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به نظر می رسد سی تی اسکن بدون داشتن محدودیت های گرافی ساده گردن بتواند در تعیین تکلیف بیماران مبتلا به ترومای گردن به عنوان مدالیته اول تشخیصی مد نظر قرار گیرد و انجام گرافی گردن را حذف نمود. یافته های این مطالعه بر روی 100 بیمار بالای 16 سال و با همودینامیک پایدار مراجعه کننده به یک مرکز ترومای دانشگاهی در تهران، ایران به دنبال ترومای متعدد حاکی از میزان توافق کلی بین یافته های رادیوگرافی و سی تی اسکن معادل 79 درصد بر اساس محاسبه ضریب کاپا بود (p = 0.001). همچنین حساسیت گرافی در خصوص تشخیص ضایعات در این مطالعه برابر با 82% و ویژگی آن برابر با 76% بر آورد گردید. به نظر می رسد نقش گرافی ساده در ارزيابي تروماهاي گردن، در زماني که گرافي ساده دقت بالایی ندارد و به خصوص در صورت در دسترس بودن سی تی اسکن بایستی مورد بازبینی قرار گیرد.

Introduction: Readmission is defined as a patient being admitted to the hospital again within a specific period, with or without previous surgery or medication program. The current study was designed with the purpose of assessing causes of readmission to emergency department. Methods: This study is a retrospective cross-sectional study that was performed on patients who were readmitted to emergency department of Imam Hossein Hospital, Tehran, Iran, in 2019 using random sampling. Results: 240 cases with the mean age of 50.47 ± 20.84 years were evaluated (59.6% male, 82.9% married). 60.4% of patients had a length of hospital stay less than one day, in 22.5% cases length of hospital stay was between 1 and 5 days, in 7.5% between it was 5 and 10 days, and in 9.6% cases it was more than 10 days. 61.7% had a history of special diseases, most of them (23%) had a history of heart disease and 38.3% had no history of disease. The most common causes of readmission were recurrence of disease (21.7%), persistence of pain (17.9%) and incorrect diagnosis (5.8%). There was no statistically significant relationship between age (p = 0.26), sex (p = 0.24), level of education (p = 0.26), drug addiction (p = 0.77), or time of discharge in the first visit (p = 0.55) and cause of readmission. However, there was a significant relationship between type of discharge (with physician’s opinion/against medical advice) in the first visit and the reason for readmission (p = 0.02). Conclusion: The Results showed that the most common causes of readmission were recurrence of disease, persistence of pain and incorrect diagnosis, respectively. Most of the patients were married men between the ages of 30 and 60 years without college education. There was a significant relationship between the type of discharge in the first visit and the cause of readmission.

Objective (s): Treatment cost and lack of insurance are the principal reasons for patients absconding or leaving without permission from a hospital. Here we aimed to investigate the effect of the Health Transformation Plan (HTP) on patients absconding from a large general hospital in Tehran, Iran. Methods: In this descriptive study, we considered March 2011 to April 2014 as the period before and June 2014 to March 2017 as the period after the introduction of the HTP. The data of 701 absconded patients were collected. For data analysis, the Mann-Whitney test and Interrupted Time Series model were used in STATA.12 software. Results: The proportion of absconding patients immediately has decreased significantly since the implementation of the HTP (P = 0.002, β = 0.342). However, during the 3-year period after the implementation of the HTP, the patient absconding rate has increased monthly by 0.12% (p = 0.019). Investigating the difference in the patient absconding rate before and after the HTP, we found that the proportion of patients absconding has significantly increased since the HTP implementation (0.011 slope; p = 0.019). Conclusion: Immediately after the implementation of the HTP, the proportion of patients absconding from hospital dropped significantly. This suggests that the HTP has been effective at reducing the patient absconding rate by creating insurance coverage and reducing costs. However, the reasons for a reversal of this trend during the third year of the HTP should be further investigated.

Antimicrobial resistance among uropathogens causing community-acquired urinary tract infections (UTIs) is a worldwide concern. It has been suggested that diabetes could be a possible cause of antibiotic resistance. This study was undertaken to identify the responsible microbial culprits for UTI in patients with different range of glycosylated hemoglobin (HbA1C) and evaluate their corresponding resistance pattern. In a prospective study between 2013 to 2018, data related to the urine culture and sensitivity of patients who had bacteriuria were gathered. For patients with positive urine culture, HbA1C was requested and correlations between HbA1C level with microorganism and its susceptibility were evaluated. In total, 121 patients were recruited. All study participants were female.The mean age of the patients was 50.2 ± 22.5 (range 19-96) . All study participants were of the same race. Fifteen (12.4%) out of 121 patients were diabetics. There were no difference between bacteriology of UTIs in diabetic and nondiabetic patients with the preponderance being caused by E. coli and other gram-negative organisms but, there were positive association between HbA1C and resistance to Nalidixic acid and Gentamicin. Our study supports the findings that diabetes in itself could be a possible cause of antibiotic resistance to some antimicrobial agents.

Introduction: In ideal conditions, the maximum length of stay in the Emergency Department (ED) is 6 h. Increased length of stay for patients has harmful effects on the quality of patient care and patient satisfaction and causes overcrowding in the ED. The present study assessed the causes of length of stay more than 24 h in the ED of Imam Hossein Hospital affiliated to Shahid Beheshti University of Medical Sciences in Tehran. Methods: This descriptive study was conducted during a 12-month period, 2017-2018, in the ED of Tehran’s Imam Hossein Hospital. The samples were randomly selected from patients referring to the ED of Imam Hossein Hospital. The data collection tool was a checklist containing information about patients and the actions taken in the ED and the final outcome of the patients. After encoding the collected data, statistical analyzes were done using the SPSS statistical software version 18. Result: Men and women constituted 54.7% and 45.3% of the participants, respectively. The participants below and above 65 years old made up 52.6% and 47.4% of the sample group, respectively. Moreover, 81.3% were admitted to general/internal ED and 18.7% were admitted to trauma/surgery ED. Lack of empty beds in admission ward and intensive care unit (ICU) ward was the main causes of delay in admitting patients. Low patient turnover rate, involvement of multiple therapeutic services, inaccurate diagnosis, delay in lab results, delayed imaging, and the possibility of improvement in condition of the patient in ED were among other notable causes of prolonged stay. Finally, the majority of the patients were hospitalized and referees to other centers had the least frequency. Comparison of trauma and general EDs regarding causes of prolonged length of stay showed that there were no significant differences between the two EDs in prolongation length of stay. Conclusion: According to the results, lack of adequate admission and ICU beds was the main causes of prolonged stay in the ED. Using EMS diversion, increasing the number of admission and ICU beds, referring patients to other centers, setting up emergency care units, and decreasing patient ED overcrowding are suggested as solutions to decrease length of stay in ED.

مقدمه: در شرايط ايده آل، حداکثر مدت بستري بيماران در بخش اورژانس 6 ساعت است. بستري طولاني مدت بيماران، اثرات زيانباري روي کيفيت مراقبت بيمار، رضايتمندي وي و ايجاد ازدحام در اورژانس دارد. این مطالعه با هدف بررسی علل بستری بیش از 24 ساعت در بخش اورژانس بیمارستان امام حسین (ع) دانشگاه علوم پزشکی شهید بهشتی تهران انجام گرفت. روش کار: مطالعه حاضر از نوع توصیفی می‌باشد که طي يک دوره 12 ماهه از فروردین تا اسفند سال ۱۳۹۶در بخش اورژانس بیمارستان امام حسین (ع) تهران انجام شد. با استفاده از روش نمونه‌گیری تصادفی، تعداد 669 مورد از بیماران مراجعه‌کننده انتخاب شدند. ابزار جمع‌آوری اطلاعات چک‌ لیست مربوط به اطلاعات بیماران و اقدامات انجام شده در بخش اورژانس می‌باشد. داده‌ها پس از جمع‌آوری کدگذاری و سپس وارد نرم افزار آماری SPSS نسخه 18 شد و مورد تجزیه و تحلیل قرار گرفت. یافته ها: نمونه‌های مورد پژوهش، 7/54% مرد و 3/45% زن بود. 6/52% از افراد در گروه سنی زیر 65 سال و 4/47% بالای 65 سال قرار داشتند. بیماران مراجعه کننده 3/81% در بخش اورژانس جنرال/داخلی و 7/18% در بخش اورژانس تروما/جراحی پذیرش شده بودند. عدم وجود تخت خالی در بخش های بستری و بخش مراقبت های ویژه مهمترین علت تاخیر در بستری بیماران بود. همچنین به ترتیب، تاخیر در چرخش بیماران، تحت نظر چند سرویس درمانی بودن، عدم تشخیص دقیق بیماری، حاضر نشدن آزمایشات، انجام نشدن تصویربرداری و احتمال بهبودی در اورژانس از دلایل دیگر افزایش مدت اقامت بیماران بود. در نهایت بیشتر بیماران مراجعه کننده بستری شده و انتقال به مراکز دیگر دارای کمترین میزان فراوانی بود. مقایسه بخش های جنرال و ترومای اورژانس از نظر علت تاخیر در بستری نشان داد که دو بخش باهم تفاوت قابل ملاحظه‌‌‌ای نداشتند (P>0.05). نتیجه گیری: براساس یافته‌های مطالعه حاضر عدم وجود تخت خالی در بخش های بستری و مراقبت های ویژه به عنوان مهمترین عامل طولانی شدن مدت اقامت بیماران در بخش اورژانس می‌باشد. پیشنهاد می‌شود با راه حل‌هایی از جمله انجام EMS diversion، افزایش سرعت تعیین تکلیف در اورژانس، افزایش تعداد تخت های بستری در بخش‌ها، افزایش تعداد تخت‌های آی‌سیو، استفاده از ظرفیت تخت های خالی سایر مراکز ،افزایشTurn Over بخش های بستری و ایجاد Urgent Care Unit از ازدحام در اورژانس و طولانی بودن بستری در اورژانس پیشگیری شود.

Introduction: Predicting the outcome of patients with intracranial hemorrhage (ICH) is the area of interest for in charge physicians as well as patients and their associates. This study aimed to evaluate the accuracy of SUSPEKT score in predicting one-month outcome of patients with hemorrhagic stroke. Methods: This prospective cross sectional study was conducted on > 18 years old patients with non-traumatic supra-tentorial ICH admitted to emergency department, from February 2017 to January 2018. SUSPEKT score was measured for each patient and its screening performance characteristics in prediction of one-month mortality were calculated. Results: 169 cases with the mean age of 63.09± 15.45 (21 – 96) years were studied (56.8% male). After one month follow up 47 (27.8%) cases had died, 30 (17.7%) cases were bed ridden, and 72 (42.6%) could walk without help or with a cane. Non-survived patients had significantly larger intra-ventricular hemorrhage (IVH) (p < 0.001) and hematoma (p < 0.001) volume, higher serum glucose (p < 0.001) and blood pressure (p = 0.028), higher frequency of IVH (p < 0.001), and higher WBC count (p = 0.037). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SUSPEKT score at the 65 cut point were 82.97% (95% CI: 68.65% – 91.86%), 74.59% (95% CI: 65.76% – 81.84%), 55.71% (95% CI: 43.38% – 67.40%), and 91.91% (95% CI: 84.23% – 96.16%), respectively. Conclusion: Total accuracy of SUSPEKT score in predicting one-month mortality of non- traumatic ICH patients is in good range and it has 82% sensitivity and 92% NPV in this regard. It seems that we need further studies before applying the score in routine practice.

Objective: Cardiopulmonary resuscitation (CPR) has been known in its present form since 1960. Different studies have reported variable outcomes among different countries. Therefore, the purpose of this study was to assess the rate of CPR success and the survival rate in managing cardiac arrest among patients in an educational medical center. Methods: This cross-sectional study was performed at Imam Hosein hospital, Tehran, Iran. All patients, admitted to the emergency department with cardiac arrest between March 2007 and January 2008 were included. We used a formerly designed registration form and hospital documentation to retrieve the data of included patients. The main outcomes were the rate of CPR success and the survival rate of these patients. Results: Totally 855 patients were included, from which 510 (59.64%) were males. The mean age of included patients was 63 ± 17.6. The CPR process was successful among 364 (42.58%) patients. A total number of 101 (11.82%) patients were discharged from the hospital. Different factors as the cause of cardiac arrest and past medical problems affected the probability of CPR success and the survival of patients with cardiac arrest. Conclusion: Survival rate at hospital discharge was less than one-third of patients and nearly half of the patients received successful CPR. More intensive care unit (ICU) facilities and educational interventions for the emergency staff and the community can enhance the survival of cardiac arrest patients in our health system.

مقدمه: نزاع یکی از مهمترین علل تهدید سلامت بوده و علت بیش از نیم میلیون مرگ در سال و از مهمترین علل مرگ و میر سنین جوانی می باشد. مطالعه بر روی موارد نزاع و درگیری می تواند میزان آگاهی از آسیبهای مرتبط را بیشتر کرده و به عنوان مبنایی برای روند نظارت بر روی جرایم محسوب شود. لذا مطالعه حاضر با هدف بررسی اپیدمیولوژیک موارد نزاع مراجعه کننده به بخش اورژانس طراحی شده است. روش کار: پژوهش حاضر یک مطالعه مقطعی گذشته نگر می باشد که اقدام به بررسی اپیدمیولوژی موارد نزاع و ضرب و جرح در مراجعه کنندگان به بخش اورژانس بیمارستان امام حسین، تهران، ایران از فروردین 1393 تا دی 1394 نموده است. متغیرهای مورد بررسی شامل سن، جنس، زمان مراجعه، سابقه اجتماعی فرد، مکانیسم تروما، محل آناتومیک تروما، اقدامات انجام شده و پیامد نهایی بودند. یافته ها: 499 بیمار با میانگین سنی 7/8 ± 4/26 سال مورد مطالعه قرار گرفتند. از این بین 442 (6/88 درصد) نفر مرد و 443 (9/88 درصد) نفر ایرانی بودند. طبق نتایج بدست آمده 321 (4/64 درصد) نفر مجرد و همچنین 335 (1/67 درصد) نفر در گروه سنی 29-20 سال قرار داشتند. 317 (3/87 درصد) مورد شرح حال منفی عادات اجتماعی (مصرف سیگار، الکل و ...) داشتند و سیگار (6/7 درصد) شایعترین ماده مصرفی در موارد با شرح حال مثبت از نظر عادات اجتماعی بود. بیشترین آمار مراجعات به بخش اورژانس در ساعات 24-16 شبانه روز (7/49 درصد)، در روزهای غیرتعطیل (1/73 درصد) و در فصل بهار (9/41 درصد) رخ داده بود. از مجموع کل موارد مورد بررسی 283 مورد (7/56 درصد) در اثر ترومای نافذ به بخش اورژانس مراجعه کرده بودند و 240 مورد (1/48 درصد) نیازمند نوعی مداخله جراحی بودند. نهایتا 398 (8/79 درصد) مورد با بهبودی کامل ترخیص شدند، 81 مورد (2/16 درصد) با رضایت شخصی اورژانس را ترک نمودند و 4 مورد (8/0درصد) نیز فوت نمودند. نتیجه گیری: بر اساس یافته های مطالعه حاضر شیوع ترومای ناشی از نزاع و خشونت حدود 16 نفر به ازائ هر 1000 مراجعه به واحد ترومای مرکز مذکور بود. بیشتر موارد نزاع در آقایان، مجرد، در گروه سنی 30 -21 سال، فصل بهار، روزهای غیر تعطیل، ساعات عصر و با ترومای نافذ اتفاق افتاده بود که در حدود 80 درصد موارد با بهبودی کامل از بخش اورژانس ترخیص شده بودند.

Introduction: Strife is one of the most important health threatening happenings that leads to more than 0.5 million deaths each year, and is among the most important causes of mortality in youth. Studying it can increase knowledge on its resulting traumas and be a base for supervising these crimes. Therefore, the present study aimed to evaluate the epidemiology of strife cases presenting to emergency department (ED). Methods: The present study is a retrospective cross-sectional one that evaluates the epidemiology of strife and violence in those presenting to the ED of Imam Hossein Hospital, Tehran, Iran, during April 2014 to January 2016. The studied variables included age, sex, time of visit, social history of the patient, trauma mechanism, anatomical site of trauma, measures taken, and final outcome. Results: 499 patients with the mean age of 26.4 ± 8.7 were studied. 442 (88.6%) were male and 443 (88.9%) were of Iranian nationality. Based on the obtained results, 321 (64.4%) were single and 335 (67.1%) were in the 20-29 years age group. 317 (87.3%) cases had negative social habits (smoking, drinking,…) and cigarette was the most commonly used substance in cases with positive social habits. The highest frequency of ED visits happened between 4PM and 12AM (49.7%), on weekdays (73.1%), and in spring (41.9%). 283 (56.7%) of the studied cases had visited ED following penetrating trauma and 240 (48.1%) needed some kind of surgical intervention. Finally, 398 (79.8%) cases were discharged with full recovery, 81 (16.2%) were discharged against medical advice, and 4 (0.8%) died. Conclusion: Based on the findings of the present study, prevalence of trauma due to strife was 16 in each 1000 visits to the trauma unit of the studied center. Most cases of strife happened in men, singles, those aged 21-30 years, in spring, on weekdays, in the evening and with penetrating trauma and about 80% were discharged from ED with full recovery.

Introduction: Although using clinical scales to predict shock severity is interesting for physicians as they provide rapid evaluation without need for special equipment, they are not highly reliable. Therefore, the present study was designed with the aim of assessing the agreement between shock index and base defects as scales of determining shock severity in multiple trauma patients. Methods: In the present prospective cross-sectional study, the agreement of shock index and base defects in determining shock severity in multiple trauma patients presenting to emergency department (ED) was assessed. Patients with blunt multiple trauma aged between 15 to 6 years with 8-15 consciousness level and without any underlying illness were enrolled and finally the data were analyzed using SPSS 20. Results: In total, 387 patients with the mean age of 36.31 ± 15.03 years (15 – 90) were studied (80.6% male). Most patients were in the 21-30 years age group (37.7%) and the most common trauma mechanisms were car accident (50.1%) and falling from height (24.8%). In addition, 15 (3.9%) patients had systolic blood pressure 100/min. According to kappa coefficient, a 0.824 agreement was seen between these scales in rapid prediction of shock index. With the shock index increasing, the number of blood units received in the initial 6 hours of admission to ED for patient resuscitation rose from 0.02 to 1.72 units. Conclusion: Considering the results of the present study, it seems that shock index and base defect scales have acceptable agreement in prediction of shock severity in multiple trauma patients. This agreement increases in the 2 extremes namely normal and severe cases (level 1 and 4).

Introduction: Different factors such as parents’ knowledge and attitudes regarding preventive measures (PM) have a great role in reducing children unintentional home injuries. The present study aims to evaluate the contributing factors of unintentional home injury prevention in preschool victims presented to the emergency department. Methods: The subjects consisted of all the mothers of preschool children who were presented to the emergency department of Imam Hossein and Shohadaie-Hafte-Tir Hospitals, with unintentional home injuries, from March 2011 to February 2012. The participants were divided into two groups according to implementation of preventive measures status. The significant confounding factors of PM application was determined by chi-squared test and entered into the backward multivariate logistic regression model. Results: 230 mothers with the mean age of 29.4 ± 5.2 years were evaluated. 225 (97.83%) of them were still married, 74 (32.17%) had high school education or higher, 122 (53.04%) were homemakers, and 31 (13.49%) worked outside the home for at least 8 hours daily. High level of knowledge (OR = 0.05; 95% CI: 0.002‒0.32; P = 0.002), appropriate attitude (OR = 0.12; 95% CI: 0.03‒0.51; P = 0.01), having at least three children (OR = 7.2; 95% CI: 1.1‒32.9; P = 0.04), daily absence of mother for at least 8 hours (OR = 9.2; 95% CI: 2.2‒35.46; P = 0.002), and a history of home injury during the previous 3 weeks (OR = 8.3; 95% CI: 2.1‒41.3; P = 0.001) were independent factors which influenced application of preventive measures. Conclusion: Increasing mothers’ knowledge level and improving their attitudes were facilitating factors and mothers’ absence from the house for more than 8 hours a day and having at least 3 children were obstacles to application of preventive measures. In addition, a history of same injury during the previous 3 weeks increased the risk of repeated event.

Introduction: Vertigo prevalence is estimated to be 1.8% among young adults and more than 30% in the elderly. 13-38% of the referrals of patients over 65 years old in America are due to vertigo. Vertigo does not increase the risk of mortality but it can affect the patient’s quality of life. Therefore, this study was designed to evaluate the epidemiologic characteristics of vertigo patients referred to the emergency department (ED). Methods: In this 6-month retrospective cross-sectional study, the profiles of all vertigo patients referred to the ED of Imam Hossein Hospital, Tehran, Iran, from October 2013 to March 2014 were evaluated. Demographic data and baseline characteristics of the patients were recorded and then patients were divided into central and peripheral vertigo. The correlation of history and clinical examination with vertigo type was evaluated and screening performance characteristics of history and clinical examination in differentiating central and peripheral vertigo were determined. Results: 379 patients with the mean age of 50.69 ± 11.94 years (minimum 18 and maximum 86) were enrolled (58.13% female). There was no sex difference in vertigo incidence (p = 0.756). A significant correlation existed between older age and increase in frequency of central cases (p < 0.001). No significant difference was detected between the treatment protocols regarding ED length of stay (p = 0.72). There was a significant overlap between the initial diagnosis and the final decision based on imaging and neurologist’s final opinion (p < 0.001). In the end, 361 (95.3%) patients were discharged from ED, while 18 were disposed to the neurology ward. No case of mortality was reported. Conclusion: Sensitivity and specificity of history and clinical examination in differentiating central and peripheral vertigo were 99 (95% CI: 57-99) and 99 (95% CI: 97-99), respectively.

Introduction: The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED) are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA) method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. Methods: This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided into one main system and six subsystems, based on FMEA. The study was divided into two phases. In the first phase, the problems leading to the loss of revenue in each subsystem were identified and weighted into four groups using risk priority number (RPN), and the solutions for fixing them were planned. Then, in the second phase, discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after intervention using the repeated measure ANOVA test. Results: 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousand US dollars/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousand US dollars/month after solving first, second, third, and fourth priority problems, respectively (337.75% increase in two years) (p

Introduction: Pro-brain natriuretic peptide (Pro-BNP) can act as an independent predictor of mortality in septic patients. This study aimed to compare the diagnostic accuracy of pro-BNP and Mortality in Emergency Department Sepsis (MEDS) score in this regard. Method: This cross-sectional study was conducted on > 14 years old sepsis patients of an emergency department (ED), during 2 years. The level of Pro-BNP and MEDS score were measured for all eligible patients and considering one-month mortality as reference, screening performance characteristics of the two tests were compared using SPSS 21 and STATS 11. Results: 121 patients with the mean age of 75.87±11.82 years were studied (55.4% male). 85 (70.25%) patients had moderate to high probability of mortality according to MEDS score. The mean Pro-BNP levels of survivor and non-survivor patients were 489.69 ± 327.47 and 3954.98 ± 2717.85 pg/ml, respectively (p < 0.0001). Sensitivity and specificity of Pro-BNP (in 1000 pg/ml cut off) and MEDS score (in level 3) in prediction of 1-month mortality were 93.6 (83.7-97.9), 94.8 (84.7-98.6), 65.0 (51.9-76.3), and 98.2 (89.5-99.9), respectively. Area under the ROC curve of the two tests were 97.36 (95% CI: 92.92-94.48) and 92.31 (95% CI: 86.35-96.53), respectively (p = 0.0543). Conclusion: Pro-BNP and MEDS score both have excellent diagnostic accuracy in predicting 1-month mortality of sepsis patients. However, considering the higher sensitivity as well as availability and ease of calculation, it seems that Pro-BNP can be considered an appropriate tool for screening patients with high risk of mortality following sepsis in ED. Â

Introduction: Timely diagnosis and treatment of post-traumatic elevated intracranial pressure (EICP) could be reduced morbidity and mortality, and improved patients’ outcome. This study is trying to evaluate the diagnostic accuracy of sonographic optic nerve sheath diameter (ONSD) in detection of EICP. Methods: Sonographic ONSD of patients with head trauma or cerebrovascular accident suspicious for EICP were evaluated by a trained chief resident of emergency medicine, who was blind to the clinical and brain computed tomography scan (BCT) findings of patients. Immediately after ultrasonography, BCT was performed and reported by an expert radiologist without awareness from other results of the patients. Finally, ultrasonographic and BCT findings regarding EICP were compared. To evaluate the ability of sonographic ONSD in predicting the BCT findings and obtain best cut-off level, receiver operating characteristic (ROC) curve were used. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of sonographic ONSD in determining of EICP was calculated. P < 0.05 was considered as statistically significant. Results: There were 222 patients (65.3% male), with mean age of 42.2±19.5 years (range: 16-90 years). BCT showed signs of EICP, in 28 cases (12.6%). The means of the ONSD in the patients with EICP and normal ICP were 5.5 ± 0.56 and 3.93 ± 0.53 mm, respectively (P

Introduction: Need for procedural sedation and analgesia (PSA) is felt in emergency department (ED) more and more each day. This study aimed to compare the effectiveness of low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination with regular dose of propofol and fentanyl combination for induction of deep sedation. Methods: In this single-blind clinical trial, candidate patients for sedation and analgesia aged more than 15 and less than 60 years old, with pain score ≥6 were allocated to one of the groups using block randomization and were compared regarding onset of action, recovery time, and probable side effects. Results: 125 patients with the mean age of 37.8 ± 14.3 years were randomly allocated to each group. 100% of the patients in group 1 (5 drugs) and 56.5% of the patients in group 2 (2 drugs) were deeply sedated in the 3rd minute after injection. The 2 groups were significantly different regarding onset of action (p = 0.440), recovery time (p = 0.018), and treatment failure (p < 0.001). Conclusion: Low-dose fentanyl, propofol, midazolam, ketamine and lidocaine combination was more successful in induction of deep sedation compared to regular dose of propofol and fentanyl combination. Recovery time was a little longer in this group and both groups were similar regarding drug side effects and effect on vital signs.

Introduction: Finding a fast-acting compound with minimal side-effects to induce a safe and efficient analgesia with short or medium duration of action is of great interest in the emergency department. The present study has been designed with the aim of comparing the effect of midazolam + fentanyl + lidocaine combination with midazolam + fentanyl + placebo in pain management of anterior shoulder dislocation reduction. Methods: The present two-arm parallel double-blind randomized controlled trial was performed on patients who presented to emergency department with anterior shoulder dislocation. Patients were randomly allocated to the 2 treatment groups of midazolam + fentanyl + placebo (double-drug group) and midazolam + fentanyl + intravenous (IV) lidocaine (triple-drug group). Then outcomes such as treatment success rate and side-effects following prescription of drugs were compared between the 2 groups. Results: 100 patients were included in the present study (50 patients in each group; mean age of the studied patients 27.3±8.9 years; 93.0% male). Using the double-drug regimen led to 35 (70%) cases of complete analgesia, while this rate in the triple-drug group was 41 (82%) cases (p=0.16). The calculated number needed to treat was 9 cases. This means that about one in every 9 patients in treatment arm will benefit from the treatment. The most important side-effects observed included dysrhythmia (1 patient in double drug and 1 patient in triple-drug group), apnea (2 patients in each group) and SPO2

Introduction: Vertigo prevalence is estimated to be 1.8% among young adults and more than 30% in the elderly. 13-38% of the referrals of patients over 65 years old in America are due to vertigo. Vertigo does not increase the risk of mortality but it can affect the patient’s quality of life. Therefore, this study was designed to evaluate the epidemiologic characteristics of vertigo patients referred to the emergency department (ED). Methods: In this 6-month retrospective cross-sectional study, the profiles of all vertigo patients referred to the ED of Imam Hossein Hospital, Tehran, Iran, from October 2013 to March 2014 were evaluated. Demographic data and baseline characteristics of the patients were recorded and then patients were divided into central and peripheral vertigo. The correlation of history and clinical examination with vertigo type was evaluated and screening performance characteristics of history and clinical examination in differentiating central and peripheral vertigo were determined. Results: 379 patients with the mean age of 50.69 ± 11.94 years (minimum 18 and maximum 86) were enrolled (58.13% female). There was no sex difference in vertigo incidence (p = 0.756). A significant correlation existed between older age and increase in frequency of central cases (p < 0.001). No significant difference was detected between the treatment protocols regarding ED length of stay (p = 0.72). There was a significant overlap between the initial diagnosis and the final decision based on imaging and neurologist’s final opinion (p < 0.001). In the end, 361 (95.3%) patients were discharged from ED, while 18 were disposed to the neurology ward. No case of mortality was reported. Conclusion: Sensitivity and specificity of history and clinical examination in differentiating central and peripheral vertigo were 99 (95% CI: 57-99) and 99 (95% CI: 97-99), respectively.

Introduction: Evaluation of cervical spine injuries makes up a major part of trauma patient assessments. Based on the existing sources, more than 98% of the cervical spine X-rays show no positive findings. Therefore, the present clinical audit aimed to evaluate the correlation of ordered cervical spine X-rays in multiple trauma patients with NEXUS and Canadian c-spine clinical decision rules. Methods: The present clinical audit, evaluated the correlation of cervical spine imaging orders in multiple trauma patients presented to the emergency department, with NEXUS and Canadian c-spine rules. Initially, in a pilot study, the mentioned correlation was evaluated, and afterwards the results of this phase was analyzed. Since the correlation was low, an educational training was planned for all the physicians in charge. Finally, the calculated correlations for before and after training were compared using SPSS version 21. Results: Before and after training, cervical spine X-ray was ordered for 98 (62.82%) and 85 (54.48%) patients, respectively. Accuracy of cervical spine X-ray orders, based on the standard clinical decision rules, increased from 100 (64.1%) cases before training, to 143 (91.7%) cases after training (p < 0.001). Area under the receiver operating characteristic (ROC) curve regarding the correlation also raised from 52 (95% confidence interval (CI): 43 – 61) to 92 (95% CI: 87 – 97). Conclusion: Teaching NEXUS and Canadian c-spine clinical decision rules plays a significant role in improving the correlation of cervical spine X-ray orders in multiple trauma patients with the existing standards.

مقدمه: بررسی آسیب های ستون فقرات گردنی بخشی مهمی از ارزیابی بیماران ترومایی را به خود اختصاص می دهد. بر اساس منابع موجود بیش از 98 درصد از تصویر برداری های ستون فقرات گردنی یافته مثبتی به همراه نداشته است. لذا مطالعه مميزي باليني حاضر با هدف ارزیابی میزان انطباق درخواست های تصويربرداري گردن در بيماران مالتیپل تروما با دو معیار نکسوس و کانادایی صورت گرفته است. روش کار: در مطالعه ممیزی بالینی حاضر، به ارزیابی میزان انطباق درخواست های تصويربرداري گردن در بيماران مالتیپل ترومای مراجعه كننده به بخش اور‍‍‍‍‍‍ژانس با معیارهای تصمیم گیری بالینی بر گرفته از دو مدل تایید شده نکسوس و کانادایی پرداخته شده است. در ابتدا طی یک مطالعه میدانی به میزان انطباق مذکور ارزیابی و در ادامه ضمن آنالیز نتایج مرحله اول و با توجه به میزان پایین انطباق اقدام به طراحی یک دوره آموزشی برای تمامی پزشکان مسوول رسیدگی به بیماران گردید. در نهایت نتایج قبل و بعد از آموزش با استفاده از نرم افزار آماری SPSS 21 مورد مقایسه قرار گرفت. يافته ها: در مرحله قبل و بعد از آموزش به ترتیب برای 98 (82/62 درصد) و 85 (48/54 درصد) بیمارگرافی ساده گردن درخواست شده بود. میزان دقت درخواست گرافی های گردن بر اساس معیار های استاندارد بالینی موجود از 100 (1/64 درصد) مورد قبل از آموزش به 143 (7/91 درصد) مورد در بعد از آموزش ارتقاء یافته بود (P < 0.001). سطح زیر منحنی ROC از جهت میزان انطباق مذکور از (61-43 : %95 CI) 52 به (97-87 : %95 CI) 92 ارتقاء پیدا کرده بود. نتيجه گيری: آموزش معیار های تصمیم گیری بالینی نکسوس و کانادایی نقش معنی داری در بهبود میزان انطباق درخواست های گرافی های گردن بیماران ترومایی با استاندارد های موجود داشت.

Introduction: Evaluating intravascular volume is an important but complicated matter in management of critically ill patients, especially in children. Although invasive techniques have the ability to accurately estimate the intravascular volume, but they have dangerous side effects. Therefore, the present study was designed with the aim of comparing the diagnostic accuracy of sonographic diameters of inferior vena cava (IVC), aorta, internal jugular vein (IJV), and IVC/aorta ratio in identifying pediatric dehydration in children presented to the emergency department (ED). Methods: The present prospective cross-sectional study was carried out with the aim of determining the diagnostic accuracy of sonographic diameters of IVC, IJV, and aorta, in estimation of dehydration rate for children presented to the ED with mild to moderate dehydration. Their screening performance characteristics, such as area under the ROC curve, sensitivity and specificity, were calculated and used for this purpose. The data were analyzed using STATA 11.0 and 0.05 was considered as significance level. Results: In the end, 54 patients were enrolled in the study (57.4% male, mean age of 4.9 ± 2.7 years). Area under the ROC curve for IVC in diagnosis of moderate dehydration in sagittal and transverse planes were 0.775 (95% CI: 0.65 – 0.91) and 0.8086 (95%CI: 0.96 – 0.93), respectively. In addition, the diameter of aorta in this regard were 0.658 (95%CI: 0.51 – 0.81) for the sagittal and 0.7126 (95% CI: 0.57 – 0.86) for the transverse plane. IJV diameter had an area under the curve of 0.7332 (95% CI: 0.59 – 0.88). Comparing the area under the ROC curves for the studied parameters showed that IVC diameter in the sagittal (p = 0.004) and transverse (p < 0.001) planes is a better index for diagnosis of moderate dehydration. Conclusion: Based on the findings of the present study, it seems that IJV, IVC, and aorta diameters are not very accurate for determining the condition of pediatric dehydration, since even sonographic IVC diameter, which was more accurate than the other parameters, had a sensitivity of 81.48% and specificity of 48.15% in differentiating mild and moderate dehydration.

مقدمه: ارزیابی حجم داخل عروقی موضوعی مهم اما پیچیده در مدیریت بیماران بدحال به ویژه در کودکان می باشد. تکنیک های تهاجمی هرچند قادرند تخمین بسیار دقیقی از حجم داخل عروقی ارائه نمایند اما عوارض ناشی از آن بسیار خطرناک می باشد. لذا مطالعه حاضر با هدف مقایسه دقت تشخیصی قطر سونوگرافیک ورید اجوف تحتانی، شریان آئورت، قطر ورید ژوگولار داخلی و نسبت قطر ورید اجوف به شریان آئورت در تعیین وضعیت دهیدراتاسیون کودکان مراجعه کننده به بخش اورژانس طراحی شده است. روش کار: مطالعه مقطعی حاضر با هدف تعیین ارزش تشخیصی قطر سونوگرافیک وریدهای اجوف تحتانی و ژوگولار و شریان آئورت در تخمین میزان دهیدراتاسیون بر روی کودکان مراجعه کننده به بخش اورژانس مبتلا به دهیدراتاسیون خفیف و متوسط انجام شد. از محاسبه شاخص های غربالگری شامل سطح زیر منحنی، حساسیت و ویژگی برای نیل به هدف مذکور بهره گرفته شد. داده ها توسط نرم افزار آماری STATA 11.0 تجزیه تحلیل گردید و سطح معنی داری معادل 05/0 در نظر گرفته شد. يافته ها: در نهایت 54 بیمار وارد مطالعه شدند (4/57 درصد پسر، میانگین سنی برابر 7/2±9/4 سال). سطح زیر منحنی قطر ورید اجوف تحتانی در تشخیص دهیدارتاسیون متوسط در نمای ساژیتال و عرضی به ترتیب برابر 775/0 (91/0-65/0:CI 95%) و 8086/0 (93/0-69/0:CI 95%) بود. همچنین قطر شریان آئورت نیز در تشخیص دهیدراتاسیون متوسط در نمای ساژیتال و عرضی دارای سطح زیر منحنی برابر 658/0 (81/0-51/0: CI 95%) و 7126/0 (86/0-57/0:CI 95%) بود. قطر ورید ژوگولار نیز دارای سطح زیر منحنی برابر 7332/0 (88/0-59/0: CI 95%) بود. مقایسه سطح زیر منحنی پارامترهای مورد مطالعه نشان داد قطر ورید اجوف تحتانی در نمای ساژیتال (004/0=p) و عرضی (001/0>p) شاخص بهتری برای تشخیص دهیدراتاسیون متوسط می باشد. نتيجه گيری: بر اساس یافته های پژوهش حاضر به نظر می رسد که قطر ورید ژوگلار، ورید اجوف تحتانی و شریان آئورت معیار چندان دقیقی برای غربالگری وضعیت دهیدراتاسیون کودکان نباشد چرا که حتی در مورد قطر سونوگرافیک ورید اجوف تحتانی که نسبت به سایر پارامترها به طور معنی داری دقت بیشتری داشت حساسیت 48/81 درصدی و ویژگی 15/48 در تمایز دهیدراتاسیون متوسط از خفیف بدست آمد.

Introduction: The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED) are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA) method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. Methods: This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided based on FMEA into one main system and six subsystems. The study was divided in two phases. In the first phase, the problems leading to the loss in the revenue in each subsystem were identified and weighted to four groups using risk priority number (RPN), and the solutions for fixing them were planned. Then, at the second phase discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after interventions using the repeated measure ANOVA test. Results: At last, 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousands US dollar/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousands US dollar/month after solving of first, second, third, and fourth priority problems, respectively (337.75% increase in two years) (p

Objective: To compare the analgesiceffects of Nitrous oxide and morphine sulfate in patients with acute renal colic due to urolithiasis. Methods: This was randomized clinical trial being performed in Imam Hossein hospital affiliated with Shahid Beheshti University of Medical Sciences during a 1-year period from May2013 to May2014. A total of number of 100 patients, with an age range of 20-50 years, who presented with renal colic secondary to urolithiasis confirmed by ultrasonography were randomly assigned to receive morphine sulfate injection (0.1 mg/kg) with 100 mg diclofenac suppository (n=50) or Entonox exhalation (50% nitric oxide and 50% oxygen)for 30-minutes with 100 mg diclofenac suppository (n=50). Quantitative measurement was of pain was performed according to a visual analogue scale (VAS), before, 3, 5, 10 and 30-minute after the intervention. The pain severity and side effects were measured between two study groups. Results: The baseline characteristics of the patients in two study groups were comparable. The frequencies of pain persistence (at least 50%) at 3-, 5-, 10- and 30-minute intervals in morphine sulfategroup were 96%, 80%, 50% and 8%, respectively; these frequencies in Entonex were 82%, 42%, 12% and 2%, respectively (p

Objective: This study aimed to determine the association of cardiac risk factors and the risk of Acute Myocardial Infarction (AMI) in Emergency Department (ED) patients with non-diagnostic ECG changes. Methods: This cross-sectional study was conducted in the ED of Imam Hossein Hospital during a period of one year. In this study, patients with symptoms suggestive of AMI including chest pain, dyspnea, palpitation, syncope, cerebrovascular incidents, nausea, vomitting, dizziness and loss of consciousness were included. The demographic data and risk factors, such as age, gender, history of diabetes, Hypertension (HTN), Hyperlipidemia (HLP), renal failure, positive family history of Coronary Artery Disease (CAD), smoking, substance abuse, alcohol consumption within the past 24 hours and cocaine use within the past 48 hours were recorded. Non-diagnostic ECG included: normal, non-specific, abnormal without ischemic symptoms such as old bundle branch block, Left Ventricular Hypertrophy (LVH), etc. The final diagnosis of AMI was determined by Creatine Phosphokinase-MB (CPK-MB) serum markers and Troponin I. The data were analyzed by using SPSS V. 20 and the level of statistical significance was considered to be P< 0.05. Results: HTN, HLP, family history of heart disease were significantly higher in those who had non-diagnostic ECG (P< 0.05). However, the ischemic heart diseases were significantly lower in those with non-diagnostic ECG. History of diabetes, stroke, renal failure, alcohol or opium and menopause showed no significant association with non-diagnostic or diagnostic ECG. Conclusion: Overall, the risk factors are limitedly associated with the occurrence of Myocardial Infarction (MI) in cases where ECG is not diagnostic and it is better to use other criteria to diagnose AMI.

Introduction: Pro-brain natriuretic peptide (Pro-BNP) can act as an independent predictor of mortality in septic patients. This study aimed to compare the diagnostic accuracy of pro-BNP and Mortality in Emergency Department Sepsis (MEDS) score in this regard. Method: This cross-sectional study was conducted on > 14 years old sepsis patients of an emergency department (ED), during 2 years. The level of Pro-BNP and MEDS score were measured for all eligible patients and considering one-month mortality as reference, screening performance characteristics of the two tests were compared using SPSS 21 and STATS 11. Results: 121 patients with the mean age of 75.87±11.82 years were studied (55.4% male). 85 (70.25%) patients had moderate to high probability of mortality according to MEDS score. The mean Pro-BNP levels of survivor and non-survivor patients were 489.69 ± 327.47 and 3954.98 ± 2717.85 pg/ml, respectively (p < 0.0001). Sensitivity and specificity of Pro-BNP (in 1000 pg/ml cut off) and MEDS score (in level 3) in prediction of 1-month mortality were 93.6 (83.7-97.9), 94.8 (84.7-98.6), 65.0 (51.9-76.3), and 98.2 (89.5-99.9), respectively. Area under the ROC curve of the two tests were 97.36 (95% CI: 92.92-94.48) and 92.31 (95% CI: 86.35-96.53), respectively (p = 0.0543). Conclusion: Pro-BNP and MEDS score both have excellent diagnostic accuracy in predicting 1-month mortality of sepsis patients. However, considering the higher sensitivity as well as availability and ease of calculation, it seems that Pro-BNP can be considered an appropriate tool for screening patients with high risk of mortality following sepsis in ED.

The present study was a double-blind clinical trial to compare the efficiency of hysocine and diazepam in vertigo treatment. Eligible patients (n=69) were randomly divided into 2 groups of 5 mg hyoscine and 10 mg diazepam. Severity of vertigo was measured in supine and sitting position, and while turning the head. Vertigo severity was assessed before, and 1 and 2 hours after administration of the drug. Treatment success rate of diazepam in relieving vertigo in different positions varied between 88.9 and 100%, while this rate was 31.273.5% in hyoscine treatment group (p

Introduction: Since many years ago several problems have been felt in emergency departments (ED) of hospitals. In fact, none of physicians in the hospital have accepted the direct responsibility of patients’ management in the EDs and emergency wards of University centers have been managed by residents of various disciplines. Thus, the first line of therapy does not have guardian and several consultants with various specialists have been performed regarding patient’s management. The necessity of physician training was noticed for the first time in 1950 and after 24 years in 1974, the academic emergency medicine was established in United States of America (USA) in response to people expectations for overnight accessibility to specialized and quality medical cares. It was performed with foundation of the first period of resident’s training in emergency medicine discipline at University of Cincinnati, Ohio. At beginning, specialists of different fields such as internal medicine, surgery, anesthesia, orthopedics, and neurosurgery initiated the training of emergency medicine residents together which could be responsible to most of referees. Finally, with formal accepting the specialty board in 1978, this field has been officially identified as the 23th discipline in USA. Today the EDs of most hospitals in European and American countries has been managing by emergency medicine specialists which leads to improve the quality of education and treatment, significantly. Also in Iran the request of establishing this major has been presented in the secretariat of the council for graduate medical education for the first time in 1996. This request was approved and principles of its initiating recognized officially by the ministry of health. But, considering to lack of an appropriate infrastructure, it postponed until 2000 that again this discipline was missioned for initiating to the council for graduate medical education by the minister and its outcome was directly declared to him. Lastly, in ministry time of Dr. Farhadi in 2001 this major was initiated for the first time in Iran University of Medical Sciences. The present report was addressed to the education guideline of emergency medicine at Shahid Beheshti University of Medical Sciences besides evaluating the formation history of emergency medicine discipline in Iran.

Introduction: Quality of life (QOL) of emergency medicine specialists can be effective in providing services to patients. The aim of the present study was evaluating the lifestyle of emergency medicine practitioners, understanding their problems, and addressing the solutions to enhance and improve their lifestyles, in teaching hospitals in Iran. Method: This descriptive cross-sectional study was conducted on emergency medicine physicians in 10 teaching hospitals of Iran in 2011. Emergency physicians with at least three years of experience who interested in the study, were enrolled in the project. All participants filled out the consent form and QOL questionnaires, then underwent physical examinations and some medical laboratory tests. Categorical variables were reported as percentages, while continuous variables expressed as means and standard deviations. p Results: Totally, 100 subjects participated in the study, of whom 48 were male. The mean and standard deviation of the physicians’ age were 38.7±5.1 years. 43% of physicians had an average QOL, while 37% good. 96% of studied physicians had a good condition regarding habitual history, while 93% of them had a poor condition in performing screening tests. Exercise program and personal health in individuals with normal BMI were correlated with higher levels of QOL. BMI was higher in 40-50 years old subjects than youngers. Hypertension was present in five cases (5%), hypercholesterolemia in six (6%), hypertriglyceridemia in six (6%), increased LDL in four (4%), low HDL in four (4%), and impaired FBS in 4 (4%). Conclusion: The findings showed that 63% of studied emergency physicians had an average level of QOL and other ones good. The majority of physicians had undesirable situation regarding the performance of screening tests.

Introduction: The balance between revenue and cost of an organization/system is essential to maintain its survival and quality of services. Emergency departments (ED) are one of the most important parts of health care delivery system. Financial discipline of EDs, by increasing the efficiency and profitability, can directly affect the quality of care and subsequently patient satisfaction. Accordingly, the present study attempts to investigate failure mode and effects analysis (FMEA) method in identifying the problems leading to the loss of ED revenue and offer solutions to help fix these problems. Methods: This prospective cohort study investigated the financial records of ED patients and evaluated the effective errors in reducing the revenue in ED of Imam Hossein hospital, Tehran, Iran, from October 2007 to November 2009. The whole department was divided based on FMEA into one main system and six subsystems. The study was divided in two phases. In the first phase, the problems leading to the loss in the revenue in each subsystem were identified and weighted to four groups using risk priority number (RPN), and the solutions for fixing them were planned. Then, at the second phase discovered defects in the first phase were fixed according to their priority. Finally, the impact of each solution was compared before and after interventions using the repeated measure ANOVA test. Results: At last, 100 financial records of ED patients were evaluated during the first phase of the study. The average of ED revenue in the six months of the first phase was 73.1±3.65 thousands US dollar/month. 12 types of errors were detected in the predefined subsystems. ED revenue rose from 73.1 to 153.1, 207.06, 240, and 320 thousands US dollar/month after solving of first, second, third, and fourth priority problems, respectively (337.75% increase in two years) (pConclusion: The findings of the present study revealed that FMEA could be considered as an efficient model for increasing the revenue of emergency department. According to this model, not recording the services by nursing unit and lack of specific identifying code for the patients' files, moving from ED to any other department, were the two first priority problems in decreasing our ED revenue.

Introduction: Timely diagnosis and treatment of post traumatic, elevated intracranial pressure (EICP), could reduce morbidity and mortality, as well as improve patients’ outcome. This study is trying to evaluate the diagnostic accuracy of sonographic optic nerve sheath diameter (ONSD) in detection of EICP. Methods: Sonographic ONSD of patients with head trauma or cerebrovascular accident suspicious for EICP were evaluated by a trained chief resident of emergency medicine, who was blind to the clinical and brain computed tomography scan (BCT) findings of patients. Immediately after ultrasonography, BCT was performed and reported by an expert radiologist without awareness from other results of the patients. Finally, ultrasonographic and BCT findings regarding EICP were compared. To evaluate the ability of sonographic ONSD in predicting the BCT findings and obtain best cut-off level, receiver operating characteristic (ROC) curve were used. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of sonographic ONSD in determining of EICP was calculated. P < 0.05 was considered to be statistically significant. Results: There were 222 patients (65.3% male), with mean age of 42.2±19.5 years (range: 16-90 years). BCT showed signs of EICP, in 28 cases (12.6%). The means of the ONSD in the patients with EICP and normal ICP were 5.5 ± 0.56 and 3.93 ± 0.53 mm, respectively (PConclusion: Sonographic diameter of optic nerve sheath could be considered as an available, accurate, and noninvasive screening tool in determining the elevated intracranial pressure in cases with head trauma or cerebrovascular accident.

Introduction: Using pan or selective computed tomography (CT) scan in management of multiple trauma patient is a matter of debate. Therefore, the present study was designed aiming to compare the findings of pan and selective CT scans in management of multiple trauma patients. Method: This is a prospective cross-sectional study, on patients presented to the emergency department (ED) of Shohadaye Haftome Tir Hospital, Tehran, Iran, following blunt multiple trauma over a 1-year period, from March 2014 to March 2015. Findings regarding presence or absence of injury in head, face, neck, chest, abdomen and hip were compared between patients that underwent pan and selective CT using SPSS 21. Results: 443 patients with the mean age of 34.54 ± 17.88 years were evaluated (78% male). 248 (56%) patients underwent selective CT scan and 195 (44%) underwent pan CT scan. The 2 groups were similar regarding vital signs and mean age. Mean hospital length of stay was 21.05 ± 24.64 days for selective CT scan group and 18.18 ± 22.75 days for the other one (p = 0.209). A significant difference was only seen regarding findings of chest injury between the 2 groups (p < 0.001). In other cases a proper overlap was seen between findings of the 2 groups. Conclusion: Based on the results of the present study, it seems that doing selective CT scan yields results similar to pan CT in detection of head and face, neck and abdomen and hip injuries in multiple trauma patients. However, using pan CT in these patients led to 16% increase in detection and diagnosis of traumatic intra-thoracic injuries.Â

Introduction: Although significant development in the field of medicine is achieved, sepsis is still a major issue threatening humans’ lives. This study was aimed to audit the management of severe sepsis and septic shock patients in emergency department (ED) according to the present standard guidelines. Method: This is a prospective audit on approaching adult septic patients who were admitted to ED. The audit checklist was created based on the protocols of Surviving Sepsis Campaign and British Royal College recommendations. The mean knowledge score and the compliance rate of studied measures regarding standard protocols were calculated using SPSS version 21. Results: 30 emergency medicine residents were audited (63.3% male). The mean knowledge score of studied residents regarding standard guidelines were 5.07 ± 1.78 (IQR = 2) in pre education and 8.17 ± 1.31 (IQR = 85) in post education phase (p < 0.001). There was excellent compliance with standard in 4 (22%) studied measures, good in 2 (11%), fair in 1 (6%), weak in 2 (11%), and poor in 9 (50%). 64% of poor compliance measures correlated to therapeutic factors. After training, score of 5 measures including checking vital signs in < 20 minute, central vein pressure measurement in < 1 hour, blood culture request, administration of vasopressor agents, and high flow O2 therapy were improved clinically, but not statistically. Conclusion: The protocol adherence in management of severe sepsis and septic shock for urine output measurement, central venous pressure monitoring, administration of inotrope agents, blood transfusion, intravenous antibiotic and hydration therapy, and high flow O2 delivery were disappointingly low. It seems training workshops and implementation of Clinical audit can improve residents’ adherence to current standard guidelines regarding severe sepsis and septic shock.

Introduction: Although significant development in the field of medicine is achieved, sepsis is still a major issue threatening humans’ lives. This study was aimed to audit the management of severe sepsis and septic shock patients in emergency department (ED) according to the present standard guidelines.Method: This is a prospective audit on approaching adult septic patients who were admitted to ED. The audit checklist was created based on the protocols of Surviving Sepsis Campaign and British Royal College recommendations. The mean knowledge score and the compliance rate of studied measures regarding standard protocols were calculated using SPSS version 21.Results: 30 emergency medicine residents were audited (63.3% male). The mean knowledge score of studied residents regarding standard guidelines were 5.07 ± 1.78 (IQR = 2) in pre education and 8.17 ± 1.31 (IQR = 85) in post education phase (p < 0.001). There was excellent compliance with standard in 4 (22%) studied measures, good in 2 (11%), fair in 1 (6%), weak in 2 (11%), and poor in 9 (50%). 64% of poor compliance measures correlated to therapeutic factors. After training, score of 5 measures including checking vital signs in < 20 minute, central vein pressure measurement in < 1 hour, blood culture request, administration of vasopressor agents, and high flow O2 therapy were improved clinically, but not statistically.Conclusion: The protocol adherence in management of severe sepsis and septic shock for urine output measurement, central venous pressure monitoring, administration of inotrope agents, blood transfusion, intravenous antibiotic and hydration therapy, and high flow O2 delivery were disappointingly low. It seems training workshops and implementation of Clinical audit can improve residents’ adherence to current standard guidelines regarding severe sepsis and septic shock.

Introduction: Using pan or selective computed tomography (CT) scan in management of multiple trauma patient is a matter of debate. Therefore, the present study was designed aiming to compare the findings of pan and selective CT scans in management of multiple trauma patients.Method: This is a prospective cross-sectional study, on patients presented to the emergency department (ED) of Shohadaye Haftome Tir Hospital, Tehran, Iran, following blunt multiple trauma over a 1-year period, from March 2014 to March 2015. Findings regarding presence or absence of injury in head, face, neck, chest, abdomen and hip were compared between patients that underwent pan and selective CT using SPSS 21.Results: 443 patients with the mean age of 34.54 ± 17.88 years were evaluated (78% male). 248 (56%) patients underwent selective CT scan and 195 (44%) underwent pan CT scan. The 2 groups were similar regarding vital signs and mean age. Mean hospital length of stay was 21.05 ± 24.64 days for selective CT scan group and 18.18 ± 22.75 days for the other one (p = 0.209). A significant difference was only seen regarding findings of chest injury between the 2 groups (p < 0.001). In other cases a proper overlap was seen between findings of the 2 groups.Conclusion: Based on the results of the present study, it seems that doing selective CT scan yields results similar to pan CT in detection of head and face, neck and abdomen and hip injuries in multiple trauma patients. However, using pan CT in these patients led to 16% increase in detection and diagnosis of traumatic intra-thoracic injuries.

Introduction: Different factors such as parents’ knowledge and attitudes regarding preventive measures (PM) have a great role in reducing children unintentional home injuries. The present study aims to evaluate the contributing factors of unintentional home injury prevention in preschool victims presented to the emergency department. Methods: The subjects consisted of all the mothers of preschool children who were presented to the emergency department of Imam Hossein and Shohadaie-Hafte-Tir Hospitals, with unintentional home injuries, from March 2011 to February 2012. The participants were divided into two groups according to implementation of preventive measures status. The significant confounding factors of PM application was determined by chi-squared test and entered into the backward multivariate logistic regression model. Results: 230 mothers with the mean age of 29.4 ± 5.2 years were evaluated. 225 (97.83%) of them were still married, 74 (32.17%) had high school education or higher, 122 (53.04%) were homemakers, and 31 (13.49%) worked outside the home for at least 8 hours daily. High level of knowledge (OR = 0.05; 95% CI: 0.002‒0.32; P = 0.002), appropriate attitude (OR = 0.12; 95% CI: 0.03‒0.51; P = 0.01), having at least three children (OR = 7.2; 95% CI: 1.1‒32.9; P = 0.04), daily absence of mother for at least 8 hours (OR = 9.2; 95% CI: 2.2‒35.46; P = 0.002), and a history of home injury during the previous 3 weeks (OR = 8.3; 95% CI: 2.1‒41.3; P = 0.001) were independent factors which influenced application of preventive measures. Conclusion: Increasing mothers’ knowledge level and improving their attitudes were facilitating factors and mothers’ absence from the house for more than 8 hours a day and having at least 3 children were obstacles to application of preventive measures. In addition, a history of same injury during the previous 3 weeks increased the risk of repeated event.

Introduction. Evaluation of Guidelines in Syncope Study (EGSYS) is designed to differentiate between cardiac and noncardiac causes of syncope. The present study aimed to evaluate the accuracy of this predictive model. Methods. In this prospective cross-sectional study, screening performance characteristics of EGSYS-U (univariate) and EGSYS-M (multivariate) in prediction of cardiac syncope were calculated for syncope patients who were referred to the emergency department (ED). Results. 198 patients with mean age of 59.26 ± 19.5 years were evaluated (62.3% male). 115 (58.4%) patients were diagnosed with cardiac syncope. Area under the ROC curve was 0.818 (95% CI: 0.75–0.87) for EGSYS-U and 0.805 (CI 95%: 0.74–0.86) for EGSYS-M (p=0.53). Best cut-off point for both models was ≥3. Sensitivity and specificity were 86.08% (95% CI: 78.09–91.59) and 68.29% (95% CI: 56.97–77.86) for EGSYS-U and 91.30% (95% CI: 84.20–95.52) and 57.32% (95% CI: 45.92–68.02) for EGSYS-M, respectively. Conclusion. The results of this study demonstrated the acceptable accuracy of EGSYS score in predicting cardiogenic causes of syncope at the ≥3 cut-off point. It seems that using this model in daily practice can help physicians select at risk patients and properly triage them.

Introduction: Quality of life (QOL) of emergency medicine specialists can be effective in providing services to patients. The aim of the present study was evaluating the lifestyle of emergency medicine practitioners, understanding their problems, and addressing the solutions to enhance and improve their lifestyles, in teaching hospitals in Iran. Method: This descriptive cross-sectional study was conducted on emergency medicine physicians in 10 teaching hospitals of Iran in 2011. Emergency physicians with at least three years of experience who interested in the study, were enrolled in the project. All participants filled out the consent form and QOL questionnaires, then underwent physical examinations and some medical laboratory tests. Categorical variables were reported as percentages, while continuous variables expressed as means and standard deviations. p

The painful nature of fractures has made it inevitable to use various anesthetic techniques to reduce or immobilize fractured parts. In the present study, axillary nerve block was compared with intravenous midazolam/fentanyl to induce anesthesia for Painless Reduction of Upper Extremity Fractures. The subjects in the present clinical trial consisted of 60 patients with upper extremity fractures. They were randomly divided into two equal groups of intravenous sedation (IVS) with midazolam/fentanyl and axillary nerve block (ANB). Rate of anesthesia induction, recovery time, and pain intensities at baseline, during the procedure and at the end of the procedure were recorded in both groups. Data was analyzed and compared between the two groups with SPSS 18 statistical software using appropriate tests. Demographic data, vital signs and means of pain intensities at the beginning of the procedure were equal in the two groups. In the IVS group, the overall duration of the procedure was shorter with more rapid onset of anesthesia (P

مقدمه: هر چند استفاده از معیارهای بالینی برای پیشگویی شدت شوک به علت عدم نیاز به تجهیزات خاص و ارزیابی سریع مورد توجه پزشکان می باشد ولی قابل اعتماد بالایی ندارند. لذا مطالعه حاضر با هدف ارزیابی میزان توافق معیارهای شوک ایندکس و نقص باز در تعیین شدت شوک بیماران مبتلا به ترومای متعدد طراحی شده است. روش کار: در مطالعه مقطعی آینده نگر حاضر، میزان توافق دو معیار شوک ایندکس و نقص باز در تعیین شدت شوک ناشی از تروما در بیماران مراجعه کننده به بخش اورژانس طراحی شده است. بیماران با ترومای متعدد غیر نافذ در محدوده سنی 15 تا 65 سال با سطح هوشیاری 8 تا 15 و بدون بیماری زمینه ای وارد مطالعه شدند و در نهایت اطلاعات با استفاده از نرم افزار SPSS نسخه 20 آنالیز گردید. يافته ها: در مجموع 387 بیمار با میانگین سنی 03/15 ± 31/36 سال (90-15) وارد مطالعه شدند (6/80 درصد مرد). بیشتر بیماران در رده سنی 21 تا 30 سال قرار داشتند ( 7/37 درصد( و شایع ترین مکانیسم های تروما تصادف با اتومبیل (1/50 درصد) و سقوط از ارتفاع (8/24 درصد) بودند. 15 (9/3 درصد) بیمار فشار خون سیستولیک کمتر از 90 میلی متر جیوه و 49 (7/12 درصد) بیمار تعداد ضربان قلب بالاتر از 100 بار در دقیقه داشتند. بر اساس ضریب توافق کاپا، توافقی برابر با 824/0 بین دو معیار مذکور در پیش بینی زودرس شوک بدست آمد. با افزایش شدت شوک تعداد واحد خون دریافتی در 6 ساعت ابتدایی ورود به اورژانس برای احیاء بیمار از 02/0 واحد به 72/1 واحد افزایش یافت. نتيجه گيری: بر اساس یافته های مطالعه حاضر به نظر می رسد معیار های شوک ایندکس و نقص باز توافق قابل قبولی در پیشگویی شدت شوک بیماران مولتیپل تروما دارند. این توافق به خصوص در دو سر طیف یعنی موارد نرمال و شدید (درجه یک و چهار) بیشتر می باشد.

Introduction: Rosacea is a chronic inflammatory dermatosis involving certain facial areas such as chin, nose, forehead, and cheeks. Several therapies were reported in the treatment of rosacea but with variable results. Aim of the Study: To evaluate the efficacy, safety, adverse effects, relapse rate and patient's satisfaction of single 250lg/kg dose of oral ivermectin in the treatment of rosacea. Patients and Methods: This clinical trial included 45 rosacea patients who were treated with single 250lg/kg dose of oral ivermectin, then patients were followed-up every 4 weeks for 3 months. Assessment of treatment response was performed using 2 digital photographs before receiving ivermectin and 3 months later. Two Standardized skin surface biopsies (SSSB1&2) were done before receiving ivermectin and 3 months later. Results: Ivermectin treatment revealed significant effect in included patients as 15 patients showed clear effect of rosacea after treatment. This was consistent with Demodex mites count that showed significant decrease after treatment compared to before treatment. There was a significant relation between patients' satisfaction and demodex mite count after treatment. Conclusion: Oral ivermectin showed significant clearing of rosacea in included patients which was reflected on patients' satisfaction. This effect can be attributed to significant reduction in demodex mite count in treated patients. [ABSTRACT FROM AUTHOR]