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Introduction: To enhance the efficiency, it is essential to understand the patterns of service users and develop policies that facilitate effective personnel and resource management. This study aimed to compare the characteristic and outcomes of patients who were transferred to emergency department (ED) by emergency medical services (EMS) and patients transported by other means. Methods: This retrospective cross-sectional study was conducted at Srinagarind Hospital, Thailand, over a 5-year period from 2017-2021. The baseline characteristics, treatment modalities, and outcomes of patients who were transported to ED using EMS and Non-EMS were gathered and compared using STATA software. Results: The study included 15,501 patients with the median age of 51 (interquartile range (IQR): 23-71) years who were referred by EMS over the five-year period (51.72% male). EMS patients had significantly higher median age (51 (23 - 71) vs. 37 (21 - 60); p < 0.001) with male preference (p < 0.001). In the EMS group, the triage level 1 (need for resuscitation) was higher than the non-EMS group (p < 0.001), most of the patients referred following trauma (p < 0.001), and the frequency of cardiac arrest was considerably higher than non-EMS group (2.54% vs 0.05%; p < 0.001). Patients in the EMS group received a higher number of blood tests (p < 0.001), plain radiographic exams (p < 0.001), computerized tomography (CT) scans (p < 0.001), and complex procedures (p < 0.001) than the non-EMS group. The EMS group had a greater number of hospital admissions (p < 0.001) and intensive care unit (ICU) admissions (p < 0.001) compared to the non-EMS group. The EMS group exhibited a significantly higher mortality rate compared to the non-EMS group (p < 0.001). Conclusion: The population utilizing EMS services had higher median age, higher frequency of emergency cases and trauma related complaint, higher need for treatment interventions and imaging procedures, higher rate of hospital and ICU admissions, as well as higher rate of mortality compared to the non-EMS group.

Introduction: Previous studies have shown higher lumbar puncture (LP) success rates when using ultrasound guidance. This study aimed to compare the first-attempt success rate of ultrasound-guided LP with blind technique of needle insertion using the palpable spinal surface landmark in patients with obesity or a difficult anatomy. Methods: This prospective randomized controlled study was performed at the emergency department of Ramathibodi Hospital, an academic tertiary university hospital, from August 2015 to July 2016. Results: 40 patients were enrolled (20 surface landmark-guided and 20 ultrasound-guided LPs). 52.5% of the patients were male with the mean age of 60.33 ± 4.24 years. The first-attempt success rate in the ultrasound-guided LP group was significantly higher than the landmark-guided LP group (80% vs. 35%, respectively), with risk difference (RD) of 45.00% (95% confidence interval (CI): 17.72%, 72.28%). This indicated absolute risk reduction and number needed to treat of 45.00% and 2.22, respectively. The median procedural duration required to achieve successful LP in the ultrasound-guided LP group was significantly shorter than the surface landmark-guided LP group (5 [IQR: 3–18] minutes vs. 13.5 [IQR: 5-30] minutes, respectively). Traumatic puncture as a complication occurred less frequently in the ultrasound-guided LP group than the surface landmark-guided LP group with risk ratio (RR) = 0.33 (95% CI: 0.08, 1.46) and RD = -20.00% (95% CI: -44.00%, 4.00%). This indicated absolute risk reduction and number needed to harm of 20.00% and 5.00, respectively. However, the difference was not significant. Conclusion: Using ultrasound to help localize the insertion point before LP increased the first-attempt success rate and improved other LP outcomes in Thai patients with obesity or a difficult anatomy. It also shortened the procedural duration and reduced the incidence of traumatic tap.

Introduction: Neurologic disorders are common reasons for emergency consultations. Most neurologic disorders seen in the emergency department (ED) are life-threatening and require urgent treatment. The goal of this study is to investigate the pattern of neurological disorders among patients evaluated in the ED. Methods: This is a cross-sectional study conducted in the ED of Mogadishu Somali Turkish Training and Research Hospital, from July 2021 to February 2022. The clinical and epidemiological characteristics of adult patients with neurologic manifestations in the ED were evaluated. Age, gender, distribution of neurological disease manifestations, neurological examination findings, and neurological diagnoses made by consultant neurologists were assessed. Results: During the study period, 321 patients were assessed (3.7 % of all ED admissions). The majority of the patients in the study were above 50 years of age (62.6% male). Hypertension was the most common comorbidity among these patients with 122 (38%) cases, followed by diabetes mellitus with 65 (20.2%), and heart diseases with 26 (8.1%) cases. The main reasons for neurology consultations were altered mental status with 141 (44%) cases, motor weakness with 102 (31.8%), seizures with 33 (10%), headache with 17 (5.3%), and vertigo with 9 (2.8%) cases. 196 (61%) had hemiplegia, 60 (18.7%) had consciousness impairment, and 38 (11.8%) had normal neurological examination. The most frequent neurological diagnoses were ischemic strokes with 125 (39%) cases, hemorrhagic strokes with 65 (20.2%), epileptic seizures with 28 (8.7%), and metabolic encephalopathies with 13 (4%) cases. The median duration of the neurology consultations was 20 minutes. 251 (78%) of the patients were admitted to the hospital, while 70 (22%) were discharged from the emergency department. After neurology consultation, the neurology department made the most admissions with 226 (90%) cases, while 25 (10%) were admitted by other departments. Of those admitted, 186 (74.2%) were admitted to the neurology ward, and 65 (25.8%) were admitted to the intensive care unit. Conclusion: In our study, neurologic emergencies accounted for 3.7% of all emergency admissions. Stroke, epileptic seizures, cerebral venous thrombosis, encephalopathies, and acute spinal cord diseases were the most common neurological disorders. The admission rate was very high following neurologic assessment by neurologists.

Introduction: A decision-making guideline on when to intubate an older person based on predictors of intubation outcome would be extremely beneficial. This study aimed to identify the associated factors that could predict the outcomes of endotracheal intubation among older adults in the Emergency Department (ED). Methods: In this retrospective cross-sectional study, patients aged ≥65 years intubated at the ED of University of Malaya Medical Centre, Kuala Lumpur, Malaysia, from 2015 to 2019 were studied. The association between age, gender, place of inhabitation, Identification of Seniors at Risk (ISAR) score for frailty, Charlson Comorbidity Index (CCI), Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score, indication for intubation, and diagnosis on admission with in-hospital mortality (primary outcome) and duration of ventilation, and length of stay (secondary outcomes) were evaluated using univariate analysis and Cox’s regression survival analysis. Results: 889 cases aged 65 years and above were studied (61.5% male). The rate of in-hospital mortality was 71.4%. There was a significant association between age (p < 0.001), nursing home residency (p = 0.008), CCI≥ 5 (p = 0.001), APACHE-II (p < 0.001), pre-intubation Glasgow Coma Scale (GCS) (p < 0.001), cardiac arrest as indication of intubation (p < 0.001), diagnosis on admission (p < 0.001), length of stay (p < 0.001), and length of ventilation (p = 0.003) and in-hospital mortality. Age ≥ 85 years (HR= 1.270; 95%CI=1.074 to 1.502) and 75 to 84 years (HR=1.642; 95%CI=1.167 to 2.076), cardiac arrest as indication of intubation (HR: 1.882; 95% CI: 1.554 – 2.279), and APACHE-II scores 25 – 34 (HR: 1.423; 95% CI: 1.171 - 1.730) and ≥ 35 (HR: 1.789; 95%CI: 1.418 - 2.256) were amongst the independent predictive factors of in-hospital mortality. Conclusion: Nearly three out of four individuals aged ≥65 years intubated at the ED died during the same admission. Older age, cardiac arrest as indication of intubation, and APACHE-II score were independent predictors of in-hospital mortality.

Introduction: It is critical to quickly and easily identify severe coronavirus disease 2019 (COVID-19) patients and predict their mortality. This study aimed to determine the accuracy of the physiologic scoring systems in predicting the mortality of COVID-19 patients. Methods: This prospective cross-sectional study was performed on COVID-19 patients admitted to the emergency department (ED). The clinical characteristics of the participants were collected by the emergency physicians and the accuracy of the Quick Sequential Failure Assessment (qSOFA), Coronavirus Clinical Characterization Consortium (4C) Mortality, National Early Warning Score-2 (NEWS2), and Pandemic Respiratory Infection Emergency System Triage (PRIEST) scores for mortality prediction was evaluated. Results: Nine hundred and twenty-one subjects were included. Of whom, 745 (80.9%) patients survived after 30 days of admission. The mean age of patients was 59.13 ± 17.52 years, and 550 (61.6%) subjects were male. Non-Survived patients were significantly older (66.02 ± 17.80 vs. 57.45 ± 17.07, P< 0.001) and had more comorbidities (diabetes mellitus, respiratory, cardiovascular, and cerebrovascular disease) in comparison with survived patients. For COVID-19 mortality prediction, the AUROCs of PRIEST, qSOFA, NEWS2, and 4C Mortality score were 0.846 (95% CI [0.821-0.868]), 0.788 (95% CI [0.760-0.814]), 0.843 (95% CI [0.818-0.866]), and 0.804 (95% CI [0.776-0.829]), respectively. All scores were good predictors of COVID-19 mortality. Conclusion: All studied physiologic scores were good predictors of COVID-19 mortality and could be a useful screening tool for identifying high-risk patients. The NEWS2 and PRIEST scores predicted mortality in COVID-19 patients significantly better than qSOFA.

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

Introduction: Medical and surgical priorities were dramatically changed during the COVID-19 pandemic. This study aimed to evaluate the impact of this pandemic on presentation to emergency department (ED) with urologic complaint. Method: This cross-sectional study was conducted at a tertiary urology referral center in Tehran, Iran. The data of all ED admissions were collected and the frequency of admissions with urologic complain and their outcomes were compared between two 90-day periods (before and during COVID-19 era). Results: 480 ED admissions were studied. The number of patients visiting the ED with urologic complaint during COVID-19 era was significantly lower than the same period in the pre-COVID-19 period (125 vs. 355 admissions; p = 0.01). The mean hospitalization days for patients in the pre-COVID-19 period were significantly higher (5.6 ± 4.4 vs. 3.2 ± 4.2 days; p

Removing embedded fishhook without causing further tissue damage from the barbed nature of the hook is a challenge in emergency department (ED). The four most commonly used techniques include advance and cut, string-yank, needle cover, and retrograde removal. This study aims to describe a modified push- through technique without cutting the barb, namely advance without cut and retrograde removal, as an effective technique of successful removal of fishhooks. There is no risk of additional injury to patients and healthcare staff, and the technique does not need tools that are not generally readily available in EDs.

Introduction: Sepsis is a significant and common cause of death and burden among critically ill patients, which has increasing incidence and mortality in adults over 60 and advanced age. This study aimed to develop an easy-to-use clinical tool for assessing 28-day mortality risk in older sepsis patients upon their initial assessment in the emergency department (ED)., Method: A retrospective cohort study was conducted using electronic medical records of older (≥60 years) ED patients with suspected sepsis from August 1, 2018, to December 31, 2018. A new prediction score was formulated based on the logistic coefficients of clinical predictors through multivariable regression analyses. Then, the score's screening performance was evaluated and compared to existing scoring systems; Systemic Inflammatory Response Syndrome (SIRS), quick Sequential Organ Failure Assessment (qSOFA), National early warning score (NEWS), and The Ramathibodi early warning score (REWS); using receiver operating characteristic curve analysis (AuROC)., Result: The study included 599 patients with the mean age of 77.13 (range: 60-101) years (56.43% male) and an overall 28-day mortality rate of 7.01%. The newly developed prediction score had seven independent predictors of 28-day mortality: malignancy, dependent status, heart rate, respiratory rate, oxygen saturation, consciousness, and lactate, which demonstrated excellent discriminative ability (AuROC: 0.87, 95% confidence interval (CI): 0.82 - 0.92), significantly outperforming SIRS (AuROC: 0.62), qSOFA (AuROC: 0.72), NEWS (AuROC: 0.74), and REWS (AuROC: 0.71), all with p-values <0.01. The score allowed risk stratification into low-risk (positive likelihood ratio (LR+): 0.37, 95% CI: 0.24 - 0.58) and high-risk (LR+: 4.14, 95% CI: 3.14 - 5.44) groups with sensitivity of 69.0% and specificity of 83.3% at a cut-off point of 6., Conclusion: The novel prediction score demonstrates a remarkable ability to predict 28-day mortality risk in older sepsis patients during their initial ED assessment, offering potential for improved risk stratification and treatment guidance in older patients., Competing Interests: The authors declare that they have no competing interests.

Introduction: The rates of unscheduled emergency department (ED) visits and readmissions after discharge from the ED in acute heart failure (AHF) patients are high. This study aimed to identify the predictive factors of 30-day adverse events after discharge from the ED. Methods: A retrospective study was conducted from 2017 to 2019 in patients diagnosed with AHF and discharged from the ED at a tertiary university hospital. Thirty-day adverse events were defined as (i) unscheduled revisit to the ED with AHF, (ii) hospital admission from AHF, and, (iii) death after discharge from the ED. The predictive factors of 30-day adverse events were examined using multivariate analyses by logistic regression. Results: 421 patients with the median age of 73 (IQR: 63-81) years were studied (52.3% male). 81 (19.2%) patients had 30-day adverse events. Significant predictive factors of 30-day adverse events consisted of underlying valvular heart disease (OR = 2.46; 95%CI: 1.27-4.78; p = 0.008), chronic obstructive pulmonary disease (COPD) (OR = 0.08; 95%CI: 0.01-0.64; p=0.001), malignancy (OR=3.63; 95%CI: 1.17-11.24; p = 0.031), New York Heart Association functional class III (OR = 4.88; 95%CI: 0.93-25.59) and IV (OR = 7.23; 95% CI: 1.37-38.08) at the ED (p = 0.035), and serum sodium 60 minutes after ED arrival (OR = 3.89; 95%CI: 2.16-7.00; p < 0.001), and no discharge advice for follow-up (OR = 2.30; 95%CI: 1.10-4.77; p = 0.028). Conclusion: AHF patients who had good response to intravenous diuretics and were discharged from the ED were at high risk for 30-day adverse events. Ten factors predicted 30-day adverse events after discharge from the ED.

Introduction: Patients’ experience in hospitals affects their satisfaction. The purpose of the present study was to assess the effect of applying a queue management system on patient satisfaction in emergency department waiting rooms. Methods: The present prospective randomized single-blinded interventional study was performed from July to August 2020 and involved 236 patients that were divided into one intervention group and one control group, each consisting of 118 patients. The mentioned patients’ perception of the waiting time and satisfaction before being visited by an emergency medicine doctor was evaluated with and without applying the queue management system. Results: The mean actual waiting time (15.5 ± 7.5 minutes) as well as the mean perceived waiting time (11.9 ± 7.4 minutes) for the intervention group were significantly lower than those of the control group with the values of 27.03 ± 8.5 and 32.8 ± 8.7 minutes, respectively (p < 0.001). The mean perceived waiting time was significantly less than the mean actual waiting time (11.9 min vs 15.5 minutes) for the intervention group (p

Introduction: The current international sepsis guideline recommends that administration of intravenous broad-spectrum antibiotics should be initiated within 1 hour of emergency department (ED) arrival for sepsis patients. This study aimed to evaluate the association between door-to-antibiotic time and in-hospital mortality of these patients. Methods: In this retrospective cross-sectional study, elderly patients (age ≥65 years) diagnosed with sepsis in the ED of a tertiary referral and academic hospital from January to December 2019 were enrolled. Door-to-antibiotic time was defined as the time from ED arrival to antibiotic initiation. The associations of door-to-antibiotic time and each hour delay in first antibiotic initiation with in-hospital mortality were assessed. Results: Six hundred patients with the median age of 78.0 (IQR: 72.0-86.0) were studied (50.8% female). The median door-to-antibiotic time was 51.0 (36.0 – 89.0) minutes and in-hospital mortality rate was 12.5%. There was no significant difference in the in-hospital mortality rate between door-to-antibiotic time ≤1 hour and >1 hour (13.1% vs. 11.6%, p = 0.726). When considering hour-upon-hour of door-to-antibiotic time, no significant difference in in-hospital mortality was observed (p = 0.866). Factors that led to a delay in door-to-antibiotic time were presenting body temperature

Introduction: An effective triage needs to consider many factors, such as good triage protocol, experienced triage nurses, and patient factors. This study aimed to evaluate the validity of Songklanagarind Pediatric Triage (SPT) for triage of pediatric patients in the emergency department (ED) and identify the factors associated with triage appropriateness. Methods: This study was done in two phases. In the first phase, a team of emergency physicians, a pediatric emergency physician, and a pediatric critical care physician developed SPT model by considering and combining Emergency Severity Index (ESI), Pediatric Assessment Triangle (PAT), Pediatric Canadian Triage and Acuity Scale (PaedCTAS), and Pediatric Septic Shock early warning signs protocol of the hospital as the core concept. In the second phase, a prospective observational study was conducted in the ED of Songklanagarind Hospital, which is a tertiary university hospital in southern Thailand, from September to October 2019 to evaluate the accuracy of the developed triage model. Results: A total of 520 pediatric patients met the inclusion criteria. The pediatric triage model had sensitivity and specificity values of 98.28% and 26.24%, respectively, and positive and negative predictive values of 27.67% and 98.15%, respectively, in prediction of death, hospitalization, and resource utilization. The rates of appropriate triage, over-triage, and under-triage were 68.8%, 28.5%, and 2.7%, respectively. Significant factors associated with appropriateness of triage were underlying disease of the respiratory system (OR = 4.16, 95%CI: 1.75‒9.23), fever (OR = 0.60, 95%CI: 0.41‒0.88), dyspnea (OR: 6.38, 95%CI: 2.51‒16.22), diarrhea (OR = 0.26, 95%CI: 0.09‒0.73), oxygen saturation

Introduction: Screening of high-risk patients and accelerating their therapeutic procedures can reduce the burden of acute coronary syndrome (ACS). This study aimed to evaluate the accuracy of HEART score in predicting the risk of one-month major adverse cardiac events (MACE) in these patients. Methods: In this prospective cross-sectional study, the accuracy of HEART score in patients over 18 years old who presented to emergency department following acute chest pain, was evaluated during a 21-month period. Each patient was followed up regarding the incidence of MACE for one month via phone call and the hospital’s integrated health information system. Results: 240 cases with the mean age of 60.50 ± 16.07 years were studied (56.3% male). MACE was observed in 77 (32.1%) cases. The most common MACE was percutaneous coronary artery revascularization (PCAR) (12.9%). The mean HEART score of studied cases was 4.74 ± 2.12. The mean score of cases with MACE was significantly higher than others (6.25 ± 1.97 versus 4.03 ± 1.79; p < 0.0001). Based on this score, the risk of MACE was high in 34 (14.2%), moderate in 118 (49.2%), and low in 88 (36.7%) cases. The incidence of one-month MACE was 85.3% in high-risk cases, 35.6% in moderate one, and 6.8% in low-risk cases based on HEART score. The area under the ROC curve of HEART score in predicting the risk of MACE was 0.796 (95% CI: 0.736 – 0.856). The best cut off point of HEART score in this regard was calculated as 4.5. The sensitivity and specificity of this score in 4.5 cut off were 83.11% (95% CI: 72.49 – 90.35) and 66.25% (95% CI: 58.38 – 73.35), respectively. Conclusion: Based on the findings of the present study the mean HEART score of ACS patients with one-month MACE was significantly higher than others and the incidence of MACE in high-risk patients was significantly higher. But the overall accuracy of score in predicting one-month MACE in ACS patients was in moderate range.

Introduction: Violence against healthcare workers mostly occurs in emergency departments and is a serious global public health issue. This study aimed to evaluate the prevalence of violence directed towards emergency department healthcare personnel and to ascertain the factors that might be correlated with it. Methods: In this cross-sectional study, an anonymous questionnaire was used to gather data from healthcare personnel working in the emergency departments under the direction of the Bangkok Metropolitan Administration between 1 August 2019 and 30 November 2019, regarding the experience of violence during the previous year. Results: A total of 258 (87.5%) responses were received from 295 personnel. The results showed that 88.4% (228 personnel) had experienced violence during the past year, of these, 37.6% involved physical abuse that caused minor injuries. Employees with shorter tenures, nurses, and those working in tertiary academic emergency departments in the central business district were found to have increased likelihood of confronting violence. Measures taken to prevent violence had a limited impact on the occurrence rate. The most common impact on employees after experiencing violence was discouragement in their jobs (75.1 %). The key factors that promoted cases of violence were the consumption of alcohol or drugs (81.3%) and long waiting times (73.6%). Most violence tended to occur during non-office hours (95.4%). One-third of emergency healthcare personnel reported facing violence during their work. Conclusion: Emergency healthcare personnel in metropolitan of Thailand had a high rate of experiencing violence in the previous year. Younger age, lower work experience, being a nurse, and working in the urban academic or tertiary emergency department increased the likelihood of being a victim of workplace violence.

Introduction: There is an evidence-practice gap in the optimal timing and volume of intravenous fluid as well as vasopressor administration in managing patients with sepsis. This study aimed to explore current hemodynamic resuscitation practice in emergency department (ED) for patients with sepsis and hypotension., Methods: This is a sub-analysis of the prospective multicentre ARISE FLUIDS observational study, which was conducted in 70 EDs across Australia and New Zealand. Baseline characteristics, as well as ED management and outcome of sepsis patients were compared between patients who were and were not admitted to intensive care unit (ICU) or high dependency unit (HDU)., Results: A total of 587 patients with a median age of 65 years and even sex distribution (49% female) were available for analysis. Almost two-thirds of patients with sepsis (63.2%, n=371) were not admitted to ICU/HDU and were given lower intravenous (IV) fluid volumes over 24-hours, compared to those receiving critical care (4077ml vs. 5421ml, p<0.001). Patients not admitted to an ICU/HDU had a lower Acute Physiology And Chronic Health Evaluation (APACHE) II score (median 14 vs. 18, P<0.001) and serum lactate level (1.8 vs. 2.8 mmol/L, P<0.001) compared to those admitted to ICU/HDU and 5.9% received a vasopressor infusion in the first 24-hours. Females, patients aged <65 years, and those with urosepsis or sepsis of non-respiratory origin received a greater volume of IV fluids., Conclusion: Almost two-thirds of patients were not admitted to ICU/HDU. In patients not admitted to ICU/HDU, 1 in 17 received a vasopressor infusion during their ED or early hospital stay. Patients not admitted to ICU/HDU received less fluid in the first 24 hours than those who were. Greater resuscitation fluid volumes were independently associated with female sex, age <65 years, higher lactate levels, and urinary or non-respiratory source of sepsis., Competing Interests: The authors have no conflicts of interests to declare.

Introduction: As the quality of care for respiratory diseases in pediatric patients in emergency departments (EDs) becomes increasingly important, this systematic review aims to evaluate the current quality indicators (QIs) specifically designed for the ED management of pediatric bronchiolitis and croup., Methods: We conducted searches in four electronic databases (Scopus, Web of Science, CINAHL, and MEDLINE) from their inception up to February 2024. We focused on English-language qualitative and quantitative publications that suggested or described at least one indicator initiative related to ED care for pediatrics with bronchiolitis and croup diseases. These publications were identified by two reviewers, independently. We extracted study characteristics, all relevant QIs reported, and the percentage of compliance with these QIs, where available. All QIs identified from expert panels and observational studies were grouped by definition and categorized by the Institute of Medicine's (IOM) and Donabedian's frameworks for healthcare quality. The percentage of compliance with the identified QIs as reported by observational studies was pooled using a random effect meta-analysis, when appropriate., Results: A total of 17 studies were identified, comprising 5 expert panel studies and 12 observational studies. Altogether, these studies reported 126 QIs for potential use in EDs for pediatric bronchiolitis and croup patients. Of these, 55 QIs were reported by expert panel studies, and 71 by observational studies. Specifically, 81 QIs were related to bronchiolitis, while 45 pertained to croup patients. In terms of the Donabedian domain, most indicators (96.5%) measured the process of care while a smaller fraction (3.5%) addressed care outcomes. In the Institute of Medicine (IOM) domain, most indicators focused on effectiveness and safety. Observational studies reported the percentage of compliance for 35 QIs identified in the expert studies. It was noted that compliance with these QIs varied significantly between studies and health sectors., Conclusions: The findings of this systematic review highlight significant disparities in compliance to the established QIs, which underscores the urgent need for dedicated strategies to enhance the treatment of pediatric bronchiolitis and croup in ED settings., Competing Interests: No conflict of interest.

Introduction: Early discharge from the emergency department (ED) or a 6-hour observation in the ED are two methods for management of patients with mild traumatic brain injury (mTBI) with normal brain computed tomography (CT) scan. This study aimed to compare the outcomes of the two management options., Methods: This study is a single-center, open-label, pilot randomized case control study conducted in the ED of Ramathibodi Hospital from June 2022 to September 2023. Eligible participants included all individuals with mTBI who had negative findings on Brain CT scans. They were randomly assigned to either the early ED discharge or 6-hour ED observation group and compared regarding the outcomes (rate of 48-hour ED revisits; occurrence of post-concussion syndrome (PCS) 1 day, 1 month, and 3 months after the initial injury; and 3-month mortality)., Results: 122 patients with the mean age of 74.62 ± 14.96 (range: 25-99) years were consecutively enrolled (57.37% female). No significant differences were observed between the early discharge and observation groups regarding the severity of TBI (p=0.853), age (p=0.334), gender (p=0.588), triage level (p=0.456), Glasgow Coma Scale (GCS) score (p=0.806), comorbidities (p=0.768), medication usage (p=0.548), mechanism of injury (p=0.920), indication for brain CT scan (p=0.593), time from TBI onset to ED arrival (p=0.886), and time from ED triage to brain CT scan (p=0.333). Within 48 hours after randomization, the incidence of revisits was similar between the two groups (1.57% vs. 3.23%; p = 1.000). There were no statistically significant differences in the incidence of PCS between the early discharge and observation groups at 1 day (33.90% vs. 35.48%, p = 0.503), at 1 month (12.07% vs. 13.11%, p = 0.542), and at 3 months (1.92% vs. 5.56%, p = 0.323) after randomization. After a three-month follow-up period, four patients in the early discharge group, had expired (none of the deaths were associated with TBI)., Conclusion: It seems that, in mTBI patients with normal initial brain CT scan and the absence of other injuries or neurological abnormalities, early discharge from the ED without requiring observation could be considered safe., Competing Interests: The authors declare that they have no competing interests.

COVID-19, in certain respects, can be viewed as a CBRN (chemical, biological, radiological, or nuclear) event due to being a consequence of SARS-CoV2 virus (the “contaminantâ€). We, thus, reorganized our emergency department (ED) into 3 distinct zones (red, yellow, and green) for the purpose of infection control. Patients with high or medium risk of COVID-19 infection are managed in the red zones. Low-risk patients are managed in the yellow zones. All patients are prohibited to enter the green zones. Green zones are used by healthcare providers (HCPs) for personal protective equipment (PPE) donning, inventory, planning, and dining. Only HCPs who work in the red zones are required to use full level PPE (aerosol precaution). HCPs working in the yellow zones require less PPE (contact and droplet precaution). No PPE is required in the green zones. Establishing red, yellow, and green zones in the ED can be helpful in reducing cross-infections and minimizing demand for PPE.

Introduction: Renal colic affects 12% of the U.S. population, accounting for nearly 1% of emergency department (ED) visits. Current recommendations advocate narcotic-limiting multimodal analgesia regimens. The objective of this review is to determine if in patients with renal colic (Population), intravenous (IV) amide anesthetics (Intervention) result in better pain control, lower requirements for rescue analgesia, or less adverse medication effects (outcome) compared to placebo, non-steroidal anti-inflammatory drugs (NSAIDs), or opiates (Comparisons). Methods: Scholarly databases and relevant bibliographies were searched using a pre-designed systematic review protocol and registered with PROSPERO. Inclusion criteria were: (1) randomized clinical trial (RCT), (2) age ≥ 18 years, (3) confirmed or presumed renal colic, (4) amide anesthetic administered IV. Eligible comparison groups included: placebo, conventional therapy, acetaminophen, NSAID, or opiate. The primary outcome was pain intensity at baseline, 30, 60, and 120 minutes. Trial quality was graded, and risk-of-bias was assessed. Results: Of the 3930 identified references, 4 RCTs (479 participants) were included. One trial (n=240) reported improved analgesia with IV lidocaine (LidoIV) plus metoclopramide, compared to morphine. All other trials reported unchanged or less analgesia compared to placebo, ketorolac, or fentanyl. Very severe heterogeneity (I2= 88%) precluded pooling data. Conclusion: Current evidence precludes drawing a firm conclusion on the efficacy or superiority of LidoIV over traditional therapies for ED patients with renal colic. Evidence suggests LidoIV may be an effective non-opiate analgesic alliterative; however, it’s efficacy may not exceed that of NSAIDs or opiates. Further study is needed to validate the potential improved efficacy of LidoIV plus metoclopramide.

Introduction: It seems that magnesium (Mg) sulfate can be helpful in controlling the acute pain caused by the stone passing from the ureter by reducing ureter smooth muscle contractions. The present study has been designed with the aim of assessing the role of Mg sulfate in controlling the renal colic pain in emergency department (ED). Methods: This double blind randomized clinical trial was performed on 18 to 60 year-old patients with acute renal colic presenting to the ED of a teaching hospital during 1 year. Patients were allocated to one of the 2 groups receiving either IV morphine or IV Mg sulfate using block randomization method and were then compared regarding pain control characteristics and probable side effects. Results: 90 patients with the mean age of 37.34 ± 12.10 (18 – 60) years were divided into 2 equal groups. The 2 groups were in a similar condition regarding mean age (p = 0.168), sex distribution (p = 0.267), underlying disease (p = 0.414) and alcohol and drug abuse (p = 0.524). Mean pain scores of the patients based on VAS were not significantly different between the 2 groups on admission and 20, 30, 60, 120, and 180 minutes after drug administration. Success rate in reducing the pain by at least 3 points on VAS was equal and 91.1% for both groups on the 20th minute and reached 100% on the 30th minute for both groups. The number of cases that were pain-free on the 20th minute was significantly higher in the morphine groups (31 versus 16 patients, p = 0.004). However, on the 30th minute both groups experienced a similar condition in this regard (39 versus 29, p = 0.063). None of the patients in the 2 groups experienced the studied side effects. Conclusion: It seems that Mg sulfate, as a muscle relaxant agent, can be considered as a safe adjunct medication in controlling the pain of renal colic patients in the ED.

Introduction: Hospitals are the most important infrastructures of any society. The hospital emergency department is one of the most important wards of hospitals in response to disasters. The purpose of this study was to evaluate the preparedness of hospital emergency departments in response to disasters in Iran via a systematic review and meta-analysis. Methods: This study was a systematic review and meta-analysis. The literature search was conducted in the national and international databases including SID, Magiran, Irandoc, Google scholar, Medline, Scopus, and ISI. Valid Persian and English keywords were used to extract articles related to the preparedness of hospital emergency departments in response to disasters. The STROBE checklist was used to evaluate the quality of the articles, and the I2 index was used to assess heterogeneity among the studies. Statistical analyses were conducted using STATA14 software. Results: In this study, 185 articles were initially recruited. Meta-analysis was finally performed on 4 articles selected based on inclusion criteria. The analysis included a total of 51 hospitals in Iran. According to our results, the mean preparedness of hospital emergency departments in response to disasters was calculated as 54.64% (95% CI = 41.15-68.13, I2 = 0.0%; p = 0.727). Conclusion: The results of this study showed that the average level of preparedness of hospital emergency departments in Iran to respond to disasters was moderate to high. Therefore, planning and actions should be considered based on the guidelines and accreditation standards to enhance the preparedness of hospital emergency departments in response to disasters.

In the wake of recent progress in computed tomography (CT) enabling to obtain high quality images within five minutes, CT scan has been widely used in emergency diagnostic radiology and is considered best suited for detection of pathologies, as well as assessing the location and extent of lesions in the emergency department. Emergency physicians often require confirmation of surface bruises or wounds coexisting with pathology on CT scan. Alternatively, they may want to confirm the presence or absence of pathology in the painful lesion. The use of an appropriate surface marker on the skin surface of the painful lesion may enable them to identify areas of interest and safely reduce radiation exposure.

Introduction: Emergency Department (ED) crowding is a global public health phenomenon affecting access and quality of care. In this study, we seek to conduct a systematic review concerning the challenges and outcomes of ED crowding. Methods: This systematic review utilized original research articles published from 1st January 2007, to 1st January 2019. Relevant articles from the PubMed (MEDLINE), EMBASE, and Google scholar databases were extracted using predesigned keywords. Following the PRISMA guidelines, two reviewers independently evaluated the quality of the studies using Critical Appraisal Skills Programme for cohort studies and qualitative studies, and Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument for studies. Results:Â Out of the total of 73 articles in the final record, we excluded 15 of them because of poor quality. This systematic review synthesized the reports of 58 original articles. The outcomes of multiple individual patients and healthcare-related challenges are comprehensively assessed. Conclusions: ED crowding affects individual patients, healthcare systems and communities at large. The negative influences of crowding on healthcare service delivery result in delayed service delivery, poor quality care, and inefficiency; all negatively affecting the emergency patients' healthcare outcomes, in turn.

Introduction: About one third of patients referring to emergency department (ED) with abdominal pain, are discharged without a definite diagnosis. This study aimed to investigate the one-month outcome of patients with unspecified abdominal pain. Methods: This cohort study was conducted on subjects who were evaluated in ED with unspecified abdominal pain and were referred to the gastroenterology clinic and followed for one month. Finally, they were divided into two groups of cases with clear cause of abdominal pain and unclear cause of abdominal pain and patients’ characteristics were compared between the groups. Results: 150 cases with the mean age of 40.68 ± 18.34 years were studied (53.3% female). After one month, 67 (44.7%) patients still complained of abdominal pain. A definitive cause of abdominal pain was established in 88 (58.7%) cases. There was not any significant difference between groups regarding, sex distribution (p = 012), duration of pain (p = 0.11), history of previous similar pain (p = 0.136), pain radiation (p = 0.737), length of hospital stay (p = 0.51), and presence of anorexia (p = 0.09), nausea and vomiting (p= 0.50), fever (p = 1.0), diarrhea (p = 0.23), and constipation (p = 0.07). There was a significant difference between the groups regarding location of pain (p = 0.017), age (p = 0.001) and history of comorbid diseases (p = 0.046). The predictive factors of finding a clear cause for abdominal pain in one-month follow-up, were leukocytosis (OR: 5.92 (95% CI: 2.62 – 13.39); p < 0.001), age (OR: 2.78 (95% CI: 1.15 – 6.71); p = 0.023), and outpatient follow-up (OR: 1.04 (95% CI: 1.02 – 1.07); p < 0.001). Conclusion: Approximately, 40% of patients who were discharged with unspecified abdominal pain did not receive a clear diagnosis after one month of follow-up. Older age, leucocytosis in initial evaluations, and outpatient follow-up increased the probability of finding a clear cause for abdominal pain in the mentioned cases.

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

Introduction: Seizure is known to be a serious complication of tramadol consumption even in its therapeutic doses. The aim of this study was to determine the prevalence of seizure and its related factors in tramadol intoxicated patients referred to emergency department (ED). Methods: In this cross-sectional study, all individuals, admitted to ED following tramadol intoxication were divided into two groups based on the presence or absence of seizures. Demographic data as well as clinical, electroencephalogram and imaging findings were compared between the two groups using SPSS software version 22. Results: 167 patients with the median age of 23 (13-45) years were studied (85% male). Seizure was seen in 97 (58.0%) cases. Risk of seizure had increased 3.7 times in patients with a history of seizure (OR: 3.71 Cl 95%: 1.17 - 11.76). Tramadol dose was significantly higher in patients who had seizure more than once (Median: 2800 IQR: 1800-4000), compared to those who had one seizure episode (Median: 850 IQR: 1800-400) (p

Introduction: Studies have claimed that low lymphocyte count is independently correlated with 28-day survival of sepsis patients. Therefore, this study aimed to evaluate the value of lymphopenia in predicting the short-term outcome of sepsis patients. Methods: This cross-sectional study was performed on sepsis patients referred to the emergency department during an 8-month period and relationship of lymphopenia with 28-day mortality and probability of septic shock and readmission due to sepsis was assessed. Results: 124 cases with the mean age of 66.12 ± 15.82 (21-90) years were studied (54.8% male). 81 (65.3%) cases had lymphopenia (59.3% male). Lymphopenic patients had a significantly higher mean age (p = 0.003), higher need for ICU admission (p < 0.001), higher prevalence of 28-day septic shock (p < 0.001), higher 28-day mortality (p < 0.001), higher probability of readmission due to sepsis (p = 0.048), and higher SOFA score (p < 0.001). During 28 days of follow up, 57 (46%) patients were expired. They had a higher prevalence of septic shock (p < 0.001) and higher SOFA score (p < 0.001). Multivariate analysis showed that septic shock (OR=364.6; 95% CI: 26.3 to 5051.7; p = 0.001) and lymphopenia (OR=19.2; 95% CI: 1.7 to 211.3; p = 0.016) were the independent predictors of 28-day mortality. Conclusions: Based on the findings, lymphopenia was independently associated with higher 28-day mortality and lymphopenic patients were older than the control group and had a significantly higher need for ICU admission, higher probability of 28-day septic shock and readmission due to sepsis, and higher SOFA score.

Introduction: The quality of healthcare for pediatric asthma patients in the emergency department (ED) is of growing importance. This systematic review aimed to identify and describe existing quality indicators (QIs) designed for use in the ED for pediatric asthma care., Methods: We systematically searched three main electronic databases in May 2023 for all English-language qualitative and quantitative publications that suggested or described at least one QI related to pediatric asthma care in the ED. Two reviewers independently selected the included studies and extracted data on study characteristics, all relevant QIs reported, and the rates of compliance with these indicators when available. The identified QIs were classified according to Donabedian healthcare quality framework and the Institute of Medicine (IOM) framework. When feasible, we aggregated the compliance rates for the QIs reported in observational studies using random effects models. The quality assessment of the included studies was performed using various Joanna Briggs Institute (JBI) tools., Results: We identified twenty studies, including six expert panels, 13 observational studies, and one trial. Together, these studies presented 129 QIs for use in EDs managing pediatric asthma. Among these QIs, 66 were pinpointed by expert panel studies, whereas 63 were derived from observational studies. Within the Donabedian framework, most indicators (86.8%) concentrated on the process of care. In contrast, within the Institute of Medicine (IOM) domain, the predominant focus was on indicators related to effectiveness and safety. Observational studies reported varying compliance rates for the 36 QIs identified in the expert studies. The included studies showed a wide range of bias risks, suggesting potential methodological variances., Conclusions: A significant number of QIs in pediatric asthma care have been proposed or documented in literature. Although most of these indicators prioritize the process of care, there is a conspicuous absence of outcome and structure indicators. This meta-analysis uncovered significant disparities in compliance to the identified QIs, highlighting the urgent necessity for targeted interventions to enhance pediatric asthma care in ED., Competing Interests: No conflict of interest.

Introduction: The burgeoning burden on emergency departments is a global challenge that we have been confronting for many years. Emerging artificial intelligence (AI)-based solutions may constitute a critical component in the optimization of these units. This systematic review was conducted to thoroughly examine and summarize the currently available AI solutions, assess potential benefits from their implementation, and identify anticipated directions of further development in this fascinating and rapidly evolving field., Methods: This systematic review utilized data compiled from three key scientific databases: PubMed (2045 publications), Scopus (877 publications), and Web of Science (2495 publications). After meticulous removal of duplicates, we conducted a detailed analysis of 2052 articles, including 147 full-text papers. From these, we selected 51 of the most pertinent and representative publications for the review., Results: Overall the present research indicates that due to high accuracy and sensitivity of machine learning (ML) models it's reasonable to use AI in support of doctors as it can show them the potential diagnosis, which could save time and resources. However, AI-generated diagnoses should be verified by a doctor as AI is not infallible., Conclusions: Currently available AI algorithms are capable of analysing complex medical data with unprecedented precision and speed. Despite AI's vast potential, it is still a nascent technology that is often perceived as complicated and challenging to implement. We propose that a pivotal point in effectively harnessing this technology is the close collaboration between medical professionals and AI experts. Future research should focus on further refining AI algorithms, performing comprehensive validation, and introducing suitable legal regulations and standard procedures, thereby fully leveraging the potential of AI to enhance the quality and efficiency of healthcare delivery., Competing Interests: The authors declare no conflict of interest.

Introduction: The specific impact on calcium dynamics after non-massive blood transfusions remains relatively unexplored. This study aimed to compare pre- and post-transfusion calcium levels in patients receiving blood and blood product in the emergency department., Methods: This is a single-center, prospective, cross-sectional study conducted at the Emergency Department of Gazi University Health Research and Application Center Hospital in Ankara, Turkey, from January 1, 2020, to August 31, 2020. The study included adult patients who underwent blood and blood product transfusions, and serum calcium levels were measured and compared from samples taken before and after transfusion., Results: A total of 292 participants were enrolled in the study, with 242 participants included in the final analysis. The mean total calcium level was 8.41 ± 0.76 mg/dL before transfusion and 8.34 ± 0.71 mg/dL after transfusion (p=0.012). When examining the corrected calcium values after receiving blood products based on the type of blood products, participants who received apheresis platelets had a post-transfusion corrected calcium value of 8.26 ±0.41 mg/dL, with a pre-transfusion value of 9.09 ±0.49 mg/dL (p<0.01). The post-transfusion ionized calcium value for participants receiving apheresis was 1.04 ±0.08 mg/dL, compared to 1.15 ±0.09 mg/dL for those who did not receive apheresis (p=0.049). There was a significant relationship between receiving fresh frozen plasma and post-transfusion ionized calcium values (p=0.024)., Conclusion: This study demonstrated that transfusion-associated hypocalcemia can occur even at mild levels in patients receiving blood and blood product transfusions in the emergency department. However, it is suggested that the clinical effects of hypocalcemia, even when occurring based on the type and quantity of blood products, are minimal and negligible., Competing Interests: The authors declare that they have no competing interests.

Introduction: MONTH Difficult Laryngoscopy Score was developed for effectively identifying difficult intubations in the emergency department (ED). This study aimed to evaluate the accuracy of MONTH Score in predicting difficult intubations in ED., Methods: We prospectively collected data on all patients undergoing intubation in the ED of Ramathibodi Hospital, Bangkok, Thailand. The screening performance characteristics of the MONTH score in identifying the difficult intubation in ED were analyzed. All data were analyzed using STATA software version 18.0., Results: 324 intubated patients with the median age of 73 (63-82) years were studied (63.58% male). The proportion of difficult intubations was 19.44%. The sensitivity and specificity of MONTH in predicting difficult intubations were 74.6% (95% CI: 61.6%-85.0%) and 92.8% (95% CI: 89.0%-95.6%), respectively. These measures in subgroup of patients with Intubation Difficulty Scale (IDS) score ≥ 6 were 44.1% (95%CI: 31.2-57.6) and 98.5% (95% CI: 96.2%- 99.6%), respectively. The area under the receiver operation characteristic (ROC) curve of MONTH in predicting difficult intubations was 0.895 (95% CI: 0.856- 0.926)., Conclusions: It seems that the MONTH Difficult Laryngoscopy Score could be considered as a tool with high specificity and positive predictive values in identifying cases with difficult intubations in ED., Competing Interests: The authors declare that they have no competing interests.

Introduction: Noninvasive positive pressure ventilation (NIPPV) is recognized as an efficient treatment for patients with acute respiratory failure (ARF) in emergency department (ED). This study aimed to develop a scoring system for predicting successful weaning from NIPPV in patients with ARF., Methods: In this retrospective cohort study patients with ARF who received NIPPV in the ED of Ramathibodi Hospital, Thailand, between January 2020 and March 2022 were evaluated. Factors associated with weaning from NIPPV were recorded and compared between cases with and without successful weaning from NIPPV. Multivariable logistic regression analysis was used to develop a predictive model for weaning from NIPPV in ED., Results: A total of 494 eligible patients were treated with NIPPV of whom 203(41.1%) were successfully weaned during the study period. Based on the multivariate analysis the successful NIPPV weaning (SNOW) score was designed with six factors before discontinuation: respiratory rate, heart rate ≤ 100 bpm, systolic blood pressure ≥ 100 mmHg, arterial pH≥ 7.35, arterial PaCO2, and arterial lactate. The scores were classified into three groups: low, moderate, and high. A score of >14.5 points suggested a high probability of successful weaning from NIPPV with a positive likelihood ratio of 3.58 (95%CI: 2.56-4.99; p < 0.001). The area under the receiver operating characteristic (ROC) curve of the model in predicting successful weaning was 0.79 (95% confidence interval (CI): 0.75-0.83)., Conclusion: It seems that the SNOW score could be considered as a helpful tool for predicting successful weaning from NIPPV in ED patients with ARF. A high predictive score, particularly one that exceeds 14.5, strongly suggests a high likelihood of successful weaning from NIPPV., Competing Interests: The authors declare that they have no competing interests.

Introduction: Accurate diagnosis and proper treatment of oncology patients presented to emergency department (ED) can dramatically enhance their quality of life and decrease their mortality rate. Therefore, the present study aimed to evaluate these patients from an epidemiologic point of view as well as identifying death-related factors. Methods: In this retrospective cross-sectional study, all the oncology patients presented to ED during one year were evaluated using census sampling. A checklist that consisted of clinical and demographic data as well as patients outcome was filled for each patient. Using SPSS 21, multivariate stepwise logistic regression analysis was done to identify independent death-related factors. Results: 568 patients with the mean age of 53.64§18.99 years were studied (56.5% male). The most common locations of tumor were brain (32.7%) and gastrointestinal tract (27.1%). Pain (32.5%) was the most frequent chief complaint on ED arrival. The overall mortality rate of studied patients was 154 (27.1%), 25 (16.2%) of them in ED. Among the evaluated factors, marital status, visiting on a weekday, arrival to ED via ambulance, type of cancer, stage of cancer, presence of metastasis, being under treatment with chemo-radiotherapy, chief complaint on arrival, tumor location, and admission to intensive care unit (ICU) correlated significantly with in-hospital mortality. Conclusion: The most common type of cancer in the studied patients was solid, located in the brain or gastrointestinal tract, in stage III and IV, metastatic, and under chemo-radiotherapy. Independent death-related factors included ICU admission, presentation with loss of consciousness or bleeding, arrival via ambulance, cancer stage > II, neuroendocrine and genitourinary location of cancer, and being under chemo-radiotherapy.

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.

Introduction: Patients' satisfaction (PS) is one of the important indicators of emergency care quality and outcomes of health care services. Some researchers believe that improve the work processes and hospital quality are not possible without caring to comments, requirements, expectations, and satisfaction of patients. The percent study was aimed to assess the emergency department (ED) PS of Poursina hospital, Rasht, Iran. Methods: In this descriptive cross sectional study, the samples was selected from 378 patients admitted to ED of Poursina Hospital, Rasht, Iran, 2013. For each patient a check list and a questionnaire, including 37 questions about PS, were filled that had categories like physical comfort and residential aspects, physicians care, nurse care, behavioral aspect, and waiting time for service presentation. Data were analyzed by SPSS version 16. Results: Entirely, 378 patients were entered to the study with mean age of 38.44±17.8 (60.8% male). The mean score of total satisfaction of ED patients was 106.94±13.62 (range: 72-144). The mean score of physical comfort was 33.25±4.76 out of the highest obtainable score of 55, nurse care 25.33±5.13 out of 40, physician care 24.34±3.38 out of 40, waiting time for services 13.42±5.48 out of 30, and behavioral aspects 10.58±2.66 out of 20. There were significant relation among PS, sex (P=0.0001), and the shift of admission (P=0.023). Conclusion: The findings of percent study showed that giving services to emergency clients in various fields such as physical comfort and residential aspects, physicians care, nurse care, and the total ED satisfaction is relatively agreeable. The periodic and continuous assessment as well as comparison of satisfaction and dissatisfaction parameters during the time, before and after performing the changes, could be effectual.

Introduction: Midazolam has turned into a common drug for pediatric procedural sedation and analgesia. However, there is not much data regarding its proper dose and potential side effects in the Iranian children population. Therefore, the present study was done to compare 2 doses of IV midazolam in this regard. Methods: The present clinical trial was performed to compare 0.1 and 0.3 mg/kg doses of IV midazolam in induction of sedation for head trauma infant patients in need of brain computed tomography (CT) scan. Conscious infants under 2 years old, with stable hemodynamics were included. Onset and duration of action as well as probable side effects were compared between the two groups using SPSS version 22. Results: 110 infants with the mean age of 14.0 §5.9 months (range: 4–24) and mean weight of 9.7±2 kg (range: 5–15) were randomly allocated to one of the 2 study groups (54.6% female). Success rate in 0.1 and 0.3 mg /kg groups were 38.2% (21 patients)and 60% (33 patients), respectively (p=0.018). Overall, 56 (50.9%) patients did not reach proper sedation and were sedated receiving ketamine (22 patients) or another dose of midazolam (34 patients, mean additional dose needed was 2.1±1.1 mg). Conclusion: The results of the present study demonstrated the higher success rate and longer duration of action for 0.3 mg /kg midazolam compared to 0.1 mg /kg. The groups were equal regarding onset of action, effect on vital signs and probable side effects.

Introduction: Using physiologic scoring systems for identifying high-risk patients for mortality has been considered recently. This study was designed to evaluate the values of Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiologic Score (SAPS II) models in prediction of 1-month mortality of critically ill patients. Methods: The present prospective cross sectional study was performed on critically ill patients presented to emergency department during 6 months. Data required for calculation of the scores were gathered and performance of the models in prediction of 1-month mortality were assessed using STATA software 11.0. Results: 82 critically ill patients with the mean age of 53.45 ± 20.37 years were included (65.9% male). Their mortality rate was 48%. Mean SAPS II (p < 0.0001) and APACHE II (p = 0.0007) scores were significantly higher in dead patients. Area under the ROC curve of SAPS II and APACHE II for prediction of mortality were 0.75 (95% CI: 0.64 - 0.86) and 0.72 (95% CI: 0.60 - 0.83), respectively (p = 0.24). The slope and intercept of SAPS II were 1.02 and 0.04, respectively. In addition, these values were 0.92 and 0.09 for APACHE II, respectively. Conclusion: The findings of the present study showed that APACHE II and SAPS II had similar value in predicting 1-month mortality of patients. Discriminatory powers of the mentioned models were acceptable but their calibration had some amount of lack of fit, which reveals that APACHE II and SAPS II are partially perfect.

Introduction: Acute coronary syndrome accounts for more than 15% of the chest pains. Recently, Hess et al. developed North American Chest Pain Rule (NACPR) to identify very low-risk patients who can be safely discharged from emergency department (ED). The present study aimed to validate this rule in EDs of two academic hospitals. Methods: A prospective diagnostic accuracy study was conducted on consecutive patients 24 years of age and older presenting to the ED with the chief complaint of acute chest pain, during March 2013 to June 2013. Chest pain characteristics, cardiac history, electrocardiogram findings, and cardiac biomarker measurement of patients were collected and screening performance characteristics of NACPR with 95% confidence interval were calculated using SPSS 21. Results: From 400 eligible patients with completed follow up, 69 (17.25 %) developed myocardial infarction, 121 (30.25%) underwent coronary revascularization, and 4 (2%) died because of cardiac or unidentifiable causes. By using NACPR, 34 (8.50%) of all the patients could be considered very low- risk and discharged after a brief ED assessment. Among these patients, none developed above-mentioned adverse outcomes within 30 days. Sensitivity, specificity, positive prediction value, and negative prediction value of the rule were 100% (95% CI: 87.35 - 100.00), 45.35 (95% CI: 40.19 - 50.61), 14.52 (95% CI: 10.40 – 19.85), and 100 (95% CI: 97.18 - 100.00), respectively. Conclusions: The present multicenter study showed that NACPR is a good screening tool for early discharge of patients with very low-risk chest pain from ED.

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

Introduction: Renal transplantation are admitted to emergency department (ED) more than normal population. The present brief report aimed to determine the reasons of renal transplant patients’ ED visits. Methods: This retrospective case series study analyzed the reasons of renal transplant recipients’ admission to one ED between 2011 and 2014. The patient data were collected via a checklist and presented using descriptive statistics tools. Results: 41 patients with the mean age of 40.63 ± 10.95 years were studied (60.9% male). The most common ED presenting complaints were fever (36.6%) and abdominal pain (26.8%). Infections were the most common final diagnosis (68.3%). Among non-infectious causes, the most common was acute renal failure (9.7 %). 73.2% of the patients were hospitalized and no cases of graft loss and mortality were seen. Conclusion: The most common reason for ED admission was fever, and infections were the most common diagnosis. Acute gastroenteritis being the most frequent infection and among non-infectious problems, acute renal failure was the most frequent one.Â

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

Many critically ill patients need aggressive procedures, such as central venous catheterization. The complication rate of central venous line placement is estimated to be 15%. Common complications include arterial puncture, hematoma, pneumothorax, hemothorax, arrhythmia, thoracic duct injury, infection, and thrombosis. Cardiac tamponade, pericardial effusions, pleural effusions, air or guidewire embolisms, and lost guide wires are rare but severe complications. Here we report a case of lost guide wire following central venous line insertion.

Introduction: Due to the stressful nature of emergency Department (ED), residents in ED are at risk of violence from patients or their associates. This study aimed to determine the prevalence of workplace violence against ED residents and the reasons for not reporting them. Methods: This cross-sectional study was conducted on ED residents of three educational hospitals, Tehran, Iran, during 2015. The national questionnaire about workplace violence was used for data gathering. In addition, prevalence of reporting the violence and the reasons for not reporting them were determined. Results: 280 questionnaires were analyzed. The mean age of residents was 32.2 ± 4.6 years (58.4% female). 224 (80%) residents stated that they had not passed any educational courses on violence management. The most prevalent type of violence was verbal (90.7%) and patients’ associates (85.4%) were the most common source of aggression. The frequency of physical violence was higher in male aggressors (p = 0.001), resident age > 30 years (p = 0.044), aggressor age > 30 years (p = 0.001), and night shift (p = 0.001). The same trend was observed regarding verbal and racial-ethnic violence. There was no significant relationship between residents’ sex, resident's specialty, and presence of security and police with frequency of violence. 214 (76.4%) residents did not report the violence, and the main reasons for not reporting from their viewpoint were uselessness of reporting (37.4%) and insignificance of the violence (36.9%). Conclusion: Based on the findings of the present study more than 90% of ED residents had experienced at least one type of verbal, physical, or racial-ethnic violence during their shifts. It is necessary for residents in EDs to be trained about violence control and also report and follow these issues through legal channels.

Introduction: Using bedside ultrasound in diagnosing acute cholecystitis in the emergency department (ED) can save time, help the decision making process and allocate resources wisely. This study aimed to evaluate the diagnostic accuracy of bedside right upper quadrant (RUQ) ultrasonography in detection of acute cholecystitis. Method: In this diagnostic accuracy study, patients presenting to ED, suffering from RUQ pain in favor of acute cholecystitis underwent RUQ ultrasonography in emergency and radiology departments and interrater agreement between reports was calculated. Results: 342 patients with the mean age of 53.92 ± 11.18 (20 – 83) years were studied (63.2% female). The number of patients with at least one sonographic finding of acute cholecystitis were 53 (15.50%) and 48 (14.00%) based on ED and radiology reports (Kappa = 0.826). Sensitivity, specificity, positive and negative predictive values, as well as positive and negative likelihood ratios of bedside sonography were 89.58 (95%CI: 76.55 – 96.10), 96.59 (95%CI: 93.63 – 98.29), 81.13 (95%CI: 67.58 – 90.11), 98.26 (95%CI: 95.77 – 99.36), 4.30 (95%CI: 2.42 – 7.62) and 0.017 (95%CI: 0.007 – 0.041), respectively. Conclusion: There was a very good agreement between ED and radiology departments’ sonography reports regarding the presence or absence of acute cholecystitis. Sensitivity and specificity of bedside RUQ sonography were 89.58 and 96.59, respectively.

Introduction: Efficient treatment of asthma can play an important role in controlling asthma attacks, rapid recovery and decrease of patient mortality. Therefore, in the present study the therapeutic effect of low-dose ketamine is evaluated in patients with acute asthma attack. Methods: In the present single-blind, randomized clinical trial with placebo control, the effect of low-dose intravenous ketamine in treating 18 to 85 year-old asthmatic patients who presented to the emergency department was evaluated. Peak expiratory flow rate (PEFR) and the patients’ response to treatment were measured before and 1 hour after treatment. Additionally, using SPSS 22.0, effectiveness of ketamine with 0.3, 0.4, and 0.5 mg/kg doses followed by infusion of the same dose during 30 minutes were compared with placebo. Results: 92 patients were enrolled (59.8% female, mean age 48.5 ± 13.9 years). 15 (16.3%) patients were treated with 0.3 mg/kg ketamine, 14 (15.2%) with 0.4 mg/kg, and 16 (17.4%) with 0.5 mg/kg doses. Mean PEFR was 336.2 ± 101.5 liters in the placebo group and 345.8 ± 84.7 liters in the ketamine group before intervention (p = 0.6), while after intervention, they were 352.1 ± 101.2 and 415.8 ± 76.2 liters, respectively (p = 0.001). Ketamine treatment with 0.4 and 0.5 mg/kg doses led to a higher increase in PEFR compared to 0.3mg/kg dose (df: 3, 88; F = 23.8; p < 0.001). Conclusion: It seems that administration of 0.4 - 0.5 mg/kg doses of intravenous ketamine followed by infusion of the same dose during 30 minutes can be effective for rapid recovery of PEFR in patients with mild to moderate asthma.

Introduction: Poor handover and inadequate transmission of clinical information between shifts cause a lot of problems in patient care and result in significant risks for physicians and patients. This study was designed to evaluate the impact of education and application of handover checklist on trauma patients’ handover quality. Methods: In this before-after trial, handover process of trauma patients in an educational hospital was evaluated before and after education and application of a handover checklist, abbreviated as “WHO MISSED IP?â€, using a questionnaire that consisted of 10 necessary items, which should be delivered during handover of trauma patients. A total score of 10 was considered for each patient handover, the score 10 out of 10 indicating that all 10 important pieces of patient information were correctly delivered. Results: 52 pre and post-intervention handover sessions were evaluated (438 patients). Prior to intervention, 18% of patients were not delivered to the next shift, most of which were in the night shift handover (p < 0.001). From the pre-intervention to the post-intervention period, significant improvements were detected in all items except for diagnosis and consulting items. The mean duration of handover changed from 1.22 ± 0.24 minutes to 1.58 ± 0.23 minutes after intervention (p < 0.01). In the pre-intervention period, the score equal or greater than 9 was observed in 7.5% of patients, while after intervention, 63.6% of patients had score ≥ 9 regarding complete handover (p < 0.01). Conclusion: Based on the findings of the present study, teaching handover standards and application of handover checklist could be helpful in improving the quality of information delivery between emergency medicine residents and improve trauma patients’ handover indices.

Capnograph is an indispensable tool for monitoring metabolic and respiratory function. In this study, the aim was to review the applications of end-tidal carbon dioxide (ETCO2) monitoring in emergency department, multiple databases were comprehensively searched with combination of following keywords: “ETCO2â€, “emergency department monitoringâ€, and “critical monitoring†in PubMed, Google Scholar, Scopus, Index Copernicus, EBSCO and Cochrane Database.

Introduction: The present study is a survey to assess the pros and cons of emergency medicine (EM) from the viewpoint of the scholars from other medicine disciplines to improve the efficiency of EM in the healthcare system. Methods: This is a semi-structured qualitative study. Face-to-face interviews with various physicians with different specialties were performed to gather information on their viewpoints. Study population was selected mainly based on their history of collaboration with emergency medicine specialists in several educational hospitals in Tehran, Iran. All interviews were recorded and then transcribed to paper. Data were mainly categorized and reported into four themes: 1) general aspects of emergency medicine, goals and policies 2) Management of emergency department 3) Educational aspects 4) therapeutic aspects. Results: 22 specialist physicians with the mean age of 47.3±7.6 years were studied (77.3% male). The average of their work experience as a specialist was 13.6±7.5 years. From the viewpoint of other experts, the establishment of EM and training of EM specialists is accompanied with relative disadvantages and advantages regarding goals and policies, patient management, therapeutic interventions and student education in the emergency department. Initiating resuscitation and maintaining hemodynamic stability and appropriate triage of the patients can add to the benefits of EM by preventing unreasonable hospitalization, and reducing the workload and difficulty of the work of other professionals working in the hospital. Conclusions: Based on the results of the current study, it seems that most Iranian specialist physicians have a positive attitude towards emergency medicine and think that emergency medicine could have beneficial effects for the health system and hospital management system.

The development of methamphetamine-associated cardiomyopathy (MACM) represents a severe complication of chronic methamphetamine abuse. MACM-induced irreversible structural and functional changes in the heart can eventually lead to decompensated heart failure, ultimately requiring heart transplantation. In this case report we present a 47-year old male with a previous history of chronic amphetamine abuse who presented to the emergency room with severe dyspnea at rest associated with mild substernal non-radiating chest pain. He denied any previous cardiac history but had a positive urinary toxicology for methamphetamine. A complete cardiac workup ruled out all other etiologies. The patient required a 3-week intensive pharmacotherapy intervention to stabilize acute heart failure symptoms. At discharge he was classified as having New York Association Class III (NYHA-III) heart failure. His medical symptoms did not improve and he was considered for heart transplantation. With the increase in availability and abuse of methamphetamine, case of MACM such as ours are more frequently being encountered in the emergency departments. In addition to raising awareness, our case provides an outline of how MACM patients likely may present and the subsequent morbid sequela. Clinicians should maintain a high degree of suspicion when assessing all patients with a history of methamphetamine abuse. Early cardiac evaluation can help identify ventricular compromise in asymptomatic patients providing an opportunity to intervene prior to the development of irreversible MACM.