Original/Research Article

Rheumatoid Arthritis Flare-ups Following Immunization with Sinopharm Inactivated Virus-based COVID-19 Vaccine

Parisa Delkash, Amir Azimi, Niloufar Taherpour , Alireza Rajaei , Faraneh Farsad , Saeid Haji Aghajani

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e24

Introduction: This study aimed to investigate the incidence of rheumatoid arthritis (RA) flare-ups following immunization with the Sinopharm COVID-19 inactivated virus-based vaccine.

Methods: We conducted a retrospective observational study at the Rheumatology Clinic of Imam Hossein Hospital, incorporating 200 RA patients in remission undergoing non-biologic Disease-Modifying Antirheumatic Drugs (DMARDs) treatments. A rheumatologist confirmed a flare-up based on patients complain of arthralgia and joint stiffness and complete examination of joints over a three-month period following vaccination.

Results: Twelve percent of all included patients experienced symptom recurrence. The average age of patients with flare-ups was significantly higher, but no gender-based differences were observed (p<0.001 and p=0.071, respectively). The second vaccine dose resulted in a higher number of symptom flares compared to the first dose (9.30% vs. 3.0%, p < 0.001). No significant differences were observed between patients experiencing flare-ups after the first dose and the second dose in terms of the number of involved joints (p=0.321) and the time gap from vaccination to symptom recurrence (p=0.526). No patients required hospitalization, and prednisolone dosage adjustments effectively managed symptoms.

Conclusion: The occurrence of flare-ups was relatively low after the Sinopharm COVID-19 vaccination in RA patients undergoing treatment with DMARDs during remission. The majority of these flares were mild and no hospitalizations were required.

Background: The measurement of mid-regional pro-atrial natriuretic peptide (MR-proANP) as a clinical biomarker has become a potent diagnostic value for identifying patients with heart failure. This study aimed to determine the diagnostic value of MR-proANP in heart failure in comparison with brain natriuretic peptide (BNP).

Methods: This prospective diagnostic accuracy study evaluated two biomarkers in consecutive patients presenting to the emergency department (ED) with acute dyspnea. Blood samples were collected immediately from the participants. A diagnostic value of MR-proANP versus BNP for the diagnosis of acute heart failure was analyzed. All patients underwent transthoracic echocardiography to classify the diagnosis as dyspnea due to heart failure or due to other causes. Patients without a subsequent diagnosis of heart failure were compared as the controls. The diagnostic performance was evaluated by receiver operating characteristics (ROC) analysis.

Results: Overall, 100 patients with heart failure and 85 controls were included in the study. The plasma levels of BNP and MR-proANP were significantly higher in the heart failure patients than in the control patients (p<0.001). MR-proANP levels significantly correlated with BNP levels (r=0.745, p<0.001). The ROC analysis demonstrated an area under the curve (AUC) of 0.872 (95% CI: 0.815–0.917) for MR-proANP and an AUC of 0.814 (95% CI: 0.751–0.868) for BNP. The AUC of MR-proANP was significantly higher than BNP to detect heart failure in patients with dyspnea (p=0.008). The optimal cut-off point of plasma MR-proANP was 134 pmol/L (sensitivity: 88.1%; specificity: 84.5%; PPV: 87.3%; NPV: 85.5%).

Conclusion: MR-proANP may be a useful biomarker for the diagnosis of acute heart failure in patients with dyspnea presenting to ED. The diagnostic value of MR-proANP was superior to BNP for diagnosing heart failure.

Nursing Student Satisfaction with a Crisis Management Game-Based Training; a quasi-experimental study

Mohsen Masoumian hosseini, Seyedeh Toktam Masoumian hosseini, karim Qayumi

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e22

Background: This study was conducted to investigate nursing student satisfaction and anxiety with an emergency and crisis management game-based training (GBT) course.

Methods: This quasi-experimental study included 60 third-year nursing students who had completed their clinical clerkships. The majority were single females, with no significant age differences, disaster experience, or crisis management training. The participants were randomly assigned to two equal group. The intervention group used disaster-themed games, while the control group received case-based training. The study comprised a four-week internship, and a self-reported anxiety levels was assessed before and after their first clinical experience. In addition, a self-report questionnaire was used to measure students' satisfaction with the Game-based Training program. The reliability of these questionnaires was assessed by a panel of ten faculty members and using Cronbach's alpha. The reliability of both the anxiety and satisfaction questionnaires was found to be 87%. The satisfaction questionnaire's alpha coefficients for realism, transferability, and value were 0.52, 0.79, and 0.74, respectively. Additionally, the face validity of these questionnaires was evaluated.

Results: Participants felt that the experiences recreated real-life situations, tested their clinical decision-making, prepared them for the "real-life" clinical setting, and increased their confidence while in the clinical setting. In comparison to students who did not take part in the preclinical GBT, students who engaged in disaster-themed games showed significantly lower self-reported anxiety scores.

Conclusion: Nursing students are increasingly utilizing game simulators for learning, practicing, and enhancing their skills. They experience positive satisfaction and reduced anxiety through GBT. These simulations offer realistic clinical scenarios, opportunities for decision-making, and confidence-building.

SARS-CoV-2 Antigen Rapid Test in The Emergency Department; a Diagnostic Accuracy Study

Saeed Safari, Faezeh Golpour, Mohammad Mehdi Forouzanfar, Behrooz Hahsemi, Shahram Ebrahimi, Nastaran Sadat Mahdavi

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e1

Title: Evaluation of diagnostic value of SARS-CoV-2 rapid diagnostic test in patients with Covid-19

Introduction: The standard RT-PCR test is a time-consuming diagnostic test with difficult accessibility and high cost, so in order to early diagnose and prevent the spread of Covid-19 disease, access to a quick, inexpensive diagnostic test with easy access is essential. This study aimed to evaluate diagnostic value of SARS-CoV-2 rapid diagnostic test in patients with Covid-19.

Materials & Methods: The present study is a cross-sectional study in type of diagnostic value that was performed on 188 patients with symptoms of Covid-19 referred to the emergency department of Imam Hossein and Shohadaye Tajrish hospitals in Tehran. In this study, SARS-CoV-2 rapid diagnostic test was performed immediately after sampling and according to the manufacturer's instructions (reading in 10 minutes). Then chest CT scan was performed less immediately after collecting samples to compare with the results of rapid antigen detection test. Data were collected and analyzed using Spss software V.26 and descriptive-mean and Chi-square statistical tests.

Results: Results showed that out of 83 patients who were diagnosed with Covid-19 positively based on rapid diagnostic test, all of them (100%) were also positive based on chest CT scan results, and out of 100 patients diagnosed Covid-19 negative based on rapid diagnostic test, 42 patients (42%) were true negative and 58 were positive base of chest CT scan results. The sensitivity of the rapid diagnostic test compared to chest CT scan was 100%, its specificity was 42%, its positive predictive value was 58.86% and its negative predictive value was 100%.

Conclusion: Due to the high accuracy and rapid diagnostic of rapid diagnostic test (SARS-CoV-2), this test is a valid and reliable tool for rapid diagnosis of Covid-19 disease in emergency cases.

Associated Factors of In-hospital Outcomes in Emergency Department's Cardiopulmonary Resuscitation; a Cross-Sectional Study

Saeed Safari, Mohammad Mehdi Forouzanfar, Masoume Bakhshi, Behrooz Hashemi, Shayan Roshdi Dizaji, Nastaran Sadat Mahdavi

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e2

Introduction: Even though the basic principles of cardiopulmonary resuscitation (CPR) are simple, the patients' outcome remains inconsistent. This study aimed to investigate the CPR outcomes and associated factors in the emergency department.

Method: This cross-sectional study was conducted on patients who underwent in-hospital CPR following a cardiac arrest in the emergency department for one year. The patient's baseline characteristics and CPR outcomes were recorded from patients' profiles, and the association of patient-related and CPR-related variables with the outcomes was assessed.

Results: 220 patients with a mean age of 71.5 ± 16.9 (range: 20-100) years were included (60.5% male). 193 cases of cardiac arrests had occurred in the hospital. Presenting cardiac rhythm in 198 cases (90.0 %) was asystole (not requiring defibrillation). The mean duration of conducted CPR was 43.2 ± 15.6 (5-120) minutes. Only 7 patients (3.2%) achieved the return of spontaneous circulation (ROSC) and were discharged from the hospital, with one suffering from neurological impairment due to CPR. There was a significant association between age (p = 0.047), consciousness status at admission (p = 0.003), presenting cardiac rhythm at CPR initiation (p = 0.0001), and establishment of ROSC under 45 minutes (p = 0.043) with patients' outcomes. Presenting cardiac rhythm at CPR initiation (p = 0.001), ROSC under 45 minutes (p = 0.012), and consciousness status at admission (p = 0.027) were independent predictive factors of survival. The area under the ROC curve for presenting cardiac rhythm and ROSC under 45 minutes was 0.817 (95% CI: 0.617-1.000) and 0.805 (95% CI: 0.606-1.000), respectively.

Conclusion: Based on the present study's findings, the survival rate of patients after CPR in ED was 3.2%. Presenting cardiac rhythm, ROSC under 45 minutes, and consciousness status at admission was among the independent predictors of mortality.

Social impact of the Iraq-Iran war as experienced by Iranian surgeons

Ahmad Pour-Rashidi, Zahra Ghodsi, Judith Aarabi, Jalil Arabkheradmand, Vali Baigi, Khatereh Nagdi, Seyed Mohammad Ghodsi, Vafa Rahimi-Movaghar

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e13

Surgeons played a vital role in the Iraq-Iran War by healing injured soldiers and reducing the rate of death. The purpose of this study was to describe their lived experiences and social impact during the war. This qualitative study was conducted from May 2018-June 2019 and surgeons who participated in the Iraq-Iran War were invited. Semi-structured in-depth interviews were used to collect the data from 28 participants. Four main themes emerged from the data:  1- Military role was important in providing essential facilities and safe zones for personnel and soldiers at the warfront. 2- It was critical to reinforce the infrastructure for immediate medical assistance. 3- Disaster training for medical personnel was vital for triage, treatment, education and research planning. 4- Spiritual and religious beliefs. Disaster planning and training for physicians by drills is essential to meet the challenges of unexpected events and operative readiness requires drill training on a quarterly or semi-annual basis.

Review Article

Efficacy of Irisin on neurological and tissue-related outcomes in ischemic brain injuries; a scoping review

Seyedeh Romina Rafiei Alavi, Seyedeh Niloufar Rafiei Alavi, Amirmohammad Toloui, Arash Sarveazad, Mahmoud Yousefifard

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e25

Background: Evidence indicates the protective role of Irisin on nervous tissue following ischemic events, by preventing the cascades of secondary damage. We conducted this scoping review to summarize what has been discovered so far on the neuroprotective effects of Irisin, with a focus on ischemic stroke.

Methods: Search strategies were designed based on the keywords related to ischemic stroke and Irisin. Next, an extensive search in Medline, Embase, Scopus, and Web of Science was conducted by the end of April 2022. Two researchers independently reviewed the articles and performed the screening of the selected papers according to the inclusion criteria. Finally, the required data were extracted to a checklist designed based on the PRISMA guideline. The “meta” package was used for the meta-analysis, and heterogeneity between studies was assessed using the I2 test.

Results: Pooled data analysis showed that the Irisin administration significantly improved the neurological function following cerebral ischemia / reperfusion injuries (SMD = 3.08; 95% CI: 1.10, 5.06; p<0.0001). Additionally, meta-regression demonstrated that the improvement in neurological function was directly related to the dose of administered Irisin (meta-regression coefficient = 0.03; p = 0.02). Moreover, Irisin administration significantly reduced the volume of infarcted lesions (SMD= -3.14; 95% CI: -4.23, -2.04; p<0.0001), the amount of edema in the brain (SMD= -2.30; 95% CI: -4.07, -0.53; p<0.0001), and the extend of neuronal-cell apoptosis rate (SMD= -4.67; 95% CI: -8.15, -1.19; p<0.0001).

Conclusion: The present study demonstrates that the administration of Irisin in animal models of cerebral ischemia / reperfusion injuries is associated with a significant dose-dependent improvement in neurological function. Due to the limited number of articles, more research on the aim of finding the optimum Irisin dosage is in high demand.

Value of Los Angeles Motor Scale (LAMS) in the detection of large vessels occlusion in suspected stroke patients; a systematic review and meta-analysis

Koohyar Ahmadzadeh, Erfan Abdollahi, Mohsen Aliyariparand, Mohammad Soleimani, Hamzah Adel Ramawad, Reza Miri, Mahmoud Yousefifard

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e6


Los Angeles Motor Scale (LAMS) is a validated prehospital scoring tool to identify stroke patients with large vessel occlusions (LVOs). While some studies have reported conflicting data in regards to the diagnostic value of LAMS, this systematic review and meta-analysis aims to provide a more concrete evidence for the value of this clinical decision tool in the diagnosis of LVO in suspected stroke patients.


Online databases of PubMed, Embase, Scopus, and Web of Science were searched until the end of October 2022, for studies evaluating the diagnostic performance of LAMS in the detection of LVOs in suspected stroke patients.


The results of our analysis demonstrated an AUC of 0.83 (95% CI: 0.79, 0.86), sensitivity of 0.65 (95% CI: 0.54, 0.74), and specificity of 0.83 (95% CI: 0.79, 0.86) for the diagnostic value of LAMS score with a cut-off value of ≥ 4. The diagnostic odds ratio of LAMS score was 8.81 (95% CI: 6.24, 12.45). Sensitivity analyses reveled that diagnostic performance of LAMS improves when utilized for detection of occlusion in the more proximal segments of large vessels, with a sensitivity of 0.75 and specificity of 0.83.


A high level of evidence showed that LAMS scale does not have a promising diagnostic value in the identification of LVOs in suspected stroke patients. The sensitivity of 0.65 for this tool makes it obsolete as a proper triaging tool. As a suggestion, LAMS could be utilized in conjunction with other additional factors to increase its diagnostic performance.

The therapeutic effect of Nesfatin-1 on acute myocardial ischemia/reperfusion injury; a systematic review and meta-analysis

Amirali Zarrin, Sina Roshankar-Roodsari, Hamed Zarei, Shayan Roshdi Dizaji, Koohyar Ahmadzadeh, Reza Miri, Mahmoud Yousefifard

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e7


In recent years, various peptides have been introduced for the complementary treatment and management of post-reperfusion injuries. Nesfatin-1, a peptide secreted by the nervous system and peripheral tissues, modulates cardiac function, and plays an important role in the cardiovascular response to stress conditions. This systematic review and meta-analysis aims to investigate the preclinical evidence on the effect of Nesfatin-1 administration in the improvement of cardiac ischemia/reperfusion injury.


Online databases of PubMed, Embase, Web of Science, and Scopus were searched until November 2nd, 2022, for articles investigating the therapeutic effects of Nesfatin-1 administration on myocardial ischemia/reperfusion injury in preclinical models. Cardiac functions, infarct size, myocardial tissue fibrosis, inflammation, oxidative stress, apoptosis, necroptosis, and necrosis were chosen as outcomes. The results are reported as an overall standardized mean difference (SMD) and 95% confidence interval (CI).


Our results demonstrate that the administration of Nesfatin-1 improves cardiac parameters such as ejection fraction (SMD = 3.94, 95% CI: 0.30 to 7.58), heart rate (SMD = 3.30, 95% CI: 0.41 to 6.18), and negative dp/dt (SMD = 2.05, 95% CI: 0.60 to 3.50) and positive dp/dt (SMD = 2.78, 95% CI: 0.56 to 4.99). Nesfatin-1 was shown to significantly reduce myocardial infarct size (SMD = -4.32, 95% CI: -5.95 to -2.69 and fibrosis (SMD = -3.91, 95% CI: -5.67 to -2.15). Apoptotic score (SMD = -2.07, 95% CI: -3.51 to -0.63) and oxidative stress were also reduced subsequent to Nesfatin-1 administration. Nesfatin-1 was not shown to decrease inflammation, necroptosis, and necrosis.


In conclusion, we demonstrated that Nesfatin-1 could serve as a potential therapeutic agent in ameliorating the secondary damages during myocardial I/R injury. Nesfatin-1 administration can preserve cardiac function by reducing oxidative stress, apoptosis, and myocardial necrosis. However, much more studies are required to endorse further clinical translation of Nesfatin-1 to be utilized in the management of myocardial I/R injury.

Hospital Preparedness for the Covid-19 Crisis; an Overview

Farhad Azadmehr, Mohammad Sistani, Ayshe Hajiesmaeilpoor, Payam Emami

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e11

Aim: The situation, structure, and facilities of hospitals change in a crisis, which negatively affects the provision of care quality of health services. One of the current world crises is the Covid-19 pandemic. This study aimed to investigate the preparedness of hospitals to deal with the Covid-19 crisis.

Materials and Methods: This narrative review searched the SID, PubMed, Scopus, Google Scholar databases/search engines in published articles between 2019-2022. A search strategy was defined for PubMed and it was translated into other selected databases. Also, the reference list of the included articles was searched.

The databases/search engines were searched by two authors independently, and any disagreement was resolved through discussions. To find related articles, Iranian and International databases were searched using Persian keywords and their English equivalents (Covid-19, Hospital, Preparedness, epidemic, and Pandemic).

Results: A total of 311 articles were found, of which 15 were reviewed. Inclusion criteria included being an original paper, in Persian or English, and compliance with the purpose of the study. The exclusion criteria included not having access to the full text of the article. The study showed that hospital preparedness against the Covid-19 pandemic in most countries and different regions in Iran is not optimal. Hospitals should be prepared in terms of personal protective equipment, staffing, and beds. Rapid response management and hospital equipment should be strengthened.

Review of Predisposing Factors of Cervical Ectopic Pregnancy; an Update

Ezzat Hajmolarezaei, Farzaneh Khoroushi, Mahboubeh Haddad Nameghi, Shohre Khatami, Azadeh Beiglarzadeh, Maryam panahi

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e17

Cervical ectopic pregnancies (CEPs) are rare, comprising less than 1% of ectopic pregnancies. On one hand, the abundant blood supply of the cervix and its incompatibility to keep the pregnancy in progress increases the potential for bleeding following CEP, mortality, complications, and infertility in affected women. CEPs are more difficult to diagnose and get identified at later gestational ages. CEP is one of the rarest forms of ectopic pregnancies and most commonly are a consequence of assisted reproductive technology (ART); while definitive risk factors are not fully known. Possible risk factors include cervical and uterine anomalies, previous curettages or cesarean sections, smoking, tubal factor infertility, or in vitro fertilization (IVF) treatment. Our analysis of literature in 200 patient restricted to retrospective case series , showed that a history of previous C-section, uterine curettage or D&C procedures, and a history of using assisted reproductive technology might be some of the potential risk factors. The increasing application of Hegar dilators was hypothesized as the cause of the rise in CEPs. Dilation and curettage (D&C) might also make the subject vulnerable to CEP development in the future. Previous D&C history could be a potential predisposing factor that is common among CEP patients.  In this review, we critically reviewed these potential risk factors. In conclusion, the risk factors of CEP and their effect on fertility are also not studied properly. The rarity of these cases makes it difficult to predict as well if the risk of their recurrence is elevated.

Letter to Editor

Artificial intelligence and Nursing: Dawn of a new era?

Ameneh Marzban; Mina Moafi; Payam Emami

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e18

Artificial Intelligence (AI) has emerged as a transformative force across various industries and healthcare. With the ever-expanding capabilities of AI, there is growing interest in the exploration of its potential applications in nursing practice to enhance patient care, improve workflow efficiency, and possibly revolutionize healthcare systems.

There is no consensus on the myocardial ischemia/reperfusion injury induction methods in animal studies

Koohyar Ahmadzadeh, Reza Miri

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e5

Dear Editor:

Ischemic heart diseases (IHDs) are among the most important causes of death and disability worldwide. Every year, 10.6 million people are diagnosed with IHDs; in 2017, 8.9 million died due to this disease (1). The treatment of myocardial infarction is principally based on prompt blood supply restoration to salvage the ischemic tissue utilizing timely thrombolytic medications and coronary revascularization (2). However, the subsequent reperfusion provokes secondary cellular damage, broadly referred to as reperfusion injury (3). Although a compendium of therapeutic agents has been proposed to allay the detrimental consequences of reperfusion, they do not yet have desirable efficacies, and the research for discovering novel promising treatments is still ongoing.

Preclinical studies are integral to the translation of preliminary research into clinical practice. Conventionally, plausible treatments and innovative drugs are tested in animal experiments to ascertain their effectiveness and safety. Experimentations on cardiac Ischemia/reperfusion injuries comprise a significant body of literature among the preclinical studies, and one can find a myriad of evidence in online databases.

Through our systematic reviews, we have encountered various myocardial ischemia/reperfusion (I/R) models, including large vessel ligation, global ischemia by administrating Isoproterenol, and interrupted perfusion of isolated hearts mounted on the Langendorff apparatus. Moreover, the studies were inconsistent regarding the duration of ischemia and, the subsequent reperfusion phase(4, 5). The secondary damages in the course of I/R injury are proportionate to the extent and duration of the ischemia (6). Moreover, Pathways leading to myocardial damage during I/R injury are considered a dynamic and evolving process (7). Therefore, the efficacy of interventions in mitigating I/R injury may be misestimated depending on the duration of the ischemic and reperfusion phases.

To surmount these concerns, we suggest an expert panel develop standardized guidelines for myocardial I/R injury induction in experimental studies to consolidate further the reliability and validity of the results obtained from preclinical studies, ultimately contributing to the better appraisal of the studies. In the meantime, tissue markers representative of the degree of infarction or tissue fibrosis can be used to compare the induced ischemia/reperfusion injuries in studies.

A cardiac tamponade that does not require pericardiocentesis; a Letter to Editor

Alireza Bahmani

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e15

Cardiac tamponade is a leading cause of death in patients with aortic dissection (1). When aortic dissection is accompanied by cardiac tamponade, emergency surgery to repair the aorta is required (2). The treatment approach for this group of patients differs from other cases with pericardial effusions, and percutaneous pericardiocentesis is contraindicated. Attempting pericardiocentesis in this type of tamponade leads to increased leakage from the aorta into the pericardium, worsening the patient's condition(3). In approximately one-third of patients, transudation of blood across the thin layers of the aorta and into the pericardial space results in an insignificant pericardial effusion due to the blood entering the pericardial cavity (4).

Case Report

Rebar Impalement Trauma in A Construction Worker: A Case Report and Literature Review

Vahid Jomeh zadeh; Tania Yeganeh; Tooraj Zandbaf, Kaveh Behnia, Ramin Hasani, Sepehr Shirzadeh

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e19

Coincident impalement trauma to the neck and chest is infrequent but life-threatening. Our case was a 35-year-old man, who presented with rebar penetration injury to the neck and mediastinal area. He was conscious and his vital signs were stable. After initial imaging, the patient was transferred to the operation room for explorative surgery; however, as the rebar was loos in its site, we simply pulled out the rod. The patient developed acute respiratory distress syndrome (ARDS) during their administration and was eventually discharged without further complications and comorbidities.

Dengue shock syndrome in sickle cell disease precipitating sickle cell hepatopathy: a case report

Zainab Mehdi, Monica Gupta, Shivam Bansal, Nidhi Arora, Chandan Singla

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e23

Sickle cell disease (SCD) is a known risk factor for the development of severe dengue, however, literature documenting dengue in SCD is scarce. Dengue fever further triggers the sickling process in a patient with SCD by augmenting endothelial dysfunction, the main identifiable cause behind organ dysfunction. Hepatic involvement in SCD due to enhanced sickling can be in the form of acute viral hepatitis, cholecystitis, acute sickle hepatic crisis, and more severe sickle cell intrahepatic cholestasis (SCIC). Initially starting as an acute sickle hepatic crisis, SCIC progresses to striking jaundice, enhanced bleeding tendency coupled with mostly renal failure. We report a rare case of a female, native of Chhattisgarh with SCD and dengue shock syndrome who had fatal hepatic complications resulting from accelerated severe endothelial dysfunction due to concurrent illnesses.

Seizure in a patient who received propofol and ketamine for procedural sedation; A

Sara Nikpour, Mohammad Reza Farnia

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e21

Procedural sedation and anesthesia (PSA) is a common practice in the emergency department (ED). We report a case of seizure after ketamine and propofol administration for procedural sedation. Seizure is not a common side effect of ketamine nor propofol. A 60 years old man admitted to the emergency department with complaint of right shoulder pain caused by the blunt trauma. Simple X-Ray revealed anterior dislocation. After administration of 30 mg ketamine and propofol (1:1) intravenously, closed shoulder reduction was performed. After 2 minutes, the patient experienced a generalized tonic-clonic seizure with upward gaze and urinary incontinence. The clonic movements resolved after about 1 minute with supportive care and without anti epilepsy drugs, then the patient entered the post-ictal phase. 45 minutes later, the patient was completely awake and after 6 hours observation, he was sent home with discharge instructions. Seizure is not a common complication of any of the administered drugs. Nevertheless, rare possibilities may also occur, and thus emergency clinicians and others who perform procedural sedation, should be ready for any possible complications to treat them appropriately.

Renal Infarction following Asymptomatic Aortoiliac Thrombosis as a Cause of Severe Flank Pain; a Case Report

AbdolGhader Pakniyat, Rojin Ramezani, Hojjat Rastegari, Alireza Bahmani

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e3

Renal infarction is rare and may be considered acute renal colic in presentation. In this report, we describe a case of renal infarction caused by thrombosis that extended from the aortoiliac to the infrapopliteal segment, along with thrombosis that occurred in the right popliteal artery and left atrium. A 48-year-old man was referred to the emergency department (ED) suffering left flank pain. The pain was significant with radiation to the left lower quadrant, and the pain did not significantly decrease despite intravenous ketorolac and morphine sulfate administration. We decided to perform a color Doppler ultrasound test of intraabdominal vessels that revealed low flow in the left iliac artery. By computed tomography angiography (CTA), it was confirmed that the left renal, iliac, and popliteal arteries were thrombosed. The patient underwent anticoagulation, thrombectomy, and Mitral valve replacement surgery during the hospitalization. After 14 days, his heart rhythm returned to normal sinus and he was discharged from the hospital with proper outpatient follow-up. Patients with severe flank pain and who do not respond to routine treatments, especially patients with significant risk factors, should be evaluated more carefully for red flag diagnosis. 

Amiodarone can still be a drug of choice at emergency departments for pre-excited atrial fibrillation even in the face of guidelines prohibition

Babak Payami, Afshin Zarrin, Mofid Hosseinzadeh, Habib Haybar , Sepideh Khodamoradi

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e8

Electrical cardioversion or intravenous ibutilide are currently recommended as the acute treatment for pre-excited atrial fibrillation. Recent guidelines for this circumstance forbid intravenous amiodarone despite its effectiveness in blocking the accessory pathway and atrioventricular node due to the possibility of ventricular fibrillation. But as our presented case, some physicians continued to favor intravenous amiodarone successfully in a suitable setting.

Incompatible Blood Transfusion as a Result of a Well-Known Human Error; a Case Report

Mohammadreza Shahmohammadi, Firoozeh Madadi, Faranak Behnaz

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e10

Blood product transfusion is a double-edged sword; it can be lifesaving in many circumstances, yet life-threatening serious complications may occur. Although transfusion-related reactions have decreased over the years as a result of hemovigilance networks all over the world, human errors still remain an important concern.  In this case report, we describe a patient undergoing elective spinal surgery who received an incompatible blood product. Then we will describe measures to mitigate such errors.

Beyond anaphylaxis: acute myocardial infarction with ischemic stroke after bee sting a case report

Zainab Mehdi, Monica Gupta, Anish Garg, Narinder Kaur

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e14

Although Hymenoptera stings mostly present with benign local inflammation, they can also be fatal. The true incidence of fatal reactions is unknown as sudden deaths due to insect bites might be regarded as heart attacks or strokes. Hymenoptera stings remain an underrecognized and underdiagnosed entity with no relation between the early cutaneous manifestations and the uncommon deadly reactions that are seen days to weeks later. We report a case of a 69-year-old farmer referred to our hospital with both acute coronary syndrome and acute ischemic stroke approximately 5 hours after a bee sting without a history of any initial anaphylaxis.

Kawasaki disease is an acute febrile disease with the vasculitis of small and medium vessels that mainly affects children under the age of five, usually occurring after a viral respiratory disease. During the coronavirus disease-19 (COVID-19) pandemic, a significant increase was reported in the number of children with symptoms similar to Kawasaki disease, which is known as a multi-system inflammatory syndrome in children (MIS-C). A Kawasaki-like disease is rare in adults, especially in the context of COVID-19. We hereby present the case of A 41 year old female patient presented with complaints of bleeding from the gums and red and watery eyes, high fever, sore throat, weakness, and lethargy. She mentioned a recent contact with a COVID-19 patient. Covid-19 was confirmed by a positive reverse transcription polymerase chain reaction (RT-PCR) test. Other lab tests and clinical manifestations revealed inflammatory phenomena that fully complied with multi-system inflammatory syndrome in adults (MIS-A) criteria. The patient was treated with a possible diagnosis of MIS-A in the context of COVID-19 and was discharged in good general condition. COVID-19 rarely presents in adults without clear respiratory symptoms and in the form of multisystem inflammatory syndrome (MIS-A). Due to the possibility of irreversible complications, MIS-A requires special attention and early diagnosis and treatment.


Point-Of-Care-Ultrasound Doppler Training for Clinicians (Part 1)

Alireza Bahmani

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e4

Today, clinicians use ultrasound, similar to the use of a stethoscope ten years ago. We will soon see ultrasound probes in the pockets of every medical student (1), Nowadays, ultrasound probes are used in the examination of patients, and ultrasound is no longer considered a para-clinical procedure, and during patient examinations, we also perform ultrasounds for our patients in order to limit differential diagnosis (2). As a result of these examinations and applying clinical and ultrasound findings, the desired treatment is determined.

ChatGPT: A useful tool for teaching orthopedic trauma to residents

Seyyed Hadi Kalantar, Seyyed Saeed Khabiri, Nima Bagheri

Iranian Journal of Emergency Medicine, Vol. 10 No. 1 (2023), 30 November 2022, Page e9

As a practicing orthopedic surgeon and educational deputy in the orthopedic ward, I have witnessed challenges teaching complex surgical procedures and managing orthopedic trauma patients to residents in real-time. However, the advancement of technology has dramatically accelerated the learning process. During Covid-19, we have benefited from online teaching and case discussions using WhatsApp and received many positive feedbacks from residents and faculties. Speaking of the new technological assets, one particular tool that has proven to be very effective for educational purposes is ChatGPT.