kashani, Saeed Safari, Hamidreza Hatamabadi, Ali Arhami Dolatabadi, Mohammad Manouchehrifar, Maryam Dokht Tabrizi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e80

Introduction: Each year a large number of patients present to emergency departments (EDs) following accidental or intentional poisoning with methadone. This study was designed with the aim of demographic evaluation of methadone poisoning in children presenting to ED and proposing preventive measures to parents and the healthcare system. Methods: This cross sectional study was carried out on children under the age of 12 years presenting to ED of a poisoning referral center. Demographic characteristics of the child and parents, cause of poisoning, form of drug consumed, dose consumed, the symptoms of the child on admission, clinical examination, laboratory findings, and final outcome were recorded and reported using descriptive statistics. Results: 179 cases were studied (59.2% boys). Cause of consumption was accidental in 175 (97.8%) cases and consumed drug dose was unknown in 53 (53.6%) cases. On admission 6 cases were in deep coma, 133 (74.3%) had miotic pupils, and 52 (29.1%) were affected with respiratory apnea and cyanosis. In 132 (73.8%) cases drugs were obtained from unapproved stores and form of drug consumed was syrup in 146 (81.6%) cases. 177 (98.9%) cases were discharged after 2 or3 days and 2 (1.1%) cases died. Conclusion: Based on the results of the present study, most cases of methadone poisoning were accidental, in children residing in poor and middle-class areas, with parents who had a low level of education and had obtained the drug from unapproved stores and stored it in improper containers or at improper places. Only 64.8% of the parents were educated regarding drug storage.

Valsalva maneuver using a Handmade Device in Supraventricular Tachycardia Reversion; a Quasi Experimental Study

Maryam Motamedi, Mohammad Ali Akbarzadeh, Saeed Safari, Mehrnoosh Shahhoseini

EMERGENCY , Vol. 5 No. 1 (2017), , Page e81

Introduction: The use of vagal nerve stimulation is identified as a proper treatment option in patients with stable supraventricular tachycardia (SVT). This study aimed to assess the success of Valsalva maneuver via a handmade device in reversion of SVT. Methods: In this quasi experimental study, using a handmade device, vagus nerve stimulation was performed for SVT patients presenting to emergency department or cardiac intervention unit and the success rate and its related factors were assessed. Results: 100 patients with the mean age of 53.05 ± 13.70 years were studied (67% female). 12 (12%) cases were unable to do the maneuver. Out of the 88 (88.0%) patients who could perform the maneuver, 75 (85.2%) cases were unsuccessful. Dysrhythmia was controlled in 6 (6.8%) cases on the first attempt and in 7 (8.0%) cases on the second one (14.8% total success rate). 12 of the 13 cases (92.3%) with successful maneuver had history of SVT (p = 0.031). There was not any significant association between success rate and sex (p = 0.084), age (p = 0.744), or other medical histories (p ≥ 0.05). Conclusion: Based on the results of the present study, the success rate of Valsalva maneuver with the mentioned handmade device was calculated to be 14.8%. The only independent related factor of successful reversion was SVT history. 

Introduction: Using alpha blockers such as intravenous (IV) lidocaine has been deemed effective in controlling acute pain. Therefore, the current study was designed with the aim of evaluating the efficiency of IV lidocaine in comparison to IV fentanyl in pain management of patients with renal colic in emergency department (ED). Methods: In this double blind clinical trial, 18-65 year old patients that presented to ED with colicky flank pain and met the inclusion criteria of the study were allocated to either lidocaine or fentanyl group using block randomization and compared regarding pain severity 5, 10, 15, and 30 minutes after drug administration. Results: 90 patients with the mean age of 35.75±8.87 years were divided into 2 groups of 45 (90% male). The 2 groups were not significantly different regarding the studied baseline variables. Pain severity was not significantly different between the 2 groups at various times after injection. Treatment failure rate 15 minutes after injection was 44.4% (20 cases) in IV lidocaine and 17.8% (8 cases) in IV fentanyl group (p = 0.006). These rates were 26.6% (12 patients) versus 22.2% 30 minutes after injection (p = 0.624). Absolute risk increase of treatment failure in case of using lidocaine was 26.7 (95% CI: 8.3-44.9) in the 15th minute and 4.4 (95% CI: 13.3-22.2) 30 minutes after injection. Number needed to harm (NNH) in treatment with lidocaine 15 and 30 minutes after injection were 4 (95% CI: 2.2-12.0) and 23, respectively. Conclusion: Although mean pain severity was not significantly different between IV fentanyl and lidocaine at various times after injection, treatment failure rate was significantly higher in the IV lidocaine group 15 minutes after injection.

Review Article

Clinical Scoring Systems in Predicting the Outcome of Acute Upper Gastrointestinal Bleeding; a Narrative Review

Hanieh Ebrahimi Bakhtavar, Hamid Reza Morteza Bagi, Farzad Rahmani, Kavous Shahsavari nia, Arezu Ettehadi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e36

Prediction of the outcome and severity of acute upper gastrointestinal bleeding (UGIB) has significant importance in patient care, disposition, and determining the need for emergent endoscopy. Recent international recommendations endorse using scoring systems for management of non-variceal UGIB patients. To date, different scoring systems have been developed for predicting the risk of 30-day mortality and re-bleeding. We have discussed the screening performance characteristics of Baylor bleeding score, the Rockall risk scoring score, Cedars-Sinai Medical Center predictive index, Glasgow Blatchford score, T-score, and AIMS65 systems, in the present review.

Based on the results of this survey, there are only 3 clinical decision rules that can predict the outcome of UGIB patients, independent from endoscopy. Among these, only Glasgow Blatchford score was highly sensitive for predicting the risk of 30-day mortality and re-bleeding, simultaneously. 

Early versus Late Decompression for Traumatic Spinal Cord Injuries; a Systematic Review and Meta-analysis

Mahmoud Yousefifard, Vafa Rahimi Movaghar, Masoud Baikpour, Parisa Ghelichkhani, Mostafa Hosseini, Ali Moghadas Jafari, Heidar Aziznejad, Abbas Tafakhori

EMERGENCY , Vol. 5 No. 1 (2017), , Page e37

Introduction: Despite the vast number of surveys, no consensus has been reached on the optimum timing of spinal decompression surgery. This systematic review and meta-analysis aimed to compare the effects of early and late spinal decompression surgery on neurologic improvement and post-surgical complications in patients with traumatic spinal cord injuries.

Methods: Two independent reviewers carried out an extended search in electronic databases. Data of neurological outcome and post-surgery complication were extracted. Finally, pooled relative risk (RR) with a 95% confidence interval (CI) was reported for comparing of efficacy of early and late surgical decompression.

Results: Eventually 22 studies were included. The pooled RR was 0.77 (95% CI: 0.68-0.89) for at least one grade neurological improvement, and 0.84 (95% CI: 0.77-0.92) for at least two grade improvement. Pooled RR for surgical decompression performed within 12 hours after the injury was 0.26 (95% CI: 0.13-0.52; p<0.001), while it was 0.75 (95% CI: 0.63-0.90; p=0.002) when the procedure was performed within 24 hours, and 0.93 (95% CI: 0.76-1.14; p=0.48) when it was carried out in the first 72 hours after the injury. Surgical decompression performed within 24 hours after injury was found to be associated with significantly lower rates of post-surgical complications (RR=0.77; 95% CI: 0.68-0.86; p<0.001).

Conclusion: The findings of this study indicate that early spinal decompression surgery can improve neurologic recovery and is associated with less post-surgical complications. The optimum efficacy is observed when the procedure is performed within 12 hours of the injury.

Pregnancy Screening before Diagnostic Radiography in Emergency Department; an Educational Review

Abdelrahman Ibrahim Abushouk, Morteza Sanei Taheri, Parichehr Pooransari, Sahar Mirbaha, Alaleh Rouhipour, Alireza Baratloo

EMERGENCY , Vol. 5 No. 1 (2017), , Page e60

Radiation exposure during pregnancy may have serious teratogenic effects to the fetus. In modern medical practice, there is an increasing dependence on imaging techniques in most medical specialties. Therefore, checking the pregnancy status before imaging women of child bearing age is essential. Lack of international regulations and standard protocols exposes the patient to unexpected fetal radiation effects and the health professionals to medicolegal suits. Recently, the American Academy of Radiology and the European community of Medical Ionizing Radiation Protection released national guidelines regarding pregnancy screening before imaging potentially pregnant females. However, different methods of pregnancy screening exist among different radiology centers. This review aims to discuss the most recent guidelines for imaging females of childbearing age and highlight the need for an international regulation to guide pregnancy screening before radiological exposure.

Brief Report

Pan vs. Selective Computed Tomography Scans in Management of Multiple Trauma Patients; a Brief Report

Anita Sabzghabaei, Majid Shojaee, Hamid Kariman, Mohammad Manouchehrifar, Kamran Heydari, Sirus Sohrabi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e38

Introduction: Using pan or selective computed tomography (CT) scan in management of multiple trauma patient is a matter of debate. Therefore, the present study was designed aiming to compare the findings of pan and selective CT scans in management of multiple trauma patients.

Method: This is a prospective cross-sectional study, on patients presented to the emergency department (ED) of Shohadaye Haftome Tir Hospital, Tehran, Iran, following blunt multiple trauma over a 1-year period, from March 2014 to March 2015. Findings regarding presence or absence of injury in head, face, neck, chest, abdomen and hip were compared between patients that underwent pan and selective CT using SPSS 21.

Results: 443 patients with the mean age of 34.54 ± 17.88 years were evaluated (78% male). 248 (56%) patients underwent selective CT scan and 195 (44%) underwent pan CT scan. The 2 groups were similar regarding vital signs and mean age. Mean hospital length of stay was 21.05 ± 24.64 days for selective CT scan group and 18.18 ± 22.75 days for the other one (p = 0.209). A significant difference was only seen regarding findings of chest injury between the 2 groups (p < 0.001). In other cases a proper overlap was seen between findings of the 2 groups.

Conclusion: Based on the results of the present study, it seems that doing selective CT scan yields results similar to pan CT in detection of head and face, neck and abdomen and hip injuries in multiple trauma patients. However, using pan CT in these patients led to 16% increase in detection and diagnosis of traumatic intra-thoracic injuries. 

Familiarity of Physicians and Nurses with Different Aspects of Oxygen Therapy; a Brief Report

Reza Goharani, MirMohammad Miri, Mehran Kouchek, Mohammad Sistanizad

EMERGENCY , Vol. 5 No. 1 (2017), , Page e39

Introduction: Oxygen is a drug and physician and nurses should be familiar with the effects and potential risks of oxygen therapy. The current study aimed to assess familiarity of physicians and nurses with various aspects of oxygen therapy.

Method: In this cross sectional study, the familiarity of physicians and nurses with various aspects of oxygen therapy in a teaching hospital was evaluated using a validated questionnaire. The collected data were analyzed using SPSS 21 software.

Results: 57 physicians and 79 nurses returned the completed questionnaire (response rate 97.1%). Mean clinical work experience of participants was 6.9±5.7 (1–15) years.

98.2% of physicians believed that oxygen therapy can be associated with risk and should be recorded in the patient's medical file. These measures were 92.4% and 98.2% for nurses. 38 (27.9%) participants correctly pointed out the reasons for oxygen therapy. Regarding necessary measurements and monitoring for oxygen therapy, 49 (86%) physicians and 65 (82.3%) nurses chose the correct answer. In addition, regarding necessity of blood gas analysis during oxygen therapy, 44 (77.2%) physicians and 55 (69.6%) nurses chose the correct answer.

Conclusion: The findings showed that the familiarity level of participants with some aspects of O2 therapy such as its indications, necessary measurements and monitoring during therapy, and identifying delivery devices was fair to weak (<80%).

Protocol Adherence in Prehospital Medical Care Provided for Patients with Chest Pain and Loss of Consciousness; a Brief Report

Mostafa Mehrara, Nader Tavakoli, Marzieh Fathi, Babak Mahshidfar, Mohammad Amin Zare, Azita Asadi, Saeedeh Hosseinzadeh, Mehdi Safdarian

EMERGENCY , Vol. 5 No. 1 (2017), , Page e40

Introduction: Although many protocols are available in the field of the prehospital medical care (PMC), there is still a notable gap between protocol based directions and applied clinical practice. This study measures the rate of protocol adherence in PMC provided for patients with chest pain and loss of consciousness (LOC).

Method: In this cross-sectional study, 10 educated research assistants audited the situation of provided PMC for non-traumatic chest pain and LOC patients, presenting to the emergency department of a tertiary level teaching hospital, compare to national recommendations in these regards.

Results: 101 cases with the mean age of 56.7 ± 12.3 years (30-78) were audited (55.4% male). 61 (60.3%) patients had chest pain and 40 (39.7%) cases had LOC. Protocol adherence rates for cardiac monitoring (62.3%), O2 therapy (32.8%), nitroglycerin administration (60.7%), and aspirin administration (52.5%) in prehospital care of patients with chest pain were fair to poor. Protocol adherence rates for correct patient positioning (25%), O2 therapy (75%), cardiac monitoring (25%), pupils examination (25%), bedside glucometery (50%), and assessing for naloxone administration (55%) in prehospital care of patients with LOC were fair to poor.

Conclusion: There were more than 20% protocol violation regarding prehospital care of chest pain patients regarding cardiac monitoring, O2 therapy, and nitroglycerin and aspirin administration. There were same situation regarding O2 therapy, positioning, cardiac monitoring, pupils examination, bedside glucometery, and assessing for naloxone administration of LOC patients in prehospital setting.

Introduction: Screening of newborns with seizure, who have curable pathologic brain findings, might be able to improve their final outcome by accelerating treatment intervention. The present study aimed to evaluate the brain ultrasonography findings of newborns hospitalized with complaint of seizure.

Methods: The present cross-sectional study designed to evaluate brain ultrasonography findings of hospitalized newborns complaining seizure.  Neonatal seizure was defined as presence of tonic, clonic, myoclonic, and subtle attacks in 1 - 28 day old newborns.

Results: 100 newborns with the mean age of 5.82 ± 6.29 days were evaluated (58% male). Most newborns were in the < 10 days age range (76%), term (83%) and with normal birth weight (81%). 22 (22%) of the ultrasonography examinations showed a pathologic finding. A correlation was only found between birth age and probability of the presence of a pathologic problem in the brain as the frequency of these problems was significantly higher in pre-term newborns (p = 0.023).

Conclusion: Based on the findings of the present study, frequency of pathologic findings in neonatal brain ultrasonography was 22%. Hemorrhage (12%) and hydrocephaly (7%) were the most common findings. The only factor correlating with increased probability of positive findings was the newborns being pre-term.

Baseline Characteristics of Fall from Height Victims Presenting to Emergency Department; a Brief Report

Hamidreza Hatamabadi, Ali Arhami Dolatabadi, Batoul Atighinasab, Saeed Safari

EMERGENCY , Vol. 5 No. 1 (2017), , Page e55

Introduction: Trauma due to accidents or fall from height is a major cause of disability and mortality. The present study was designed aiming to evaluate the baseline characteristics of fall from height victims presenting to emergency department (ED).

Methods: This prospective cross-sectional study evaluates the baseline characteristics of fall from height cases presenting to EDs of three educational Hospitals, Tehran, Iran, during one year. Data were analyzed using SPSS 21 and presented using descriptive statistics.

Results: 460 patients with the mean age of 27.89 ± 20.95 years were evaluated (76.5% male). 191 (41.5%) falls occurred when working, 27 (5.9%) during play, and 242 (52.6%) in other times. Among construction workers, 166 (81.4%) had not used any safety equipment. Fracture and dislocation with 180 (39.1%) cases and soft tissue injury with 166 (36.1%) were the most common injuries inflicted. Mean height of falling was 3.41 ± 0.34 (range: 0.5 – 20) meters. Finally, 8 (1.7%) of the patients died (50% intentional) and 63% were discharged from ED. A significant correlation was detected between mortality and the falls being intentional (p < 0.0001) as well as greater height of fall (p < 0.0001).

Conclusion: Based on the findings, most fall from height victims in the present study were young men, single, construction workers, with less than high school diploma education level. Intentional fall and greater height of falling significantly correlated with mortality.

Role of Serum Creatinine Phosphokinase in Outcome Prediction of Intoxicated Patients; a Brief Report

Bita Dadpour, Shahrad Tajoddini, Elham Shaarbaf Eidgahi, Mohsen Shokouhizadeh, Azam Shafahi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e63

Introduction: Several mechanisms were introduced as causes of serum creatinine phosphokinase (CPK) raise in intoxicated patients. This study aimed to assess the relationship between serum CPK level in the first 24 hours and baseline characteristics as well as outcomes of these patients.

Methods: This one year retrospective cross-sectional study was conducted on all intoxicated patients, who were admitted to a referral toxicology center, Northwest of Iran, stayed for at least 24 hours and had serum CPK level more than 500 IU/L in the first 24 hours of admission. The relationship between serum CPK level and some baseline and outcome variables were studied using SPSS version 21.

Results: 413 patients with the mean age of 34.52 ± 15.24 years were studied (78.7% male). The mean CPK level at the time of presentation to ED was 3702.85 ± 6375.29 IU/L. There was not any significant relationship between presenting CPK level and type of poisoning (p = 0.258), sex (p = 0.587), and age (p = 0.817). The area under the ROC curve of CPK in prediction of need for dialysis, need for intensive care unit (ICU) admission, and mortality was 0.67 (95% CI: 0.57 – 0.77), 0.60 (95% CI: 0.52 – 0.69), and 0.60 (95% CI: 0.51 – 0.68), respectively.

Conclusion: Based on the finding of present study, there was no significant association between serum CPK level in the first 24 hours and age, sex, and type of poisoning of  intoxicated patients and it had poor accuracy in prediction of their need to do dialysis, need for ICU admission, and mortality.

Introduction: Focused training in transthoracic echocardiography enables emergency physicians (EPs) to accurately estimate the left ventricular function. This study aimed to evaluate the efficacy of a brief training program utilizing standardized echocardiography video clips in this regard.
Methods: A before and after design was used to determine the efficacy of a 1 hour echocardiography training program using PowerPoint presentation and standardized echocardiography video clips illustrating normal and abnormal left ventricular ejection fraction (LVEF) as well as video clips emphasizing the measurement of mitral valve E-point septal separation (EPSS). Pre- and post-test evaluation used unique video clips and asked trainees to estimate LVEF and EPSS based on the viewed video clips.
Results: 21 EPs with no prior experience with the echocardiographic technical methods completed this study. The EPs had very limited prior echocardiographic training. The mean score on the categorization of LVEF estimation improved from 4.9 (95% CI: 4.1-5.6) to 7.6 (95%CI: 7-8.3) out of a possible 10 score (p<0.0001). Categorization of EPSS improved from 4.1 (95% CI: 3.1-5.1) to 8.1 (95% CI: 7.6- 8.7) after education (p<0.0001).
Conclusions: The results of this study demonstrate a statistically significant improvement of EPs’ ability to categorize left ventricular function as normal or depressed, after a short lecture utilizing a commercially available DVD of standardized echocardiography clips.

Case Report

Isolated Oculomotor Nerve Palsy Following Minor Head Trauma; a Case Report

Iraj GoliKhatir, Hamed Aminiahidashti, Hasan Motamed Motlagh, Seyed Farshad Heidari

EMERGENCY , Vol. 5 No. 1 (2017), , Page e42

Isolated third nerve palsy develops in numerous intracranial pathologies such as closed head trauma, tumor, and aneurysm. This report describes a 61 years old female with an abrasion on the left forehead and ptosis of the left eye. Initial computed tomography did not reveal any causative cerebral and vascular lesions or orbital and cranial fractures. High-resolution and multi-axial enhanced Magnetic resonance imaging (MRI) can be helpful in diagnosis and monitoring of patients with this rare phenomenon.

Head Trauma as a Precipitating Factor for Late-onset Leigh Syndrome: a Case Report

Farzad Ashrafi, Hossein Pakdaman, Mehran Arabahmadi, Behdad Behnam

EMERGENCY , Vol. 5 No. 1 (2017), , Page e43

Leigh syndrome is a severe progressive neurodegenerative disorder with different clinical presentationsthat usually becomes apparent in the first year of life and rarely in late childhood and elderly years. It is causedby failure of mitochondrial respiratory chain and often results in regression of both mental and motor skills and might even lead to death. In some of the inherited neurodegenerative diseases like Alexander disease, head trauma is reported as a trigger for onset of the disease. We present a late onset Leigh syndrome in a 14-year-old girl whose symptoms were initiating following head trauma.

A Rare Case of Gastrointestinal Tract Foreign Body; Glassy Stomach

Mohsen Ebrahimi, Jafar Malmir, Azadeh Mahmoudi Gharaee, Mahdi Foroughian

EMERGENCY , Vol. 5 No. 1 (2017), , Page e44

Ingestion of foreign bodies is common and conservative treatment can eliminated most particlesfrom the gastrointestinal tractunless peritoneal signs appear. A 22-year-old man presented to emergency department who had ingested glass particles of a crushed beverage bottle. He complained of epigastric and periumbilical pain. Physical examination did not revealany peritoneal signs. Abdominal X-ray showed stomach full of small glass particles. Conservative treatment, without any surgical intervention,resulted insafely eliminating glass particlesin this patient.

Acute Myocardial Infarction following Naltrexone Consumption; a Case Report

Bita Dadpour, Arash Gholoobi, Shahrad Tajoddini, Amir Habibi

EMERGENCY , Vol. 5 No. 1 (2017), , Page e45

Cardiovascular effects of opioid withdrawal have long been studied. It was reported that patients with underlying ischemic heart disease and atherosclerotic vessels may be complicated by a sudden physical and emotional stress due to withdrawal syndrome. But some other believes sudden increase in catecholamine level as a sympathetic overflow might effect on heart with and without underlying ischemia. In the current study, a patient on methadone maintenance therapy (MMT) who experienced myocardial infarction (MI) after taking naltrexone was described.

Paradoxical Embolism due to Persistent Foramen Ovale; a Case Report

Dormar David Barrios, Jonathan Roncancio, Albert Alejandro Avila, Jaime Andrés Alvarado, Ana Cristina Montenegro

EMERGENCY , Vol. 5 No. 1 (2017), , Page e46

The mean percentage of cryptogenic strokes among ischemic strokes is 31%, of which one-third may be associated with patent foramen ovale. The foramen ovale is required for blood flow through the fetal atrial septum.  It is formed as of the fourth week of gestation, and this leads to right-left interatrial shunt that allows the passage of oxygenated blood to systemic circulation. In 75% of cases, its closure is complete by 2 years of age, but it may persist in 25% of patients. We present the case of a patient with paradoxical embolism in the lower extremities and ischemic stroke in the clinical context of a patent foramen ovale.

Recurrent Syncope following Substance Abuse; a Case Report

Forod Salehi, Mohammad Mehdi Hassanzadeh Taheri, Hamid Reza Riasi, Omid Mehrpour

EMERGENCY , Vol. 5 No. 1 (2017), , Page e47

Drug abuse is considered as the most common poisoning in the world. Stimulants agent especially amphetamines and methamphetamines are among important abused substances. Different types of neurologic, psychiatric, respiratory, gastrointestinal, and cardiogenic complications have been reported to be related to methamphetamine consumption. Some of these substances could cause dysrhythmias which is the most prevalent etiology of cardiogenic syncope. Ecstasy, as one of the most commonly abused drugs, is known as a cause of cardiac dysrhythmias. Here we report a young boy who was admitted into the emergency department following three syncope attacks. All cardiac and neurologic assessments were normal; and finally ecstasy abuse was detected as the main etiology of syncopes.

A 5-Month-Old Infant with Right Scrotum Swelling

Shih-Wen Hung, Kuo-Chih Chen, Chin-Chu Wu, Tzong-Luen Wang, Aming Chor-Ming Lin

EMERGENCY , Vol. 5 No. 1 (2017), , Page e48

Case presentation:

A five-month-old male infant (gestational age 28 weeks, birthweight 1020 gm) with posthemorrhagic hydrocephalus subsequent to prematurity had a left sided ventriculoperitoneal shunt 3 months after birth. Frontal radiography of the chest and abdomen check-up after operation are shown in figure 1. He was referred to our emergency department with a history of right scrotal swelling for several days. Physical examination, he appeared malnourished. He was afebrile. The right scrotum was found to be distended. Bilateral testicles were palpable on both sides. There were no features of shunt malfunction. A complete blood cell count showed the following: leukocyte count, 7900/mm3; segmented neutrophils, 65%; hemoglobin level of 9.3 mg/dL; hematocrit, 25.9%; and platelet, 190000/uL. Other laboratory studies included: glucose, 92 mg/dL; serum urea nitrogen, 10 mg/dL; serum creatinine, 0.2 mg/dL; sodium, 140 mEq/L; potassium, 3.9 mEq/L; C-reactive protein, 2.9mg/L; and prothrombin time with an international normalized ratio of 1.2. His abdomen x-ray is shown in figure 2.  

Spontaneous Adrenal Hematoma in a Pregnant Woman; a Case Report

Mahshid Ghasemi, Ali Akbar Beigi, Faranak Behnaz, Farhad Fathi, Elham Memary

EMERGENCY , Vol. 5 No. 1 (2017), , Page e59

Spontaneous adrenal hematoma is a very rare condition and its prevalence has been reported to be about 1% in previous studies. Although various causes have been proposed to explain its incidence in existing case reports, the etiology and pathology of this condition is still not known. The present study presents a case of spontaneous adrenal hematoma in a pregnant 31 year old woman without history of trauma or other probable risk factors of hemorrhage, presenting to the emergency department with chief complaint of pain in the right flank. Diagnostic measures, imaging and laparotomy, confirmed the diagnosis of spontaneous adrenal hematoma for her.

Accidental Chronic Poisoning with Methotrexate; Report of Two Cases

Reza Bidaki, Mojgan Kian, Hamid Owliaey, Mojtaba Babaei Zarch, Masoud Feysal

EMERGENCY , Vol. 5 No. 1 (2017), , Page e67

Methotrexate has been used widely in dermatology, oncology and rheumatology fields. However, methotrexate-induced mucocutaneous lesions may occur in rare cases. In this case presentation, we report two cases of accidental poisoning with methotrexate. They had accidentally used methotrexate instead of digoxin. This case report emphasizes that early diagnosis and appropriate management is critical in order to improve outcome.  

Warfarin induced skin necrosis (WISN) is a rare but important side effect of warfarin. Early diagnosis may lessen the amount of permanent tissue damage and can prevent progression to full thickness skin necrosis. So, physicians should be aware of such a complication. Screening for protein C or S or anti-thrombin deficiencies, or presence of anti-phospholipid antibodies before beginning warfarin therapy, could be helpful to avoid high levels of international normalized ratio (INR). Here, we report a 54-year-old man who presented to the emergency department with acral and penile gangrene following prolonged use of warfarin. 

Photo Quiz

A 41-Year-Old Woman with Seizure

Fatemeh Mohammadi, Reza Mosaddegh, Samira Vaziri

EMERGENCY , Vol. 5 No. 1 (2017), , Page e65

The patient was a 41 year old woman that was brought to the emergency department (ED) by her husband following seizure. According to the relatives accompanying her, the seizure was of tonic-clonic type, had occurred one hour before presentation to ED, and had lasted 3 minutes. The patient had been drowsy for about 15 minutes after the end of the seizure. She had no history of head trauma and did not mention headache, nausea and vomiting, fever, vision problems or others. On presentation, amnesia regarding the things that happened was evident. In her history, she had a generalized tonic-clonic seizure 4 years back, regarding which she had not done proper follow up for taking necessary diagnostic measures and had not been treated with anti-epileptic medication. She had a history of surgery for removing cold thyroid nodule 20 years ago and was under calcium treatment for 15 years but she had decided to stop taking her medications since 5 year ago. She did not have a history of alcohol or drug abuse. The patient was conscious and awake on presentation and did not have any specific clinical complaints. Her vital signs on presentation were as follows:

Blood Pressure = 120/70mmHg, Pulse Rate = 68/minute, Respiratory Rate = 16/minute, O2saturation= 98% at air room, Oral Temperature= 37°C, and bedside blood sugar in the normal range.

In head and neck examination, the surgery scar was seen in the thyroid region. Examination of the thyroid also showed a nodular surface in palpation. Examination of the heart, lungs, abdomen and extremities did not have pathologic findings. Neurologic examinations including evaluation of cranial nerves, sense and power of the muscles, cerebellar examination and deep tendon reflexes were normal. Based on the opinion of the in-charge physician, anti-epileptic drugs were not prescribed at this stage. Laboratory tests including complete blood cell count, liver function tests (LFT), and level of blood sugar (BS), sodium, potassium, calcium, phosphorus, magnesium, urea and creatinine electrolytes were ordered. Considering the full consciousness of the patient and stability of vital signs and clinical examinations, by taking safety measures and accompanied by a nurse, the patient was referred to the radiology unit to undergo a brain computed tomography (CT) scan, the results of which are shown in figure 1.


In recent years, academic publishing has been faced with many destructive phenomena. “Predatory publishers” (or journals) are one challenge for  cholarly publishing. This term was introduced to academic societies for the first time by Jeffrey Beall in 2010. This letter to editor is about predatory journals and perished articles in the field of emergency medicine.

Australasian Triage Scale (ATS) is used to prioritize incoming patients in the emergency department (ED) according to patient acuity. It`s a five-level triage scale endorsed by the Australasian College for Emergency Medicine (ACEM). The ATS categories are defined by physiological predictors (airway, breathing, circulation, and disability) and maximum waiting time to treatment (1: immediate, 2: 10 minutes, 3: 30 minutes, 4: 60 minutes and 5: 120 minutes). Triage scales should be valid and reliable to ensure safe practice and promote clinical applicability in ED. Ebrahimi et al. reported that the pooled coefficient for ATS is fair: 0.390 (95% CI 0.307–0.466). 

Urgent Need to Strengthen the Chain of Survival in the United Arab Emirates; a Letter to the Editor

Alan Michael Batt, Ahmed Saleh Mohamed Al-Hajeri, Fergal Henry Cummins

EMERGENCY , Vol. 5 No. 1 (2017), , Page e51

Further to our recently published findings, we have completed the analysis of our second year of prehospital data collection for the same service. We wish to expedite the availability of this data to clinicians, researchers and policy makers in the region.

Our 2015/2016 out-of-hospital cardiac arrest (OHCA) data displayed the following demographic results: 514 OHCA resuscitation attempts were attended by national ambulance (NA) emergency medical services (EMS) in the Northern Emirates region (75% male). Male patients continued on average to be younger than female ones (50 vs. 61 years), and the median age of OHCA cases in the United Arab Emirates remains well below that of cases in Western countries (52 years, interquartile range: 38; 69).

Over half of these cases occurred at a home residence, with the next most common location being a street or highway. A total of 282 (54.5%) incidents were witnessed by a bystander, 43 (8.3%) events by NA crew, and 189 (36.7%) incidents were not witnessed. Bystander cardiopulmonary resuscitation (CPR) was attempted in 135 (28.6%) of non-EMS-witnessed cases (n=471). A bystander or public access defibrillator was applied in only five cases (1%) and no shocks were delivered by bystanders in any case. A total of 34 (6.6%) patients had a return of spontaneous circulation in the pre-hospital setting, over twice the rate demonstrated in the first year of our study. Survival to discharge data has been collected for the first time by our hospital partners, and the publication of these results in the near future will contribute greatly to our understanding of the OHCA issue in the region.

The increase in the number of OHCA responses by NA crew is notable in our findings. This may be attributable to several reasons, including greater public awareness of EMS capabilities, and improved access to EMS via the dedicated 998 emergency number and the NA mobile application. This trend is to be welcomed, as implementation of the chain of survival increases the odds for survival. However, similar to our previous findings, a large number of the cases that were witnessed still had a significant time lapse before EMS was activated.

A chain is only as strong as its weakest link. As such, increasing public awareness of the need for early EMS activation, improving bystander CPR rates, and increasing the availability of public access defibrillators still remain significant challenges in implementing the chain of survival in full to address this public health issue in the United Arab Emirates.

There are several factors that lead to early return of patients to the medical centers. These could be due to latent illnesses, misdiagnosis or even inadequate medical care due to staff being worn out. Determining the mentioned factors could help decrease the rate of readmission, restore patient's confidence in health centers and decrease the cost of medical care.

Chi lung Wu et al. in 2010 sought to find out the major cause of patients’ return within 24 hours after discharge from emergency department (ED) and showed that abdominal pain and fever were the most common causes of patients' return, respectively. They found that, on average, 5.5% of discharged patients returned to the hospital.

Tazhibi et al. carried out a research to find out major causes of readmission in Alzahra Hospital, Isfahan, Iran, and concluded that factors related to the patient and hospital could be held responsible for the patients’ readmission to the studied hospital.

Verelst S et al., investigating the reasons for patient re-hospitalization within 72 hours after discharge in a teaching hospital in Belgium, found that 1.9% of admissions to the ED were in fact readmissions. 12% of this population were readmitted because of misdiagnosis.

Chang SY et al. carried out a research in a teaching hospital in Taiwan to investigate the reasons for non-traumatic patient readmission within 72 hours of their discharge. They reported the rate of 3.5% for their readmissions out of their overall 72000 visits. Misdiagnosis was the most common problem among patients who had been readmitted shortly after discharge.

In a retrospective cross-sectional study, we evaluated the medical profiles of all patients who were readmitted within 72 hours of their discharge from the ED of Golestan Hospital, Ahvaz, Iran, during July to December 2013, aiming to find the readmission rate of this ED. 63736 patients were admitted to the ED during the 6-month study period, 635 (0.99 %) cases of which were readmitted within the first 72 hours of discharge (67.1% male). 338 (53.2%) were 16 – 45 years old. Traumatic injuries (37.1%), flank pain (8.3%), acute coronary syndrome (7.2%), Cerebro-vascular accident (5.2%), and abdominal pain (4.8%) were among the most frequent causes of previous ED visit of readmitted patients.  Finally, 70.2% of these patients were discharged again, 15.7% were admitted to other hospital wards, and 14.1% were transferred to other hospitals.

Comparing the results of the present study with previous ones indicates that readmission rate can vary widely not only among different countries but also among various hospitals of the same country. For instance, in the studied hospital, which is a trauma center in the region, readmission rate of trauma patients is higher.

Since readmissions cause unnecessary overcrowding in ED, it would be best if each hospital evaluated their rate of readmission and its causes, and then tried to relieve the problems found. This can be effective in better management of ED, reduction of treatment costs, increasing patient satisfaction, and prevention of ED overcrowding.

With interest we read the article by Ashrafi et al. about a 14-year-old female who is regarded to have developed Leigh syndrome (LS) after traumatic brain injury (TBI). We have the following comments and concerns:We do not agree with the notion that traumatic brain injury was the precipitating factor for LS. The patient had a history of hypoacusis, which is a typical clinical manifestation of a mitochondrial disorder (MID). Hypoacusis obviously had developed long before the TBI. Additionally, the patient was diagnosed with neuropathy of the peripheral nerves two months after TBI. It is rather unlikely that neuropathy was triggered by TBI and more likely it was already present before the trauma. Thus, the initial manifestations of LS in the presented patient were most likely hypoacusis followed by neuropathy and TBI only might have triggered the seizure but not the MID. Why was the patient put on phenytoin, which is well-known to be mitochondrion-toxic? Phenytoin may worsen epilepsy and MID in general and it is conceivable that in fact phenytoin was responsible for worsening of the phenotype and not the TBI. In a 16-year-old female with MELAS syndrome due to the mutation m.3243A>G, phenytoin caused intestinal pseudo-obstruction one month after intravenous phenytoin for status epilepticus. In a patient with Kearns-Sayre syndrome phenytoin decreased cerebrospinal fluid (CSF) folate levels. In rat hepatocytes, phenytoin increased reactive oxygen species (ROS) formation, decreased intracellular reduced glutathione, increased intracellular oxidised glutathione, and enhanced lipid peroxidation and mitochondrial damage. In a hepatic microsomal system, phenytoin decreased state-3 respiration, ATP synthesis, and the mitochondrial membrane potential. In this model, phenytoin increased state-4 respiration, impaired Ca++-uptake and release, and inhibited Ca++-induced swelling. It would be interesting to know how the GJB2 mutation was detected. Was whole exome or panel sequencing carried out? Did the authors choose a gene by gene sequencing approach? Did the parents undergo genetic investigations? Did each of them carry the mutation in the heterozygous state? Did either of the parents manifest clinically? We should be informed about the exact sequence of the TBI. Is it conceivable that the fall was already due to a seizure or syncope? Was the patient unconscious after the TBI? The authors mention that basal ganglia lesions were “negative” on DWI. However, basal ganglia appear hyperintense on DWI in figure 2.  What was the cause of respiratory insufficiency at the second admission? Was it attributable to the cerebral lesions, to myopathy affecting the respiratory muscles, to lactic acidosis, or to a pulmonary infection? Simultaneous application of a bunch of drugs is not advisable since it cannot be differentiated which of them is effective in case the administration is followed by a beneficial response. Overall, the report is not convincing with regard to TBI as the precipitating factor of LS. Most likely, worsening of LS was a random event or triggered by phenytoin. It is also conceivable that stress from TBI triggered the production of ROS, which were mitochondrion-toxic to such a degree that a previously subclinical condition became gradually symptomatic.

Evidence-Based Emergency Medicine

Clinical research usually involves patients with a certain disease or a condition. The generalizability of clinical research findings is based on multiple factors related to the internal and external validity of the research methods. The main methodological issue that influences the generalizability of clinical research findings is the sampling method. In this educational article, we are explaining the different sampling methods in clinical research.