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Objective: This study aims to characterize the demographic, clinical, and radiological features of gunshotwound (GSW) patients as well as identify predictors of prolonged hospitalization.Methods: In this retrospective study, a consecutive sampling method was used, including all patients withGSWs in any anatomical region. Data collection included demographic and clinical information, radiologicalfindings, treatment specifics, and outcome variables, such as hospitalization length of stay (LOS) as the primaryoutcome. To identify predictive factors associated with prolonged LOS, logistic regression analysis was used.Results: We studied 212 GSW cases, including 95.8% were men and 4.2% were women. The mean age of thestudied group was 30.17±7.80 years. GSWs occurred in extremities (80.2%), abdomen (9.0%), thorax (4.7%),and head or neck (5.2%). Two patients (0.9%) had both abdominal and thoracic GSWs. The most prevalentradiological study was an X-ray (83.0%). Patients with head and neck GSWs had the longest emergencydepartment stay, while patients with abdominal GSW patients had the shortest (p=0.068). The highest ratesof blood product transfusion were observed in abdominal GSWs (63.2%), emergency surgery (63.2%), andICU admission (42.1%). Head and neck GSWs had the longest hospitalization LOS (7.5 days). Longer LOSwas significantly associated with abnormalities in radiological findings, receiving blood products, and ICUadmission (p≤0.001). Significant predictors of prolonged LOS were major abnormalities in radiological findings[odds ratio (OR)=5.3; 95% confidence interval (CI):2.8-10.2], head and neck GSWs (OR=6.1; 95% CI:1.2-31.9),and blood product transfusion (OR=4.1; 95% CI: 1.0-16.3).Conclusion: This study provides insights into factors influencing prolonged hospitalization in GSW patients,highlighting the importance of radiological findings, head and neck injuries, and blood product transfusion.

Objective: Considering the growing use of emergency medical services (EMS), we evaluated the level ofpublic awareness of emergency situations in Iran.Methods: This cross-sectional study was conducted from August 2021 to January 2023 on Iranian residentsin Tehran, who were older than 18 years old. The participants were directed to a URL for an online surveylink and asked to select their preferred options for the predetermined scenarios. We divided the participantsinto three groups: abuse, misuse, and non-use. At least 12 correct answers were required to qualify asacceptable knowledge and practice responses (KP score). Then, the relationship between participants’ baselinecharacteristics and their level of awareness was investigated.Results: Totally, 3864 people participated in the study, of whom 50.5% were men. The participants’ agesranged from 18 to 90 years old, with a mean age of 40.01±11.30 years. In general, the rate of abuse, misuse,and not-use in at least one scenario was 74.5%, 64%, and 70.4%, respectively. The results of the multivariableregression analysis indicated that female sex (OR=1.29), a higher education level (OR=3.36), a higher incomelevel (OR=1.64), and Turkish ethnicity (OR=1.20) were significantly associated with the correct KP score.Conclusion: The degree of inappropriate utilization of EMS services in Iran was significant. We found thatthe proper knowledge regarding the appropriate use of EMS was significantly associated with the participant’slevel of education, academic field, job, and income.

Objective: To probe the factors associated with the outcomes of traumatic brain injury (TBI) patients admittedto emergency department (ED).Methods: This is a cross-sectional study that data gathering was performed via census methods, retrospectively.During one year, all head injury’s patients who admitted to the ED of a tertiary center in Tehran, Iran wereincluded. Age, gender, mechanism of injury, Glasgow coma scale (GCS) and injury severity score (ISS)on admission, presence of extra-cranial injuries, findings of brain computed tomography (CT), duration ofhospitalization, and in hospital outcomes were recorded. Outcome’s assessment for survivors was performedwithin a 6 months-period after discharge based on Glasgow outcome scale (GOS). The variables and outcomes’association were assessed.Results: Totally, 506 patients were evaluated with the mean age of 36.77±21.1 years that 411 (81.2%) were men.Follow up at 6-months post injury was feasible in 487 (96.2%) patients; 59 (11.7%) out of 506 eligible patientsdied. Logistic regression analysis showed the association between assessed variables and patients’ outcome asfollows: age>65 years (OR: 12.21; p

Introduction: Clinical decision tools have been shown to reduce imaging rates for clearance of suspected cervical spine injury (CSI). This review provides more comprehensive evidence on the diagnostic capabilities of National Emergency X-Radiography Utilization Study (NEXUS) and Canadian C-spine rule (CCR) in this regard. Method: A systematic review of the current literature was performed on studies published until Jan 26th, 2023, in databases of Medline, Scopus, Web of Science, and Embase, investigating the performance of NEXUS and CCR in blunt trauma patients. QUADAS-2 and GRADE guidelines were used to assess the quality and certainty of evidence. All analyses were performed using the STATA 14.0 statistical analysis software. Results: 35 articles comprising 70000 patients for NEXUS and 33000 patients for CCR were included in this review. NEXUS and CCR were evaluated to have a sensitivity of 0.94 (95% confidence interval (CI): 0.88 to 0.98) and 1.00 (95% CI: 0.98 to 1.00) in the detection of any CSI and 0.95 (95% CI: 0.89 to 0.98) and 1.00 (95% CI: 0.95 to 1.00) in the detection of clinically important CSI. The area under the curve (AUC) of NEXUS and CCR was 0.85 and 0.97 for any CSI and 0.78 (95% CI: 0.74 to 0.81) and 0.94 (95% CI: 0.91 to 0.96) for clinically important CSI. Conclusion: Our study demonstrates that both NEXUS and CCR can be used in ruling out patients with low risk of CSI, and CCR was shown to have superior performance. Even though these tools have low specificity, their application can still greatly reduce the number of radiographic imaging performed in emergency departments.

Background: After recovery from acute phase of the COVID-19, some patients suffer from persistent/late-onset complications. The main objective of this study was to investigate the prevalence of such complications in a large scale of COVID-19 patients in Tehran, Iran. Methods: In this cross-sectional study, those patients who called Tehran emergency medical services center and were visited by the emergency medical technicians from 20 March 2020 until 21 September 2020 and diagnosed as a confirmed COVID-19 case were enrolled. The minimum required sample size was estimated 385 cases, and they were selected randomly. The patients were interviewed by phone at least 4 weeks since initiation of their symptoms. Using a pre-prepared checklist, made by an expert panel who were involved in management of COVID-19 patients, data were collected on the types and duration of the complications, clinical information, and factors which could interfere with developing the complications. All analyses were performed using STATA 16 software. The association of the prevalence of each complication with independent factor was assessed using Chi-square test (or Fisher’s exact test) for categorical variable, and the mean difference of numerical variables in the two groups (with and without complication) was assessed using independent t-test. Statistical significance was accepted at P value

Aim:This study aimed to investigate the diagnostic accuracy of the Cincinnati Prehospital Stroke Scale (CPSS), Los Angeles Prehospital Stroke Screen (LAPSS), and Melbourne Ambulance Stroke Scale (MASS) in detecting acute ischemic stroke (AIS) in suspected cases and to compare these scales with each other.Materials and Methods:This diagnostic accuracy study included patients with suspected AIS brought to the emergency department. Patients’ data were collected from their medical records. All test data were compared with the final diagnosis of AIS based on the brain magnetic resonance imaging (MRI) report. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were measured separately using statistical tests with confidence interval of 95%.Results:Finally, 766 patients were included, among which 57.6% were male. The mean age of the patients was 66.8±13.7 years. All patients underwent brain MRI, which showed that 537 (70.1%) patients had an actual diagnosis of AIS. The accuracy rates of CPSS, MASS, and LAPSS were 82.9%, 79.2%, and 78.1%, respectively. In this study, the differences between the sensitivity and specificity of these scales were significant (p

Introduction: Just as failure to diagnose an acute ischemic stroke (AIS) in a timely manner affects the patient's outcome; an inaccurate and misplaced impression of the AIS diagnosis is not without its drawbacks. Here, we introduce a two-stage clinical tool to aid in the screening of AIS cases in need of imaging in the emergency department (ED). Methods: This was a multicenter cross-sectional study, in which suspected AIS patients who underwent a brain magnetic resonance imaging (MRI) were included. The 18 variables from nine existing AIS screening tools were extracted and a two-stage screening tool was developed based on expert opinion (stage-one or rule in stage) and multivariate logistic regression analysis (stage-two or rule out stage). Then, the screening performance characteristics of the two-stage mode was evaluated. Results: Data from 803 patients with suspected AIS were analyzed. Among them, 57.4 % were male, and their overall mean age was 66.9 ± 13.9 years. There were 561 (69.9%) cases with a final confirmed diagnosis of AIS. The total sensitivity and specificity of the two-stage screening model were 99.11% (95% CI: 98.33 to 99.89) and 35.95% (95% CI: 29.90 to 42.0), respectively. Also, the positive and negative predictive values of two-stage screening model were 78.20% (95% CI: 75.17 to 81.24) and 94.57% (95% CI: 89.93 to 81.24), respectively. The area under the receiver operating characteristic (ROC) curve of the two-stage screening model for AIS was 67.53% (95% CI: 64.48 to 70.58). Overall, using the two-stage screening model presented in this study, more than 11% of suspected AIS patients were not referred for MRI, and the error of this model is about 5%. Conclusion: Here, we proposed a 2-step model for approaching suspected AIS patients in ED for an attempt to safely exclude patients with the least probability of having an AIS as a diagnosis. However, further surveys are required to assess its accuracy and it may even need some modifications.

Abstract Background Ultrasonography (US) is recently used frequently as a tool for airway assessment prior to intubation (endotracheal tube (ETT) placement), and several indicators have been proposed in studies with different reported performances in this regard. This systematic review and meta-analysis reviewed the performance of US in difficult airway assessment. Methods This systematic review and meta-analysis was conducted according to the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane book. All the studies that had carried out difficult airway assessments using US, had compared the indicators in difficult and easy groups, and had published the results in English by the time we conducted our search in April 28, 2020, were included. Results In the initial search, 17,156 articles were retrieved. After deleting the duplicate articles retrieved from multiple databases, 7578 articles remained for screening based on the abstracts and titles. Finally, the full text of 371 articles were assessed and the data from 26 articles were extracted, which had examined a total of 45 US indicators for predicting difficult intubation. The most common US index was the “thickness of anterior neck soft tissue at the vocal cords level”. Also, “skin to epiglottis” and “anterior neck soft tissue at the hyoid bone level” were among the most common indicators examined in this area. Conclusion This systematic review showed that US can be used for predicting difficult airway. Of note, “skin thickness at the epiglottis and hyoid levels”, “the hyomental distance”, and “the hyomental distance ratio” were correlated with difficult laryngoscopy in the meta-analysis. Many other indicators, including some ratios, have also been proposed for accurately predicting difficult intubation, although there have been no external validation studies on them.

Introduction: Vascular system injuries (VSIs) are one of the main causes of preventable mortality and morbidity of trauma patients. This study aimed to evaluate baseline characteristics, presenting signs, managements, and outcomes of patients presenting to emergency department (ED) with traumatic VSIs. Methods: This retrospective cross-sectional study was conducted on patients with traumatic VSIs admitted to the ED of a referral tertiary trauma center, during one year. Using a pre-prepared checklist, demographics, pre-hospital care, type of VSIs, injury severity score (ISS), anatomical location of trauma, associated injuries, method of surgery, complications, and outcome were collected from patients’ profiles and reported. Results: One hundred and twelve patients with the mean age of 33.5 ± 14.7 (range = 8 - 80) years were studied (90.2% male). Most of the patients were categorized as mild or moderate in terms of their ISS. 90 (80.4%) patients had at least one soft sign and 99 (88.4%) patients had at least one hard sign. Isolated arterial injury was diagnosed in 90 (80.4%) patients, isolated venous injuries in 12 (10.7%) cases, and combined arteriovenous injuries in 10 (8.7%) patients. The most common associated injury was tendon rupture (63.4%) and nerve injuries were present in 60.7% of patients. 1 (0.9%) patient died, 6 (5.4%) patients went through amputation, and 3 (2.7%) patients were discharged against medical advice. The rest of the patients were discharged in perfect health. There was a significant correlation between trauma type (p = 0.001), upper and lower extremity trauma (p < 0.001), presence of distal ischemia and lack of pulse (p = 0.041), penetrating injury close to a major vessel (p = 0.006), type of injured vessels and arteries (p

Context: Based on current literature, there is no consensus regarding the proper emergency management of Pediatric Acute Ischemic Stroke (P-AIS). In other words, there are lots of considerable controversies in this regard. Therefore, the current review was conducted to provide a more comprehensive discussion on this topic. Evidence Acquisition: The search was conducted using the terms “pediatrics”, “stroke”, and “recombinant tissue plasminogen activator” in the PubMed database. English papers on the management of P-AIS published after 2000 were selected. An expert panel performed a critical appraisal to summarize the findings and make them applicable. Finally, the extracted data were categorized under proper subheadings, and the manuscript was prepared. Results: The related papers provided limited evidence on this topic. All extracted findings were categorized as follows: etiology and the underlying diseases, clinical presentations, diagnosis, management (thrombolytic therapy and thrombectomy), and outcome. Conclusions: Although thrombolytic therapy is recommended in P-AIS, most cases are diagnosed outside the therapeutic window, so P-AIS is practically impossible, and they are candidates for mechanical interventions. On the other hand, the proper device may not be available to fit the size of the younger children’s vasculature.

OBJECTIVES: In this study, we aimed to investigate the accuracy of recognition of stroke in the Emergency Room (ROSIER) Scale in the diagnosis of patients with acute ischemic stroke (AIS) transferred to the emergency department (ED). METHODS: The present study was a multicenter study. Records from patients suspected of stroke, who referred to the ED were reviewed. Demographic, clinical, and diagnostic data were extracted and then entered in checklists. ROSIER Scale was used to evaluate the possible diagnosis in this study. The definitive diagnosis of a stroke was made based on neurologist's assessment and clinical and neuroimaging findings, mainly brain magnetic resonance imaging (MRI). Receiver operating characteristic (ROC) curve analysis was conducted for assessing the accuracy of ROSIER in discrimination of stroke. RESULTS: The data of 356 suspected stroke patients were analyzed. Of all, 186 patients (52.2%) were male, and the mean age was 65.2 (standard deviation = 14.0) years ranging from 26 to 95 years. One hundred and fifty-one patients (42.4%) had AIS based on the final diagnosis. The area under the ROC curve was 0.85. The best cutoff point for ROSIER scale was ≥1 with a sensitivity of 85.4% (95% confidence interval [CI]: 78.8, 90.6%) and specificity of 65.8% (95% CI: 58.9, 72.3%). CONCLUSION: Based on the findings, although the best cutoff point was the same as the original (derivation) study, its sensitivity (85.4% vs. 92%) and specificity (65.8% vs. 86%) were considerably lower.

Background: This study aimed to evaluate the efficiency of pre-hospital triage tools including the qSOFA, NEWS, and PRESEP in determining the prognosis of probable COVID-19 patients. Methods: In this diagnostic accuracy study, all probable COVID-19 patients older than 16-year-old who were transferred to the hospital by the Tehran Emergency Medical Services (EMS) during the first month of the pandemic, entered to the study. The scores of qSOFA, NEWS, and PRESEP were calculated using data gathered while providing pre-hospital care. The primary outcome was death; and the secondary outcomes were ICU admission, length of stay in the ICU, and length of hospital stay. Results: The data of 557 individuals with the mean age of 56.93±18.31 were analyzed of whom 67.5% were males. The area under the ROC curve (AUC) of qSOFA, NEWS, and PRESEP for ICU admission was 0.553, 0.557, and 0.551, respectively. The AUC of qSOFA, NEWS, and PRESEP for death was 0.596, 0.566, and 0.604, respectively. The best obtained cut-off point for qSOFA was a score >0 (the sensitivity and specificity were 25.0 and 85.68%, respectively), for NEWS was a score >2 (the sensitivity and specificity were 83.61 and 32.67%, respectively), and for PRESEP was a score >1 (the sensitivity and specificity were 54.10 and 55.56%, respectively). Conclusion: Based on the findings of the current study, it is likely that the available pre-hospital triage tools (qSOFA, NEWS, and PRESEP) do not have proper efficacy to predict death, ICU admission, and disease severity of COVID-19 patients.

Background: We aim to assess the predictive value of serum neuron-specific enolase (NSE) level in patients with acute ischemic stroke referring to the emergency department. Methods: This systematic review and meta-analysis performed, considering the PRISMA and MOOSE statement guidelines. A computerized literature search of the known medical database conducted by using the relevant keywords. We included studies published before November 2016 in which stroke patients compared with non-stroke controls and also studies evaluating the serum levels of NSE in the study groups. Statistical analysis was pooled in a random effect model analysis using the Comprehensive Meta-Analysis software. Results: We included 12 articles in the qualitative and quantitative analysis, that their quality acceptable based on the Newcastle Ottawa Scale (NOS scale). The pooled effect estimates showed that NSE is significantly higher in ischemic stroke patients in comparison with their controls with a high effect estimate [OR 9.68, 95% CI (3.06 to 30.6)]. The effect estimate remained statistically significant under the fixed and random effects model. Conclusion: Our results show higher levels of NSE in patients with stroke than in the control group, indicating that NSE plays a role in the diagnosis of stroke. In terms of prognosis, there is evidence regarding the direct and indirect relationship; and it founded that serum levels of NSE is higher in larger stroke volume, which needs further research.

Context: The current review article considered the latest published papers on reducing unnecessary head Computed Tomography (CT) scans in pediatric patients, to pave the way for further surveys. Evidence Acquisition: The papers were selected through Google Scholar and PubMed. We searched “reducing unnecessary head CT scan in pediatric patients” with related keywords compatible with MeSH system in accordance with the search strategy. Original articles and systematic reviews published after 2010 were included. Other types of manuscripts such as a letter to editor, editorial reviews, case series, etc. were excluded. The title and abstract of the eligible articles were assessed in terms of relevance to our topic. The full text of final selected papers were studied by the investigators. Furthermore, a critical appraisal was performed in an expert panel to summarize it and make it applicable. Results: The extracted manuscripts have addressed this issue by various strategies. The findings could be categorized as follows: observation period, focused history taking, protocol and guideline development, implementation of validated clinical prediction rules, and blood-based decision making by assessing neuro-biomarker levels. Conclusions: Most of the reviewed articles were focused on clinical findings to discover the minimum or low risk category of the pediatric patients with blunt head trauma. Other articles attempted on facilitating the use of available clinical prediction rules in this regard. Also, the measurement of serum biomarker levels has been considered; however, their widely application in practice is not well supported by evidence yet.

Introduction: Gathering information regarding the risk factors of mortality and disability due to road traffic injuries can provide evidence for adopting effective interventions to reduce the burden of the injury. Therefore, the present study intends to identify the most important risk factors of road accident-related mortality in Iran by conducting a systematic review and meta-analysis. Methods: Search was done in English and Persian electronic databases, for articles published until the end of 2020. Cross-sectional, cohort and case-control studies were included. Risk factors were divided into age and sex, road related factors, exceeding speed limit, road user behaviors, vehicle related factors, weather condition, and light condition. Data were reported as adjusted odds ratio (OR) of death with 95% confidence interval (95% CI). Results: 20 studies were included (2,682,434 traffic accident victims and 23,272 deaths; mortality rate=1.28%). The risk of death in road traffic injuries in men was 1.66 times higher than women (OR = 1.66; 95% CI: 1.03, 2.68) and with each year increase in age, the risk increased by 1% (OR = 0.01; 95% CI: 1.00, 1.01). In addition, accident in urban streets (OR = 1.76; 95% CI: 1.08, 2.88), roadway defects (OR = 2.15, 95% CI: 1.59, 2.91), and not driving on a flat and straight road (OR = 1.60; 95% CI: 1.14, 2.24) were the most important road-related risk factors for mortality. Exceeding the speed limit was another risk factor of death (OR = 3.16; 95% CI: 2.83, 3.54). However, regarding exceeding safe speed, only three studies have been included, which greatly reduces the power of analysis. Not maintaining focus on the road (OR = 2.99; 95% CI: 1.49, 6.04), not fastening seatbelt (OR = 3.11; 95% CI: 1.08, 8.91), and reckless overtaking (OR = 4.04; 95% CI: 3.34, 4.89) were independent road user-related risk factors for mortality. Risk of pedestrian mortality in comparison with drivers and passengers is 2.07 times higher (OR = 2.07; 95% CI: 1.53, 2.58). In addition, risk of death in accidents occurring during daylight hours (OR = 0.26; 95% CI: 0.18, 0.37) is lower than that of other hours. No significant relationship was present between mortality and vehicle types (four-wheeled vehicle: OR = 0.99; 95% CI: 0.050, 1.97; two-wheeled vehicle: OR = 0.75; 95% CI: 0.48, 1.16). In the case of vehicle-related factors, only 2 studies were included, which also dealt only with the type of vehicle (two-wheeled/four-wheeled). Vehicle-related factors such as the car model, its safety rating, and safety standards were not mentioned in any study. Conclusion: Low to very low-level evidence shows that there is a significant relationship between factors related to age, sex, road, road user, exceeding the speed limit, and light condition with the mortality of traffic accident victims. However, all studies included in the present study were retrospectively designed and the analyses were not adjusted for most of the key potential confounders. Therefore, it seems that despite years of effort by researchers in the field of traffic accidents in Iran, there is still no comprehensive and reliable picture of the most important risk factors for road accident mortalities in Iran.

Introduction: Mapping of COVID-19 infection in the city can help us know more about how the disease is distributed and spread. This study was conducted to investigate the geographical distribution of probable COVID-19 patients who were transferred to destination hospitals by emergency medical services (EMS) in the first wave of the epidemic, in Tehran, Iran. Methods: This cross-sectional study was performed based on recorded missions during the first 3-month period of the pandemic in Tehran, Iran. All probable cases of COVID-19 who were transferred to the hospitals following contact with Tehran EMS during the study period were enrolled. Arc-GIS software was utilized to draw the distribution map of the contact places of the cases. Results: In this study, the data of 4018 patients were analyzed (60.9% male). The mean age of the patients was 54.1 ± 20.7 years; and the mean age of the patients had increased with time during the studied 3 months (p = 0.003). The average incidence rate of this disease in Tehran during the study period was 4.6 per 10,000 population. Generally, the lowest and highest raw frequencies of Tehran COVID-19 contamination were seen in municipal districts 21 and 4, respectively. The raw frequency of cases during the 3-month study period also showed that the highest number of cases in Tehran occurred in municipal districts 5 and 4, respectively. Conclusion: In the present study, using geographic information systems (GIS), geographical distribution map of COVID-19 in Tehran, Iran, during the first 3 months of the pandemic was drawn.

Introduction: Like other infectious diseases, it is expected that COVID-19 will mostly end with the development of neutralizing antibody immunity. This study aimed to evaluate the value of COVID-19 antibody rapid test assessment in emergency medical services (EMS) personnel. Methods: This cross-sectional study was conducted in Tehran, Iran from 20th March until 20th May 2020. The results of chest computed tomography (CT) scan, and antibody rapid test were compared in EMS personnel with confirmed COVID-19, as well as symptomatic and asymptomatic ones who had exposure to a probable/confirmed COVID-19 teammate. In symptomatic or asymptomatic individuals who were only IgM-positive, chest CT scan or RT-PCR was recommended. Results: A total of 243 EMS personnel with the mean age of 36.14±8.70 (range 21 to 59) years took part in this study (87.7% were males). Most of the participants (73.3%) had history of exposure. One hundred sixty-three EMS personnel were tested using either RT-PCR test or chest CT-scan or both, and 78 (47.9%) of them had at least one positive result. Among the participants who had undergone chest CT-scan and/or RT-PCR test (n=163), 78 had positive chest CT-scan and/or RT-PCR test; of these, 18 individuals had negative results for IgM and IgG. The rate of positive IgM and IgG in participants with positive chest CT-scan was 1.6 or 1.3 times more than those with negative chest CT-scan, respectively (p < 0.05). The percentage of positive results for both IgM and IgG in participants having positive RT-PCR test was 1.7 times more than those having negative RT-PCR test (p < 0.05). Conclusion: Rapid antibody test could help in diagnosis of COVID-19 in asymptomatic or symptomatic EMS personnel who did not undergo RT-PCR test or the test was reported as negative. However, its sensitivity could be enhanced through use along with other diagnostic methods.

Background: Extended-focused assessment with sonography in trauma (E-FAST) has been introduced as a free fluid identification technique in the abdomen, and currently, like stethoscopes, it is routinely used to assess traumatic patients, as part of physical examination tools. We decided to examine the effect of using E-FAST in the clinical judgment of the physicians managing patients with blunt abdominal and chest wall trauma. Materials and Methods: In this cross-sectional study, all patients who were admitted from May 2014 till May 2015 to the emergency department of Imam Khomeini and Sina Hospitals, Tehran, Iran, with an abdominal or chest blunt trauma and for whom E-FAST was conducted were enrolled. In a preprepared checklist, possible consequences based on the primary clinical judgment of a physician were recorded; and then, the results from E-FAST on existence or nonexistence of free fluid or air in the peritoneal or pleural space were presented, and the possible consequences according to the results obtained from the E-FAST were also recorded again. Based on actual outcome of patients' condition in the first 24 h, statistical characteristics for each pathology were calculated. Results: In this study, 115 patients with a mean age of 36.20 ± 12.37 years were examined including 92 (80%) men. The correlation coefficient between the possibility of hemorrhagic shock, pneumothorax, hemoperitoneum, solid organ damage, and hemothorax before and after the E-FAST based on the Kappa criteria was 0.803, 0.642, 0.430, 0.331, and 0.318, respectively. Conclusion: The results of this study showed that performing E-FAST increases the sensitivity of history and physical examination in diagnosis of pneumothorax, hemoperitoneum, solid organ damage, and hemothorax.

Background: All the trauma scoring systems (TSSs) have some limitations, and none is useful for patient monitoring. Recently, investigators have tried to modify the TSSs to improve their use. Aims: This study was conducted to determine whether any correlation exists between dysoxia metabolism markers (DMMs), including venous base deficit (BD) and HCO3level with different TSSs. Materials and Methods: In this cross-sectional study, all multiple trauma patients admitted to the emergency department were eligible. Blood samples for venous blood gas analysis were taken at the onset of resuscitation process. TSSs, including trauma index (TI), abbreviated injury score (AIS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma Score-ISS (TRISS), were calculated for the patients. Spearman's rank correlation coefficient test was applied to find the association between the independent variables. Results: A total of 285 patients with a mean age of 33.37 ± 15.29 fulfilled the inclusion criteria, of which, 211 cases (74.0%) were male. Statistical analysis revealed that there was a correlation between TI and HCO3level (P = 0.0001, r = −0.37) and also TI and BD (P = 0.0001, r = −0.47). Furthermore, there was an indirect correlation between AIS and ISS with HCO3and BD levels and the direct correlation between RTS and TRISS with HCO3and BD levels. Conclusion: It is likely that there is a statistical correlation, although weak, between TSSs with DMMs, including HCO3and BD level.

Background: With the emergence of social media, physicians who use social media, including emergency medicine physicians, have shared their experiences with their colleagues instead of working alone and keeping their experiences to themselves. Objective: This study aimed to evaluate the rate and type of use of electronic online sources and social media, in order to improve learning and education among emergency medicine residents. Methods: This was a cross-sectional study carried out from September 2015 until August 2016 on emergency medicine residents of two main medical universities of Tehran, Iran. A questionnaire was prepared by reviewing the existing studies and asking emergency medicine professors inside and outside Iran for opinions. Census sampling method was applied and all emergency medicine residents were included. The gathered data were analyzed using statistical tests of chi square, Independent-samples t-test and Pearson’s correlation coefficient via SPSS version 21. Results: Seventy three residents with the mean age of 34.2±5.2 years participated in this study (60.3% female). Smart phone is the most important tool they use for connecting to the Internet. About 30% use the Internet for about 1-2 hours a day. In half of these participants less than 25% of this time is spent on something related to their academic field of study. The correlation of sex (p=0.034) and age (p=0.049) with extent of using social media related to the academic field of study were significant. Other analytical analyses were not statistically significant (p>0.05). Conclusion: In summary, the findings of current study showed that despite sufficient access to proper technology, use of social media and online sources by high majority of the studied EM residents regarding improvement of their learning and educational level is very limited.

Objective: Personality disorder is a multi-factorial condition in which workplace stress plays a significant role. This study was undertaken due to scarcity of information regarding the role of workplace stress which can cause personality disorder among nurses. We aimed to evaluate the prevalence of personality disorders in nurses working in different hospital departments and assess factors affecting its onset. Methods: In this cross-sectional study the personality disorders of nurses working in various hospital departments were evaluated based on Minnesota Multiphasic Personality Inventory-2 (MMPI-2) test. After the completion of questionnaires, data were entered to MMPI-2 test’s special software and the final result was interpreted based on the opinion of a clinical psychologist. Finally, multivariate logistic regression model was used to assess the independent effect of the mentioned factors on prevalence of personality disorders in nurses. Results: We gathered data from 2 groups of participants (n = 206). These groups included nurses in emergency departments and nurses in other hospital units. The mean of age was 32.5 ± 6.9 years. Overall, 54.3% (n = 38) of non-emergency nurses and 45.7% (n = 32) of emergency nurses showed symptoms of personality disorders respectively. Multivariate logistic regression analysis showed that history of a serious accident or trauma increased the odds of detecting personality disorders up to 3.8 times (odds ratio [OR] = 3.84; 95% CI: 1.33-11.06; P = 0.01). In addition, an unpleasant incident in the past year increased it up to 2.2 times (OR = 2.23; 95% CI: 1.18 – 4.22; P = 0.01) in both groups. Conclusion: The present study showed that there was no significant difference between emergency departments and other units of hospitals regarding the prevalence of personality disorders among nurses. Overall, somatization, hysteria, and pollyannaish were the most common personality disorders among the studied population

Introduction: Although previous articles and reviews suggest that ketamine might effectively manage pain in trauma patients, these articles have serious limitations. Accordingly, the current meta-analysis aims to investigate the efficacy of ketamine administration in prehospital pain management of trauma patients. Method: In the present meta-analysis, controlled human studies were included. An extensive search was conducted in electronic databases including Medline (via PubMed), Embase, Central, Scopus, Web of Science, and ProQuest, gathering data to the end of 2018. The efficacy and side effects of ketamine administration in pre-hospital pain management were compared with those of opioid analgesics based on standard mean difference (SMD) and odds ratio (OR) calculations with 95% confidence interval (95% CI). Results: Data from seven articles were included in the present meta-analysis. Ketamine administration was not more effective than administrating morphine or fentanyl in prehospital pain management of trauma patients (SMD = -0.56, 95% CI: -1.38 to 0.26, p = 0.117). However, co-administration of ketamine+morphine was considerably more effective than ketamine alone, in alleviating pain in prehospital settings (SMD = -0.62, 95% CI: -1.12 to -0.12, p = 0.010). Finally, it was concluded that ketamine alone had less side effects than morphine alone (OR = 0.25, 95% CI: 0.11 to 0.56, p = 0.001). However, co-administration of ketamine+morphine increases the risk of side effects to 3.68 times compared to when morphine is prescribed solely (OR=3.68, 95% CI: 1.99 to 6.82, p

Introduction: A standard guideline concerning pre-hospital pain management is still a matter of discussion. Therefore, the current umbrella review is determined to perform a comprehensive search in databases and Grey literature and collect and summarize the guidelines and protocols dealing with prehospital pain management. Â Â Â Â Â Â Methods: In the present study, all of the available guidelines and protocols concerning pre-hospital pain management were reviewed. Presented guidelines are from 2010 up to present, as the majority of guidelines are considered old and become renewed after 10 years. Finally, the development quality of each guideline was evaluated using AGREE II instrument. Results: The search conducted in databases and non-indexed protocols resulted in inclusion of 12 pre-hospital pain management guidelines. The time interval of the guidelines was from 2010 to 2019. Four guidelines were designed for pain management in trauma patients and other guidelines were presented for all of the clinical conditions associated with pain. All of the 12 included guidelines presented pain management instructions in adults. Pain management in children was reported in 10 guidelines. All of the guidelines persisted on a standard method for pain evaluation. Pain management was categorized in three groups; mild, moderate and severe pain. Most of the guidelines recommend paracetamol as an optional treatment for management of mild pain in both adults and children. In management of moderate and severe pain, fentanyl and morphine were suggested for both adults and children. In most of the treatment guidelines fentanyl is the optional choice for children. Conclusion: The present umbrella review has summarized the current evidence in pre-hospital pain management for the first time via investigation of guidelines and protocols related to the matter. Based on the obtained evidence, no guideline is yet presented concerning opioid-free management of moderate and severe pain. The evidence is insufficient for using non opioid medications such as ketamine.

Introduction: The aim of this study was to evaluate the correlation between malampathy score, upper lip bite test and 3-3-2 maneuver with anthropometric factors of body in people. Methods: This cross-sectional study was carried out during 2014-2015 in Yazd, Iran. Samples were selected from the whole population using simple randomization and were included in the study after giving informed consent. Baseline and demographic data including age, sex, and anthropometric factors of their body such as weight, height, neck circumference, waist circumference, hip circumference, body mass index (BMI), and waist to hip ratio were gathered in a pre-designed checklist. Then malampathy score, upper lip bite score, and 3-3-2 maneuver were evaluated and recorded by the researcher. Results: 498 people with the mean age of 42.1 ± 16.1 were studied (51% female). In total, 168 (69%) of the studied men and 182 (72%) of the studied women had a BMI higher than 25. 74 (39%) of the men had a waist to hip ratio over 0.93 and 152 (60%) of the women had a waist to hip ratio over 0.81. Results of the upper lip bite test was a score of 3 in 10 (2%) people, result of malampathy test was a score of 3 or 4 in 152 (31%) participants and result of 3-3-2 maneuver showed an abnormal condition in 20 (4%), which indicate the probability of difficult intubation. With an increase in age, based on all 3 methods, the probability of difficult intratracheal intubation rises (p < 0.001). However, none of the 3 evaluation methods showed a significant correlation between difficult intratracheal intubation and sex (p > 0.05). There was a significant correlation between malampathy score and upper lip biting with all anthropometric factors of the body. 3-3-2 rule also significantly correlated with weight, height, waist circumference, hip circumference, and BMI, but not with neck circumference (p = 0.328) or waist to hip ratio (p = 0.121). Conclusion: It seems that with an increase in age, based on all 3 methods, the probability of difficult intratracheal intubation rises. However, none of the 3 methods of intratracheal intubation difficulty evaluation have a significant correlation with sex. In addition, according to the results of the current study, a significant correlation exists between upper lip biting and malampathy score with all anthropometric factors of the body assessed in this study. Yet, 3-3-2 maneuver does not have a significant correlation with neck circumference or waist to hip ratio.

Unusual walking and non-weight bearing on one side of the body is called limping. The incidence of this complication, as an acute complaint in children, is among the causes of emergency department visits and considered as one of the medical challenges in this unit. It is safe to claim that in emergency department, finding the exact cause is not a priority; conversely, it is more important to know that it is not caused by a serious condition. In other words, in the emergency department, ensuring that the cause does not threaten the patient’s life or limb is prioritized over reaching the final diagnosis. Emergency medicine specialists play an important role in detection, diagnosis, and proper referral of these patients. The current manuscript was written in order to facilitate clinical decision-making regarding treatment of children with acute limping visiting emergency department.

Introduction: To date, many prognostic models have been proposed to predict the outcome of patients withtraumatic brain injuries. External validation of these models in different populations is of great importancefor their generalization. The present study was designed, aiming to determine the value of CRASH prognosticmodel in prediction of 14-day mortality (14-DM) and 6-month unfavorable outcome (6-MUO) of patients withtraumatic brain injury. Methods: In the present prospective diagnostic test study, calibration and discriminationof CRASH model were evaluated in head trauma patients referred to the emergency department. Variablesrequired for calculating CRASH expected risks (ER), and observed 14-DM and 6-MUO were gathered. Then ERof 14-DM and 6-MUO were calculated. The patients were followed for 6 months and their 14-DM and 6-MUOwere recorded. Finally, the correlation of CRASH ER and the observed outcome of the patients was evaluated.The data were analyzed using STATA version 11.0. Results: In this study, 323 patients with the mean age of 34.0´s 19.4 years were evaluated (87.3% male). Calibration of the basic and CT models in prediction of 14-day and6-month outcome were in the desirable range (P Ç 0.05). Area under the curve in the basic model for predictionof 14-DM and 6-MUO were 0.92 (95% CI: 0.89–0.96) and 0.92 (95% CI: 0.90–0.95), respectively. In addition,area under the curve in the CT model for prediction of 14-DM and 6-MUO were 0.93 (95% CI: 0.91–0.97) and0.93 (95% CI: 0.91–0.96), respectively. There was no significant difference between the discriminations of thetwo models in prediction of 14-DM (p Æ 0.11) and 6-MUO (p Æ 0.1). Conclusion: The results of the presentstudy showed that CRASH prediction model has proper discrimination and calibration in predicting 14-DMand6-MUO of head trauma patients. Since there was no difference between the values of the basic and CT models,using the basic model is recommended to simplify the risk calculations.

The term "weaning" is used to describe the gradual process of decreasing ventilator support. It is estimated that 40% of the duration of mechanical ventilation is dedicated to the process of weaning. Spontaneous breathing trial (SBT) assesses the patient's ability to breathe while receiving minimal or no ventilator support. The collective task force in 2001 stated that the process of SBT and weaning should start by assessing whether the underlying cause of respiratory failure has been resolved or not. Weaning predictors are parameters that are intended to help clinicians predict whether weaning attempts will be successful or not. Although the international consensus conference in 2005 did not recommend their routine use for clinical decision making, researchers did not stop working in this area. In the present article, we review some of the recent studies about weaning predictors, criteria, procedure, as well as assessment for extubation a mechanically ventilated patient.

Objective: The determination of pre-hospital triage based on electrocardiogram and telecardiology in shortening the initial angioplasty time in patients with ST segment elevation myocardial infarction (STEMI) treated with PCI. Methods: This cross-sectional study was conducted from September 2015 to January 2018 in six hospitals equipped with 24-hour angioplasty facilities in Tehran, Iran. Patients referred to the hospital with a diagnosis of STEMI by Emergency Medical Services (EMS) and undergoing primary angioplasty in the equipped centers were included. Patients were divided into two groups: 1) Patients who were transferred to Cath Lab after electrocardiography (ECG) and telecardiology by EMS (EMS247 group); 2) Patients who did not have ECG and telecardiology in the ambulance and were transferred to the emergency department. Results: A total of 1205 people with the mean age of 58.99 ± 12.33 years (19-95 years) entered the study of whom 996 (82.65%) were male. Of these, 841 (69.8%) patients were transmitted via EMS, who have a 12-lead ECG carried out in the ambulance and after consultation with the cardiologist emphasizing the need for direct transmission to the angioplasty for PPCI. In the study, time interval of Symptom-to-device in the EMS247 group was less than the EMS routine group (P = 0.001). There was a similar finding about the time interval of First medical contact (FMC) to device. Mean differences of interval time in two groups were 100.4 and 22.5 min for symptom-to-Device and FMC-to-Device, respectively. Conclusions: It is likely that the use of telecardiology in prehospital triage plays an important role in reducing time of PPCI for patients with acute myocardial infarction with ST segment elevation.

Ebola hemorrhagic fever (EHF) was first reported in 1976 with two concurrent outbreaks of acute viral hemorrhagic fever centered in Yambuku (near the Ebola River), Democratic Republic of Congo, and also in Nzara, Sudan. The current outbreak of the Ebola Virus was started by reporting the first case in March 2014 in the forest regions of southeastern Guinea. Due to raising infection rates of over 13,000% within a 6-month period, now is considered as a global public health emergency and in August 8, 2014 the World Health Organization (WHO) has declared the epidemic to be a Public Health Emergency of International Concern. With more than 5000 involved cases and also nearly 3000 deaths, this event has turned to the largest and most dangerous Ebola virus outbreak in all around the world. Based on above mentioned, the present article aimed to review the virologic characteristics, transmission, clinical manifestation, diagnosis, treatment, and prevention of Ebola virus disease.

In the previous two parts of educational manuscript series in Emergency, we explained some screening characteristics of diagnostic tests including accuracy, sensitivity, specificity, and positive and negative predictive values. In the 3rd part we aimed to explain positive and negative likelihood ratio (LR) as one of the most reliable performance measures of a diagnostic test. To better understand this characteristic of a test, it is first necessary to fully understand the concept of sensitivity and specificity. So we strongly advise you to review the 1st part of this series again. In short, the likelihood ratios are about the percentage of people with and without a disease but having the same test result. The prevalence of a disease can directly influence screening characteristics of a diagnostic test, especially its sensitivity and specificity. Trying to eliminate this effect, LR was developed. Pre-test probability of a disease multiplied by positive or negative LR can estimate post-test probability. Therefore, LR is the most important characteristic of a test to rule out or rule in a diagnosis. A positive likelihood ratio > 1 means higher probability of the disease to be present in a patient with a positive test. The further from 1, either higher or lower, the stronger the evidence to rule in or rule out the disease, respectively. It is obvious that tests with LR close to one are less practical. On the other hand, LR further from one will have more value for application in medicine. Usually tests with 0.1 < LR > 10 are considered suitable for implication in routine practice.

Emergency physicians, like other specialists, are faced with different patients and various situations each day. They have to use ancillary diagnostic tools like laboratory tests and imaging studies to be able to manage them. In most cases, numerous tests are available. Tests with the least error and the most accuracy are more desirable. The power of a test to separate patients from healthy ones determines its accuracy and diagnostic value. Therefore, a test with 100% accuracy should be the first choice. This does not happen in reality as the accuracy of a test varies for different diseases and in different situations. For example, the value of D-dimer for diagnosing pulmonary embolism varies based on pre-test probability. It shows high accuracy in low risk patient and low accuracy in high risk ones. The characteristics of a test that reflects the aforementioned abilities are accuracy, sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios. In this educational review, we will simply define and calculate the accuracy, sensitivity, and specificity of a hypothetical test.

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.

Hemodynamic monitoring is needed in up to 58% of patients presented to the emergency department. Central venous pressure (CVP) monitoring is generally useful to assess general volume status. There are several methods of CVP measurement, which can be categorized as invasive and non-invasive. CVP manometer and electronic transducer are among the invasive methods and direct observation, ultrasonography and plethysmography are examples of non-invasive ones. All the mentioned methods have some negative points and shortcomings. Here we introduce a new device that can facilitate CVP measurement and provide physicians with further data that can be helpful regarding decision making and patient management.

Introduction: To date, many prognostic models have been proposed to predict the outcome of patients with traumatic brain injuries. External validation of these models in different populations is of great importance for their generalization. The present study was designed, aiming to determine the value of CRASH prognostic model in prediction of 14-day mortality (14-DM) and 6-month unfavorable outcome (6-MUO) of patients with traumatic brain injury. Methods: In the present prospective diagnostic test study, calibration and discrimination of CRASH model were evaluated in head trauma patients referred to the emergency department. Variables required for calculating CRASH expected risks (ER), and observed 14-DM and 6-MUO were gathered. Then ER of 14-DM and 6-MUO were calculated. The patients were followed for 6 months and their 14-DM and 6-MUO were recorded. Finally, the correlation of CRASH ER and the observed outcome of the patients was evaluated. The data were analyzed using STATA version 11.0. Results: In this study, 323 patients with the mean age of 34.0 ´s 19.4 years were evaluated (87.3% male). Calibration of the basic and CT models in prediction of 14-day and 6-month outcome were in the desirable range (P Ç 0.05). Area under the curve in the basic model for prediction of 14-DM and 6-MUO were 0.92 (95% CI: 0.89–0.96) and 0.92 (95% CI: 0.90–0.95), respectively. In addition, area under the curve in the CT model for prediction of 14-DM and 6-MUO were 0.93 (95% CI: 0.91–0.97) and 0.93 (95% CI: 0.91–0.96), respectively. There was no significant difference between the discriminations of the two models in prediction of 14-DM (p Æ 0.11) and 6-MUO (p Æ 0.1). Conclusion: The results of the present study showed that CRASH prediction model has proper discrimination and calibration in predicting 14-DMand 6-MUO of head trauma patients. Since there was no difference between the values of the basic and CT models, using the basic model is recommended to simplify the risk calculations.

Nowadays, many researches in the field of medicine are conducting all around the world and medical journalism is a way to share the results. In fact, dissemination of the related manuscripts can prevent the repetitive research or may even lead to conducting a better survey. Therefore high quality medical journals are considered as up-to-date resources for further investigations. Medical journals are propagating their papers in various media including television programs, newspapers, internet websites and different social media. So they can influence the government policy makers, health-care professionals and even public. Moreover, most researchers hear about medical discoveries for the first time through medical journals and their related social media. So as well a high quality journal can help to improve medical science, a journal of poor quality can be damaging and distorting. Indeed, popular journals have the power of inventing a “communication storm†to draw attention to a certain topic. Thus they have to respect the accepted international principles to prevent spreading inaccurate and misleading data. This paper aims to review the previous and current situation of medical journalism by focus on field of emergency medicine.

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 years were 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.