Original/Research Article

Work Related Burden of Stress among Emergency Medical Service Personnel

Abbas Dadashzadeh, Azad Rahmani, Hadi Hasankhani, Safa Elmi

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e2

Introduction: The staff of pre-hospital emergency medical service experience many stresses daily in the frontline of emergency responses. Critical conditions and trying to save patients’ lives make operation difficult for emergency medical technicians. The burden of stress in this job group is related with critical incidents, and functional and emotional problems that are the result of the rate of exposure and the intensity of the stressor. Methods: In this descriptive-correlation study, 320 technicians working in pre-hospital emergency bases participated. To gather data, stress burden evaluation questionnaire, which was the result of rate of exposure to stressors, was used. Data were analyzed using SPSS statistical software and descriptive and inferential statistics. Results: In the present study, the most important causes of burden of stress were reported to be environmental occupational factors and patient-related factors. Mean and standard deviation of stress burden was 8.70 ± 3.61. Working with trauma patients, unrealistic expectations of the patient or their relatives, and driving in critical conditions and resuscitation of patients inflicted the highest burden of stress upon the staff. In this study, the mean score of stressor intensity was higher than the mean score of exposure to stressors and a significant correlation was seen between the rate of stress burden with number of operations, educational degree, emergency bases, and status of employment. Conclusion: Proper identification of stressors in terms of prevalence and intensity, leads to better understanding of these factors in pre-hospital emergency and can be of great help in prevention and control of stress burden among emergency medical service staff. 

Knowledge of Emergency Medical Service Staff on Crisis Management

Hedayat Lalehgani, Salman Yadollahi, Yousef Fadaee, Farshad Ansari, Mousa Karimifard

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e3

Introduction: Since emergency medical service (EMS) staff members are the first providers of health care at times of crisis, this study was done with the aim of determining the knowledge of EMS staff on crisis management and its related factors in all emergency bases located throughout Chaharmahal and Bakhtiari province, Iran. Methods: This study was done as a descriptive cross-sectional one. Sampling was done via convenience sampling. The tool used for data gathering was a questionnaire prepared by a researcher that included questions regarding demographic characteristics and knowledge of EMS staff on crisis management, which evaluated their knowledge in 4 categories of educational, management related, professional, and safety related. 4 questions were asked in each category that assessed the knowledge of EMS staff on Likert scale using 5 choices of none, low, moderate, high, and very high. Validity of the questionnaire was evaluated using the content validity method and its reliability was calculated to be 88% via Cronbach’s alpha. To analyze the data, SPSS 13 software and descriptive statistics methods were applied. Results:Data analysis showed that 100% of the participants in this study were male and their mean age was 27.52 ± 6.47 years. Knowledge of the EMS staff on crisis management was very high in 2.2 % of the participants; high in 10.2%; moderate in 48.4%; and low in 39.2%. In evaluation of statistical correlations it was determined that educational level, attending crisis maneuvers, and crisis committee membership directly correlated with knowledge of the participants on crisis management (p < 0.05). Conclusion: The results of the present study indicate the relatively low knowledge of EMS staff members on crisis management and its related factors, which points out the need for education and holding maneuvers to improve their knowledge in order to be prepared for facing crises. 

Affecting Factors on the Quality of Resident Education in Emergency Department; a Cross-Sectional Study

Mehdi Momeni, Farzaneh Shirani, Maryam Lachini, Elnaz Vahidi, Morteza Saeedi, Ehsan Karimialavijeh

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e5

Introduction: Considering the differences between the infrastructures of healthcare systems in Iran and advanced countries, there is a need for directing the education of emergency medicine residents in a way that not only meets the treatment needs of the society, but can also cover the determined educational goals for the residents of this specialty with the guidance and help of the faculty members. The first steps might be evaluating the present status and surveying the residents and faculty members who are active in emergency medicine specialty. Therefore, the present study was designed and performed with the aim of evaluating the factors affecting the quality of resident education in emergency department (ED). Methods: Initially, a group that consisted of 5 experienced faculty members expressed their opinions on the factors affecting the quality of resident education in an interview, which resulted in the design of a questionnaire with 27 topics that led to preparation of a 23-item questionnaire after validity and reliability evaluation. These items were classified in 3 groups of personal factors, environmental factors, and patient-related factors. Consecutive sampling was done and all the residents and faculty members of emergency medicine in Tehran University of Medical Sciences who were active in this specialty during the study period were eligible to participate in the study. A quantitative survey was done using 5-point Likert scale. Then the data were statistically analyzed to evaluate the agreement rate of the residents and faculty members in each item. Results: In total, 57 residents with the mean age of 32.75 ± 6.12 years and 23 faculty members with the mean age of 39.65 ± 5.54 years participated in the study and filled out the questionnaires. Mean scores of the 3 categories of evaluated factors, namely personal, environmental, and patient-related factors from the viewpoint of all participants were 1.17 ± 0.12, 1.09 ± 0.15, and 1.52 ± 0.22, respectively. The mean scores calculated for the 3 studied categories were not significantly different between the residents and faculty members of emergency medicine who participated in the study (p > 0.05). In the opinion of faculty members, decreasing the number of shifts does not lead to improvement in the quality of resident’s training. However, they believed that 12-hour shifts, clinical rounds in ED and the residents teaching to each other are effective in improvement of the quality of their education and the opinion of residents and faculty members were significantly different in these cases (p < 0.05). Conclusion: Faculty members and residents of emergency medicine do not share the same opinion on working hours, and the number of clinical shifts and their effect on resident training. The faculty members believed that 12-hour shifts provide more opportunities for education compared to 8-hour shifts and reducing the number of clinical shifts would decrease the quality of education. 

Introduction: Although some physicians insist on performing plain radiography for all trauma patients, some others recommend performing it for symptomatic ones. Therefore, the present study has been designed with the aim of evaluating the screening performance characteristics of plain radiography in identifying traumatic neck injuries. Methods: The present diagnostic accuracy study was performed on injured patients presenting to the trauma unit of emergency departments of hospitals affiliated with Shahid Beheshti University of Medical Sciences (Imam Hossein and Shohadaye Tajrish), Tehran, Iran, during March 2015 to March 2016. Results: 180 patients with the mean age of 32.30 ± 11.32 (16-68) years were evaluated (76.7% male). Most patients (73.3%) were in the 16-40 years age range and the most common mechanism of injury was motor vehicle collision (83.3%). Fracture of the 7th cervical vertebrae was the most prevalent fracture seen in radiography (7.2%) and computed tomography (CT) scan (17.2%). Based on the findings of cervical radiography and CT scan, respectively, 54 (30.0%) and 139 (77.2%) of the patients had at least 1 pathological finding (fracture or dislocation) in their cervical spine. Area under the ROC curve, sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio of plain radiography in detection of traumatic cervical injuries and with 95% confidence interval were 0.568 (0.472-0.664), 33.09 (25.48-41.64), 80.48 (64.63-62.90), 85.18 (72.32-94.62), 26.16 (18.95-34.91), 5.75 (3.00-11.00) and 2.81 (2.43-3.26), respectively. Conclusion: Accuracy of plain radiography in detection of traumatic cervical injuries is very low. This is due to the very low sensitivity of plain cervical radiography in detection of fractures and dislocations of the cervical spine. Therefore, it seems that plain radiography cannot be considered as a proper tool for ruling out cervical spine injuries following head and neck trauma. 

Comparison of Liquid Tissue Adhesive and Suture in Pediatric Wound Repair; a Case Control study

Mojtaba Sanji Rafsanjani, Hossein Dinpanah, Afsaneh Esmaeili Ranjbar, Mohammad Rostami Shahrebabaki

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e7

Introduction: An ideal method for wound closure is one that is rapid, easy, safe, inexpensive, and pain-free with minimal infection and most importantly has minimum effect on the cosmetic issues. Therefore, this study was designed with the aim of evaluating the outcome of wound repair with liquid tissue adhesive agent and suture in pediatric traumatic wound repair. Methods: In this case-control study, 1 to 14 year-old children admitted to emergency department following traumatic injuries in need of wound closure via either suture or liquid tissue adhesive, were compared regarding speed of performance, rate of satisfaction in patient and the parents, rate of inflammation, pain and rate of wound closure on the 4th day as well as beauty results in the 6th month after wound repair. Data were analyzed via SPSS 20 and p<0.05 was considered as significance level. Results: 100 children with the mean age of 7.84 ± 3.33 years were evaluated (61% male). The 2 study groups were in the same condition regarding age, sex, and wound location; however, they were significantly different regarding wound shape (p < 0.0001), length (p = 0.037) and depth (p < 0.0001). Patient satisfaction (p < 0.0001) and parent satisfaction (p = 0.017) in addition to rate of procedure performance (p < 0.0001) were higher in cases of using adhesive. Regarding 6-month beauty outcome no significant difference was detected between the 2 groups (p = 0.463). Meanwhile, inflammation, pain and wound closure on the 4th day after repair was in better condition in the adhesive group. The results of sub-group analysis of the 2 study groups based on depth showed that the difference between the groups regarding pain (p = 0.756) and inflammation (p = 0.422) on the 4th day was not significant in cases with low depth (2-4 mm). Based on multivariate analysis, the only independent factor affecting better 4-day outcome of the patients was wound depth (p = 0.004) and in this model, closure type was removed from the final model. Conclusion: Based on the results of the present study, liquid tissue adhesive was superior to suture regarding speed of repair performance and satisfaction of the patients and the parents. Liquid tissue adhesive was accompanied by less inflammation and pain and higher probability of complete wound closure on the 4th day after repair. Regarding beauty, no significant difference was seen between the 2 mentioned methods. 

Time Indices of Emergency Medical Services; a Cross-Sectional Study

Alireza Zeraatchi, Bahram Rostami, Abbas Rostami

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e8

Introduction: Considering the importance of the role and function of emergency medical services (EMS) in a society’s health and the need for continuously evaluating its function, especially in indices affecting the process of giving service to the patients, the present study was done with the aim of comparing time indices of providing services in EMS during two 6-month periods 1 year apart throughout Zanjan province, Iran. Methods: This study was a retrospective cross-sectional study. Out of all the calls recorded in EMS centers of Zanjan province during October to March 2013 and 2014, 742 calls that had resulted in the patient being transferred to a hospital were randomly selected and the required data including time indices and population indices were extracted from EMS forms that are filled by a medical emergency technician for each mission. Results: Among the total of 742 patients transferred by EMS during October to March 2013 and 2014, 452 were male and 290 were female. Mean age of the patients was 28 years. Most calls to EMS were related to trauma due to accident (345 cases) and internal (114 cases), respectively. Regarding time indices, mean times observed, respectively, were 0.02 minute (delay time), 8 minutes (response time), 10 minutes (time to reach the scene), 20 minutes (total of the 3 mentioned times), 27 minutes (time to reach hospital), 94 minutes (total mission time). Only 2 time indices, namely time to reach hospital (t=3 and p=0.001) and total mission time (t=2 and p=0.009), were significantly different between the studied periods and no significant difference was detected regarding other time indices. Conclusion: Based on the findings of this study, time indices of EMS were desirable and at the same level as national and international indices. Meanwhile, differences in time indices were only significant regarding time to reach hospital and total mission time and these indices were lower in 2013 compared to 2014. 

Introduction: The health sector evolution (HSE) plan has been implemented since 2014 and includes seven programs. Since one of the goals of this plan was to improve the condition of emergency departments, in this study we evaluated the effect of HSE plan on performance indices of emergency department in hospitals affiliated with Tehran and Iran Universities of Medical Sciences, Tehran, Iran. Methods: The present cross-sectional study was conducted in all Hospitals affiliated with Tehran and Iran Universities of Medical Sciences. Six performance indices of emergency department were collected monthly in two 12-month periods before and after implementation of the HSE plan by referring to the hospitals’ statistics unit. Data were analyzed via SPSS 22 using paired T-test and Interrupted Time Series (ITS) model. Results: The results of ITS showed that implementation of HSE plan had no significant effect on the rate and trend of indices such as percentage of patients who left the emergency department within 12 hours and percentage of patients discharged against medical advice (p > 0.05). On the other hand, HSE plan implementation affected the rate and trend of indices such as percentage of patients who were decided upon within 6 hours and the average turnaround time for emergency tests significantly (p < 0.05). The rate of both indices has increased but their trend has decreased. Conclusion: Implementation of HSE plan has resulted in improved percentage of patients who were decided upon within 6 hours and increased average turnaround time for emergency tests. In addition, although it has significantly increased the trend of successful CPR percentage, it has decreased the rate of successful CPR. 

Knowledge and Practice of medical Interns Regarding Use of Neck Collar in Trauma Patients; a Cross-Sectional Study

Seyyed Mahdi Zia Ziabari, Vahid Monsef Kasmaei, Seyed Hashem Pourshafiei, Sepideh Saadatmand

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e11

Introduction: Having the skill for choosing the proper collar and correctly fastening it is very important for preventing neurovascular injuries in patients with head and neck trauma. Therefore, the present study was designed and carried out with the aim of evaluating the knowledge and practice of medical interns regarding use of neck collar for trauma patients. Methods: In this cross-sectional study, the knowledge and practice of medical interns who were admitted to the medical internship program of Guilan University of Medical Sciences in 2009 was assessed in winter of 2017 using a questionnaire, the validity and reliability of which had been approved. Results: 80 medical interns with the mean age of 25.93 ± 1.02 years were studied (76.2% female). Mean knowledge score of the participants was 11.5 ± 2.7 (3 to 19). In addition, their mean practice score was 16.5 ± 2.3 (10 to 20). The highest rate of lack of knowledge was observed regarding factors predicting the rate of damage to neck and spinal cord (98.8%), the importance of injury (95.0%), the maximum time allowed for using neck collar (91.3%) and incorrect measures (91.3%). In addition, the highest rate of error in practice also belonged to leveling external auditory meatus with shoulder after fastening the neck collar in children (98.8%), putting a protective pad behind the rib cage after fastening the collar in children (95%) and employing at least 3 people when fastening the collar and maintaining the immobility of the vertebra before fastening the collar (65.0%), respectively. The score of practice and knowledge had a reversed correlation (p = 0.023, r = -0.225). Conclusion: Based on the findings, the rate of knowledge regarding neck collar usage in more than 70% of the medical interns in the present study was in the intermediate to poor range. In addition, the practice of 60% of them was in the intermediate to poor range. There was no direct correlation between the knowledge and practice of the students in this regard. 

Introduction: Based on the protocol of American Heart Association (AHA), target temperature of 32°C to 36°C for at least 24 hours should be provided, continuously, for all cases of spontaneous return of blood flow following successful cardiopulmonary resuscitation (CPR) in adult patients with evident altered level of consciousness. Therefore, the present study was done to evaluate the obstacles and assess the possibility of performing this protocol for patients in emergency department. Methods: This study was a qualitative research that consisted of 2 phases. In the first phase, by meeting the specialists involved with these patients, a standard questionnaire was filled regarding the obstacles to performing this protocol from their viewpoint. In the second phase, hypothermia protocol was done on a sample of eligible patients in emergency department. The aim of this phase was to find the problems of doing this protocol in real practice. The findings were reported using descriptive statistics. Results: A total of 100 questionnaires were filled. Lack of experience or needing more information with 58%, limited facilities and equipment with 46% and lack of a national protocol with 24%, respectively, were the most important obstacles from the specialists’ point of view. In addition, losing golden time (57.14%), the in charge attend not giving permission (28.57%), and the relatives not giving consent (14.28%) were among the most important obstacles in the executive phase. Conclusion: Based on the findings of the present study, it seems that training the physicians involved with these patients regarding induction of hypothermia with the primary equipment present in emergency departments, writing inter-department protocols and preparing national protocols in this regard can help in spreading this treatment method. 

Evaluating the Knowledge and Attitude of Service Providing Personnel of Sari Regarding First Aid; a Cross-Sectional Study

Farhad Masdari, Seyed-Hossein Hosseini, Hamidreza Khankeh, Reza Habibi-Saravi

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e15

Introduction: Having sufficient data regarding the knowledge and attitude of individuals towards any planning and appropriate educational interventions with the aim of learning first aid in society is essential. The present study was performed in 2015 for evaluating knowledge and attitude of service providing personnel of Sari, Iran, regarding first aid in 4 occupational groups of police, taxi driver, bus driver, and firefighter. Methods: This study is a cross-sectional one and the study population consists of city taxi and bus drivers, police and firefighters of Sari, Iran, in 2015. Sampling was done via simple random method and with a sample size of 500 individuals. Knowledge and attitude of the participants was evaluated using a questionnaire designed by the researchers and via SPSS software version 22. Results: A total of 500 individuals with an average age of 40.32 ± 8.51 (at least 28 and a maximum of 60) years, all men, participated in this study. Participants of the study had a mean family dimension of 4.1 ± 13.8. Mean attitude score was 11.2 ± 51.8. The highest frequency of obtained score in attitude belonged to 12 and the highest attitude score belonged to firefighting and safety services organization with the mean score of 17.8 and the lowest score belonged to taxi drivers of taxi driving organization with the mean score of 11.2 from the maximum possible score of 20. Mean knowledge score obtained was 7.2 ± 42.7. The highest mean of knowledge belonged to firefighters with the mean score of 11.6 and the lowest score belonged to taxi drivers with the mean score of 7.1 from the maximum possible score of 20. Conclusion: The results of the study showed that level of knowledge and attitude of those providing service to people was not proper regarding first aids and trainings in this regard is not desirable. To improve it, there is a need for schedule planning, retraining classes and trainings at the beginning and during service with concentration on improving the skills. 

Introduction: Crisis management plays an important role in preparing hospitals for responding to disasters. Therefore, improvement of knowledge and attitude of the crisis management team is an unavoidable necessity for increasing the preparedness of the hospitals in the response phase to critical conditions and real disasters. Since, based on previous studies, lack of knowledge and proper attitude is one of the main problems of disaster management in Iran, teaching crisis management using simulated training method has been considered as a solution. Therefore, the aim of this study was determining the effect of teaching crisis management in traffic accidents with a high rate of mortality using simulated training (maneuver) method on the knowledge and attitude of nursing staff of Hospital. Methods: The present experimental interventional study was performed from September 2017 to January 2018, in Shahid Motahari Hospital, Marvdasht. The study population consisted of the nursing staff of the hospital and the sample included all of the emergency department nurses of the hospital (100 nurses). Data were gathered with the attitude scale in crisis, emergency preparation questionnaire and triage knowledge test of accidents before and 2 weeks after intervention. Intervention included a one-day workshop training for all of the study population and then performing table maneuver and stimulated road accident maneuver for the test group. Analysis of data was done using SPSS 22 and descriptive statistics, paired t-test and ANCOVA test. Results: Mean score of emergency preparation knowledge showed a statistically significant difference between the 2 groups of test (166.69 ±25.47) and control (136.14±39.24) after intervention (p<0.0001). In addition, the overall score of attitude towards crisis management after intervention was significantly different between test (21.44±1.10) and control (20.92±1.57) groups (p=0.02). Conclusion: The results showed that training via simulation method and workshop could improve knowledge and attitude towards crisis management better than educational workshop alone. Therefore, simulation training of educational programs is suggested for improvement of knowledge and attitude regarding crisis management.

Introduction: As one of the most important departments in the hospital, emergency department is responsible for providing rapid treatment care for reducing mortality and disability among patients. Achieving this aim is possible with managing and evaluating the activities in this department via complete, accurate, and timely documentation of data based on standard principles. Therefore, the present study has been designed with the aim of determining the extent to which documentation standards are adhered to in mission forms of patients in pre-hospital emergencies. By evaluating the mission forms, existing problems can be identified and plans can be made to relieve them. Methods: The present study is a cross-sectional one performed on pre-hospital mission forms from March 2017 to March 2018. To gather data, a checklist consisting of 24 questions in 2 parts was used. The first part consisted of 11 questions to determine the extent to which standards of patient characteristics documentation were adhered to and the second part consisted of 14 questions for determining the rate of adherence to documentation standards in mission forms. Based on Likert scale, each question was rated as no answer (1 point), illegible (2 points), incomplete (3 points) and complete (4 points). Therefore, the minimum and maximum obtainable points were considered (11-44) in the section regarding correct documentation of patient characteristics and (14-56) in the mission reports part. Finally, data were analyzed via SPSS statistical software version 18 using chi square and Fisher’s exact tests for comparing qualitative data and student’s t-test for comparing qualitative data. Results: In this study, 250 pre-hospital mission forms were evaluated. Mean score obtained in evaluating the quality of documenting medical orders was 22.4±15.0 (minimum 15 and maximum 34). Mean total score obtained for documentation of mission form reports was 32.0±4.8 (minimum 28 and maximum 46). The overall score of emergency medical services (EMS) mission forms regarding adhering to the standards of documentation was 50.7±5.2 (minimum 45 and maximum 74). Conclusion: Based on the results of the present study, the state and quality of adhering to documentation standards in mission forms of the studied EMS unit was not at a desirable level.

Review Article

Maintaining health is a requirement for having a satisfying job and being efficient. 24-hour activity and working every day of the week leads physicians who work in emergency departments to facing the effects of imbalance in physiological status of the body due to changes in working shifts and working hours. It has been proved that working in shifts leads to decreased quality of sleep, fatigue, mental state disorders, dysfunction in social and family relationships, and problems in providing the mental needs of individuals. With increase in mental and physical tiredness, physicians gradually develop feelings of depersonalization, frustration and emptiness. They develop a negative view towards the patients and their treatment and if the fatigue continues the patient-physician relationship will suffer. The basis of the solution in cases of fatigue is providing a balance in life and looking after oneself and personal health. To improve sanity and mental-physical health in a healthcare system, an array of people are involved, each of whom plays an important role in this major issue.

Thyroid Storm: an Endocrine Emergency

Mahtab Niroomand, Mohammad Jalili

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e21

Thyroid storm also known as thyrotoxic crisis, is an acute and severe hypermetabolic condition that occurs due to increase in synthesis and release of thyroid hormones or increased sensitivity of peripheral tissues to thyroid hormones due to a dangerous increase in metabolism speed in all the systems of the body. Most cases of thyroid storm manifest due to appearance of an initiating factor in the presence of an underlying thyroid disease. Strong clinical suspicion and ability to rapidly diagnose imminent thyroid storm cases in patients are vital. In cases of clinical suspicion to this condition, preparing the grounds for rapid diagnosis and providing proper treatment leads to improvement in prognosis of the patient.

Letter to Editor

Platelet Count in Patients with Acute Coronary Syndrome

Hasan Barzegari, Mohammad Reza Maleki Verki, Seyed Masoud seyedian, Mohammad Reza Ghani Kakhaki

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e1

Platelets play an important role in pathogenesis of coronary artery obstruction. Acute coronary syndromes are associated with endothelial injuries, atherosclerotic plaque rupture, platelet activation, thrombosis formation and finally artery obstruction. Platelets are activated by attachment to the subendothelial structure and release granules containing A2 Thromboxane, serotonin, vasoconstrictors and platelet aggregation factors.

Increased platelet activity has been associated with higher severity of ischemic cardiac disease. It has been shown that patients with cardiac ischemia who have a higher platelet count are more at risk of mortality. A study by Shefaee et al. in 2005 showed that platelet count change in those with acute coronary syndrome is significant; in these individuals, platelets decrease at the site of lesion due to being used up. In other words, patients with acute coronary syndrome have a lower platelet count compared to those with stable angina and normal people. Zhang et al. study in 2015 showed that platelet count in patients with unstable angina and myocardial infarction decreases more compared to patients with chronic stable angina and those with non-cardiac chest pain. The writers of this letter studied 180 patients with the mean age of 55.57 ± 15.11 years (20-86) and compared the number of platelets in 3 groups of non-cardiac chest pain (60 cases), stable cardiac angina (60 cases) and unstable cardiac angina or myocardial infarction (60 cases). Mean platelet count in the 3 mentioned groups was 258.73 ± 62.92, 238.95 ± 65.88 and 218.78 ± 47.82 thousand/µl, respectively (p = 0.001). As you can see, the number of platelets in the group with unstable angina was significantly lower in this comparison, too. However, the important point is that in all these cases platelet count is in the normal range (150-400 thousand/µl) and perhaps considering the number of platelets alone cannot help in differentiation of this group of patients. It seems that measuring substances released from platelet instead of considering platelet count can be more helpful in differentiating the 3 mentioned conditions. However, reaching a decision regarding the correlation of rate and pattern of platelet decrease with various states of coronary syndrome needs more accurate studies with bigger sample sizes.

Which Stroke Patients are Suitable for Endovascular Treatment in Emergency Department?

Behnam Mansouri, Farhad Assarzadegan, Omid Hesami

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e4

Stroke makes up a significant part of causes for emergency department (ED) visits. This complication can be accompanied by a desirable outcome in case of rapid diagnosis and proper treatment intervention. However, in case of delay in treatment, it will bring about many costs for the individual, his or her family and the health care system. Therefore, timely diagnosis is the first and major step in managing these patients in ED and after that, choosing the proper treatment method is the priority. Currently, various treatment methods are available for managing these patients, from palliative care to thrombolytic therapy and endovascular interventions and one of the major questions in treatment of acute brain stroke in ED is which patient is suitable for receiving which treatment? Endovascular intervention is a relatively new treatment method that can extract the blood clot from the brain vessels and various studies have shown that it is one of the most effective treatment interventions in management of brain stroke. Various studies have been published in favor of its benefits in recent years, which have resulted in changes in treatment guidelines of stroke patients in America and Europe and highlighting the role of endovascular interventions in them. However, this interventional treatment is considered an invasive method that can be accompanied by side effects and thus, for reaching maximum success in this method, efforts should be made to select patients who have a higher probably to benefit from this intervention. It has been said that if obstruction of a big vessel is the reason for brain stroke, the patient is the best candidate for intervention and endovascular treatment. In this situation, the most important duty of the ED physician is to identify the obstructed arteries. The most important diagnostic method that existing guidelines suggest in this regard is performing computed tomography (CT) angiography that shows the status of big arteries from the beginning of Aorta to the smallest arteries inside the brain. Some treatment centers do this only for cases with the probability of extensive brain stroke, but it is suggested to perform both brain CT scan and CT angiography for all stroke cases including mild cases; because these patients might be at risk of an upcoming extensive stroke. Some centers add CT perfusion technique to the brain CT scan and CT angiography (CTA) duo. Unfortunately, this technique is not available in most centers in Iran. However, in the advanced centers around the world it can be performed at the same time as brain CT scan and can show an accurate picture regarding the extent of the brain tissue involved and even the reversibility of the tissue involved in the stroke. Proper arteries for thrombectomy are the middle cerebral artery (MCA) branch of intracranial carotid, especially its horizontal part (M1) and in some cases after branching of the carotid (M2). In addition, with the advances made, extracranial carotid thrombectomy can also be done today. But anterior and posterior cerebral arteries (ACA and PCA) are almost never intervention candidates. Extensive studies including IMS-3, MR-CLEN, ESCAPE, EXTEND-IA, SWIFTPRIME, and PREVASCAT have been done with the aim of selecting the proper vessels and candidates of endovascular interventions, almost none of which have evaluated the possibility of performing thrombectomy of basilar artery. However, a study called BASICS has been done in this regard that has even reported the time of thrombectomy for basilar artery and its prognosis even better than the other arteries and most interventionist and stroke neurologists have gained a positive view to performing it. Overall, in the above-mentioned studies about 1700 patients underwent emergency thrombectomy and the success rate without performing CTA was about 40% and if aware of the artery involved via CTA, the success rate has been reported to be about 70%. Regarding processing the situations in which CTA cannot be performed it should be noted that after enabling thrombolytic therapy, using thrombectomy even without knowing the status of the arteries involved with techniques such as CTA, the success rate of treating patients with stroke increased from about 23% to at least 40%. Therefore, it seems that preparing the equipment for performing CTA before emergency thrombectomy should be seriously supported, at least in major hospitals of Iran. In addition, the presently available equipment such as CT scan device and neurology and angiography departments and the specialists in these fields should be employed effectively. If the CT scan device can be programmed in a way that when performing brain CT scan, CT angiography can also be performed simultaneously, the candidate patients for undergoing thrombectomy can be selected more properly and by using these solutions the rate of improvement in patients with brain stroke and thus, being relieved from paralysis and long-term problems might increase to 70%.


Isn’t it Time to Use Opioid Drugs in Emergency Medical Services?

Hamidreza Aghababaeian, Ladan Araghi Ahvazi

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e12

درد احساس و تجربه حسی ناخوشایند می باشد که در نتیجه یک آسیب بالقوه و بالفعل بوجود می آید و کنترل آن به قدری مهم است که انجمن درد آمریکا برای تأکید بیشتر بر درد و کنترل آن، از درد بعنوان پنجمین علامت حیاتی نامبرده است. تقریبا همه انسانها تجربه دردهای متوسط تا شدید را داشته اند و بیشتر اوقات به دنبال انجام پروسیجرهای جراحی، شرایط پزشکی و یا تروما، این تجربه اتفاق افتاده است. وقتی درد و رنج در یک موقعیت بالینی مشخص می گردد، دنبال کردن و رفع آن به عنوان یک هدف و وظیفه بر عهده پرسنل سیستم بهداشتی درمانی می باشد. از این رو درد و درمان آن یک اولویت درمانی است. درد بر تمام افراد با هر سن، جنس، نژاد و طبقه اجتماعی و اقتصادی تأثیرگذار است و درد درمان نشده می تواند بر سیستم های مختلف بدن اثر منفی گذاشته و منجر به عوارض فراوانی گردد. افزایش سطح سرمی کورتیزول، نوراپی نفرین و رنین آنژویوتانسیون، افزایش قند خون، کاهش انسولین، بروز اضطراب، اثرات قلبی مثل ایسکیمی، دیس ریتمی، افزایش نبض، افزایش بار قلبی، افزایش مصرف اکسیژن، افزایش انعقادپذیری خون، افزایش فشار خون بخصوص در بیماران با صدمات سر، کاهش اکسیژن خون، افزایش حجم مایعات بدن، کاهش پتاسیم خون، خستگی، گرفتگی عضلانی، کاهش عملکرد سیستم ایمنی، کاهش قدرت ترمیم زخم و غیره، از جمله عوارض نامطلوب درد می باشند. همچنین عدم درمان دردهای حاد نیز منجر به تحمل دردهای غیرضروری، افزایش طول مدت بستری، افزایش هزینه های پزشکی و احتمال پیشرفت و تبدیل شدن درد حاد به درد مزمن می شود. چنانچه بار اقتصادی عدم درمان درد در آمریکا حدود 100 میلیارد دلار در سال برآورد شده است. درد شکایت بسیار شایعی بوده و بخش قابل توجهی از علل تماس بیماران با سیستم اورژانس پیش بیمارستانی را شامل شده و همچنین در مصدومان و بیماران ترومایی معمولا وجود دارد. نتایج مطالعات نشان می دهد که بین 20 الی 31 درصد بیماران منتقل شده با آمبولانس دارای درد متوسط و شدید بوده اند. همچنین درد با شیوع 52 الی 86 درصد در اورژانس ها یکی از موضوعات اصلی بهداشتی درمانی کشورهای مختلف می باشد. پرسنل اورژانس پیش بیمارستانی نیز اولین اعضای کادر درمانی هستند که در بلایا و سوانح با این بیماران مواجه شده و بیشتر در معرض درد و رنج بیماران قرار دارند. علیرغم رشد کمی پایگاههای فوریتهای پزشکی کشور ایران به بیش از 1900 پایگاه در سراسر کشور، مشاهدات پژوهشگر و شواهد و دستورالعمل های موجود در اورژانس پیش بیمارستانی 115 ایران، نشان دهنده عدم بکارگیری کافی داروهای ضد درد، علی الخصوص ضد دردهای اپیوئیدی به عنوان راهکاری برای کاهش درد بیماران و مصدومان در آمبولانس های فوریتهای پزشکی 115 می باشد. برخی مطالعات ذکر می کنند نزدیک به یک سوم بیماران پیش بیمارستانی و بیش از 80 درصد بیماران دارای شکستگی درد متوسط تا شدید را گزارش می کنند و از طرفی تأثیر مثبت کاربرد مسکن ها در مناطقی که بکار رفته به وضوح بر اکثریت بیماران نشان داده شده است. به نظر می آید که کاربرد داروهای ضد درد در فوریتهای پیش بیمارستانی مبحث بسیار مهمی می باشد و محققان بیان می کنند که مدیریت مناسب درد یک اصل مهم در اقدامات پیش بیمارستانی و خدمت رسانی به بیماران می باشد و مسکن های مخدر نظیر مورفین و فنتالین جایگاه ویژه ای در دستورالعمل های اورژانس پیش بیمارستانی برخی کشورهای پیشرفته در فوریتهای پزشکی بعنوان درمان دردهای حاد ترومایی و غیرترومایی و به ویژه درد قفسه سینه مربوط به بیماری های قلبی دارند. با نگاهی به مطالب پیشگفت در مورد اهمیت درد و درمان آن به خصوص اهمیت درمان درد در تروما و بیماری های ایسکمیک قلبی، شیوع بالای درد در مأموریت های پیش بیمارستانی، شدت درد و نوع ماموریت های پیش بیمارستانی که اکثراً با درد همراه می باشند، هزینه های بالای عدم درمان درد و نیاز مبرم به استفاده از مسکن در تروما و بیماری های ایسکمیک قلبی، آیا زمان آن نرسیده است که فکری به حال درمان مؤثر و علمی تر درد در فوریت های پزشکی گردد؟ آیا بهتر نیست در کنار این همه امکانات که بر بالین بیمار مهیا کرده ایم، چند نوع داروی ضد درد مسکن و مخدر حداقل برای بیماری های ایسکمیک قلبی و یا ترومای شدید نیز در نظر گرفته شود؟ هرچند نتایج مطالعه ای که در خوزستان انجام شد نشان داد که پرسنل فوریتهای پزشکی 115 از نظر اطلاعات و محاسبات دارویی بسیار ضعیف می باشند. بعضا مطالعاتی نیز بیان کرده اند که ممکن است دوزاژ دارویی و کاربرد داروهای مخدر درست انجام نگردد و یا بعضاً ممکن است از داروهای مخدر سوء استفاده شود، اما همه اینها دلیل قانع کننده ای برای عدم کاربرد این داروها نمی باشد و می توان با ارایه راهکارهای بهتر نظیر آموزش بیشتر و بهتر پرسنل فوریتهای پزشکی، ایجاد پروتکل های آفلاین و آنلاین و برنامه های مثمر ثمر در جهت جلوگیری از سوء استفاده از داروهای مسکن بطور مؤثری از این دارو در فوریتهای پزشکی 115 استفاده نمود . از این رو مجدد متذکر می شویم که این اولویت درمانی نباید به هیچ دلیل نادیده گرفته شود.

Preventing Seizure due to Head Trauma in Patients Visiting Emergency Department

Mehrdad Esmailian, Saeid Haghighi, Alireza Aboutalebi, Mohammad Zare’

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e13

Head trauma is a known cause of seizure and about 10% of patients with severe or moderate head trauma are affected with seizure. Preventing and controlling seizure after head trauma is of great importance for minimizing secondary brain injuries. Depending on their time of occurrence, post-trauma seizures are divided into 3 types, namely immediate seizures, early seizures, and late seizures. Immediate seizures occur within less than 24 hours after the trauma, while early seizures happen in less than a week and late seizures happen more than a week after trauma. Phenytoin is an antiepileptic drug that is widely prescribed for preventing seizure in trauma patients. This drug has nonlinear pharmacokinetics even in therapeutic doses and its prescription requires cardiac monitoring, continuous monitoring of the drug’s plasma levels and dose adjustment. Studies have shown that phenytoin prevents early seizures but is not effective in decreasing late seizures. On the other hand, in most cases, due to pharmacokinetic changes in patients with head trauma, blood concentration of phenytoin is outside the therapeutic range and determining its serum levels cannot always be done. Therefore, finding replacement treatments for preventing seizure in these patients is necessary. Sodium valproate is an antiepileptic drug that is usually used along with other drugs for treating different types of epilepsy. This drug decreases electric discharges in the brain. Sodium valproate is also used for prevention of seizure attacks. The side effects of this drug are rare and mostly unimportant. The authors of this letter randomly divided 70 patients presenting to emergency department with severe head trauma (consciousness level of 8 or less on Glasgow coma scale) with the mean age of 36.41 ± 14.81 years (18 – 64) into 2 groups of 35 and prescribed phenytoin for 1 group and sodium valproate for the other as antiepileptic drugs and monitored them for 6 hours (91.4% male). The 2 groups were not significantly different regarding baseline characteristics. The results of this study showed that out of the 5 patients who had seizure during the first 6 hours, all 5 were in the group receiving phenytoin. It seems that before reaching a conclusion in this regard, studies with larger sample sizes and longer follow-up periods are required for comparing the efficiency and side effects of the mentioned drugs in prevention of seizure due to trauma. 

Pain Management in Prehospital Emergency Service: A Neglected Necessity in Iranian Healthcare System

Hadi Hassankhani, Amin Soheili, Samad Shams Vahdati

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e16

Pain, as a complex neurophysiological and neuropsychological mechanism, is one of the most common experiences among patients in prehospital emergency service. Although, there is no accurate data regarding the prevalence of pain in prehospital settings like there is for hospital emergency departments, in developed countries, despite the contradictions in the results of the numerous studies, the evidence indicate the high prevalence of acute pain in prehospital emergency service ranging from 20% to 53%. Yet, unfortunately, in Iran there is no statistics available in this regard. The physiological (affecting cardiovascular, respiratory, endocrine and other systems) and psychological (anxiety, anger, aggression, and …) complications due to uncontrolled acute pain have many adverse effects on the clinical outcomes of medical and traumatic patients and impose immense direct and indirect financial burdens on the limited resources of healthcare systems. Therefore, effective pain management using various pharmaceutical and non-pharmaceutical methods both on the scene and during transportation has become a potentially indispensable necessity and considered as a potential key performance indicator according to the National Association of EMS Physicians.

An extensive literature review also revealed remarkable improvements in the use of analgesics in prehospital emergency service of many developed countries and opioid analgesics (e.g., morphine sulfate, fentanyl and ketamine); nonsteroidal anti-inflammatory drugs (e.g., Ketorolac and ibuprofen); and Paracetamol and Nitric Oxide (inhalation gas) have been put on the list of prehospital emergency service for relieving patients’ pain, which can be used based on qualification/competencies, roles, responsibilities, and degrees (EMR, EMT, AEMT, paramedic) of the providers of prehospital care with approval of the consultant physician or through use of a combination of off-line and on-line medical protocols in this regard. The majority of recent studies in this field focus on the inadequacy of prehospital pain management as well as the comparison and combination of various analgesic drugs to enhance efficacy, effectiveness and quality of healthcare provision.

Brief Report

Assessing the Incidence rate of Violence against Emergency Department Staff

Arash Forouzan, Kambiz Masoumi, Hassan Barzegari, Hassan Motamed, Mohammad Karimi

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e22

Introduction: The tense environment of the emergency department (ED) exposes the staff of this department to risks resulting from physical and verbal confrontations and attacks, which can affect not only the staff’s job satisfaction and safety but also the process and quality of care and service provided for the patients. Methods: In this descriptive cross-sectional study, using a questionnaire, all the staff members working in the EDs of Imam Khomeni and Golestan Hospitals, Ahvaz, Iran, were questioned regarding encountering verbal and physical violence from March to September 2017. Data were then gathered and analyzed via SPSS software version 20. Results: In the studied EDs, 132 staff were employed in different categories and 100% of them participated in the study, of whom 58% were male. The mean age of the participants in the study was 31.7 ± 5.8 (rang from 21 to 56) years old. Among them, 78.1% of the studied individuals had faced verbal violence at least once and the mean incidence rate of verbal violence in the studied 6 months was 34.8 times in each month. 17.4% of the ED staff had faced physical violence with the mean incidence rate of 7.31% times per month in the studied 6 months. 17% of ED staff members reported feeling highly safe, 61% felt moderately safe, and 12% felt a low level of safety, and 10% did not feel safe at all. Conclusion: Considering the results of the present study, the rate of violence incidence is high in the EDs of Imam Khomeni and Golestan Hospitals, Ahvaz, Iran, and this has raised concerns among the staff members of these EDs. In addition, in this study, violence has been mostly on the part of patients’ companions.

Case Report

Ruptured Abdominal Aortic Aneurism with Atypical Manifestations; a Case Report

Fateme Mohammadi, Gholamreza Masoumi, Samira Vaziri, Mehdi Rezai, Reza Mosaddegh

Iranian Journal of Emergency Medicine, Vol. 5 No. 1 (2018), , Page e17

Abdominal aortic aneurysm is a condition with a high mortality rate among those presenting to the emergency department. Its common symptoms include abdominal, back, and flank pain and hypotension and syncope are among its other manifestations. However, sometimes these patients present with uncommon manifestations. Considering this important point, we have introduced a patient with atypical manifestations in the present report. Initial diagnosis of this condition is based on high clinical suspicion and performing bedside abdominal ultrasonography. Diagnostic standard is abdominal computed tomography (CT) scan in patients with stable vital signs. The treatment is performing endovascular or open surgery and delay in treatment is accompanied with a high rate of mortality.