Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 09 e2 e2 Alireza Baratloo Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, Iran Sahar Mirbaha Department of Emergency Medicine, Imam Hosein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Maryam Bahreini Department of Emergency Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Mohsen Banaie Department of Emergency Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Arash Safaie Department of Emergency Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran 2017 10 06 2017 10 07 Introduction: Full Outline of Unresponsiveness (FOUR) score is one of the existing scoring scales, which has been used for evaluating the level of consciousness in recent years. Objective: The present study has been done with the aim of evaluating the ability to predict the outcome of patients with head trauma based on FOUR score on admission to emergency department (ED). Methods: In the present prospective cross-sectional study, head trauma patients with any changes in alertness level presenting to ED were evaluated. FOUR score measurement was done on admission and 6 hours after that. The studied outcomes in the current study included discharge without sequel, discharge with neurologic sequel, brain death or death during 1 month after admission of the patients. To evaluate the correlation between FOUR score and the studied outcomes, area under the receiver operating characteristic (ROC) curve was used. Results: In the end, 52 patients with the mean age of 32.67 ± 15.20 years were evaluated (84.6% male). Traffic accident with the frequency of 39 (75.0%) patients was the most common mechanism of trauma among the studied patients and finally, after 1 month follow up it was determined that 13 (25%) patients were discharged without sequel and 31 (59.6%) died. Area under the ROC curve for prediction of the final outcome of death using FOUR score on admission and after 6 hours were 0.889 (95% confidence interval: 0.800 - 0.977) and 0.974 (95% confidence interval: 0.938 – 1.000), respectively. Best cutoff points for FOUR score were the scores 8 and 9 on admission of the patients, and the score 5, six hours after admission. Conclusion: Based on the findings of this study, it seems that FOUR score is applicable for prediction of probable death outcome in patients with head trauma presenting to ED. https://fem.tums.ac.ir/index.php/fem/article/view/1 https://fem.tums.ac.ir/index.php/fem/article/download/1/4

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 13 e8 e8 Elnaz Vahidi Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. Zeinab Naderpour Internal Medicine Department, Tehran University of Medical Sciences, Tehran, Iran. Morteza Saeedi Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. 2017 10 06 2017 10 13 Context: The present review discusses different studies about the treatment of hemorrhagic shock (HS) with hypertonic saline (HTS). Evidence acquisition: We have searched the title in the most popular databases containing recent meta-analysis or randomized clinical trials (RCTs). Results: We introduce the hemodynamic effects and mechanisms of action of HTS in HS. Evidence in this field shows controversial results. There are some data supporting the potential benefits of HTS infusion in HS. The goal of research in this field is to identify the best therapy in HS with the least mortality. Conclusion: Our conclusion shows that although HTS can decrease inflammatory response during HS, it can attenuate hypercoagulability and cause complications. There are no data supporting less mortality while treatment with HTS versus other fluids in HS. https://fem.tums.ac.ir/index.php/fem/article/view/2 https://fem.tums.ac.ir/index.php/fem/article/download/2/6

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 15 e10 e10 Mehran Sotoodehnia Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran 2017 10 13 2017 10 15 In this case, changes are made to the shape or amplitude of ECG complexes change alternatively. In the most common form, alternative changes can be viewed better in QRS complexes and in mid precordial leads. These alternative changes can be seen simultaneously in every other QRS complex and T wave. This means that in one beat the amplitude or shape of QRS complexes and T wave are normal and in the next beat the amplitude or shape of QRS complexes and T wave change. Since at times QRS complexes get closer, then they collapse and overlap and after that they gain distance from each other again. The answer to this ECG is a heterotropic transplanted heart.     https://fem.tums.ac.ir/index.php/fem/article/view/7 https://fem.tums.ac.ir/index.php/fem/article/download/7/8

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 12 e1 e1 Mohammad Jalili Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran 2017 10 25 For many years, emergency care had been abandoned and left in the hands of practitioners whose main interest was not working in the not-so-much respected “emergency room (ER)”. They were usually obliged to serve the first years of their career in the ER, where senior colleagues did not want to be bothered with, before they were allowed to focus on their ultimate goals. This fact had led to delivery of a fragmented, suboptimal care to the patients who were seeking care for the most urgent threats to their health. Not only were these emergency physicians’ novice and inexperienced, but they also suffered from an inevitable tunnel vision rooted in their primary specialty, which adversely affected their practice by causing inability to take care of the often undifferentiated ER patients. Another issue, which resulted from this model of emergency care, was that some areas of emergency care did not fit well into the realms of the existing specialties and so had remained under-developed for many years. These included but were not limited to topics such as pre-hospital and disaster medicine, environmental and wilderness medicine. Last but not least on the list of problems that emergency care faced was the problem of stewardship and leadership, something that the emergency room urgently needed. With people considering the ER as a platform for their next move in their career, or as a marshland they were stuck in, one could not expect a long-term visionary, strategic plan.  Being faced with these challenges, the community of medicine resigned itself to giving birth to a new specialty: “emergency medicine”.  It was then that the now-called “emergency departments (ED)” were staffed by professionals whose first and ultimate work arena was the ED; their main interest and focus was to deliver high quality care to the critically ill and injured people who were brought to the EDs. Moreover, their training and experience were also related to the emergent situations and their broad vision and multi-tasking capabilities made them very suitable for work in the hectic environment of the ED. With increasing utilization of the EDs and diversity of the services provided, the role of these physicians in the healthcare system became more pronounced. Although first created with an intention of service delivery in mind, this new specialty has experienced tremendous advancements; changes that not only have resulted in its further establishment, but also have transformed it into an “academic discipline”. Like any other academic discipline, emergency medicine incorporates elements such as expertise, people, communities, and research areas. Formation of communities such as American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), and International Federation for Emergency Medicine (IFEM) as well as the scientific bodies such as American Board of Emergency Medicine (ABEM) endorsed this position and emergency medicine successfully introduced itself to the academia. Emergency medicine residency programs flourished throughout the United States and around the world and new fellowships and subspecialties emerged. Emergency medicine programs were active and vigorous and contributed a lot to the field of medical education. Research activities were also part of this movement and led to the compilation of an enormous amount of evidence pertaining to the practice of emergency medicine. These pieces of evidence have found their way into the guidelines and protocols developed by well-known scientific organizations. This added to the reputation of emergency medicine among other disciplines. In Iran, since the establishment of this specialty in the country about 25 years ago, a more or less similar path has been followed. Beginning with only one program, there are now 25 emergency medicine residency programs around the country with around 350 medical graduates entering these programs. The national board is well established and the Iranian Society of Emergency Medicine functions as a member of IFEM. Emergency medicine trained specialists are working in tandem with the most recent advances in emergency and critical care in highest volume emergency departments, which are now much better equipped than in the past. Emergency medicine has become an integral part of the medical curriculum at undergraduate level and now several other specialties also ask their residents to do a clinical rotation in the emergency department under the supervision of emergency medicine attending physicians. In addition to these achievements, one should not forget the huge share of this discipline in the research products. While there is still a long way ahead, many cutting-edge research projects have been accomplished and the results have been published in prestigious emergency medicine journals. However, the presence of a platform for dissemination of the results of these scholarly activities at a national level is an urgent need. Many researches are of interest to a national or local readership and not necessarily for a wider population around the world. Furthermore, many manuscripts are facing difficulty getting published due to non-academic reasons such as the problems with paying the publication fees or the reluctance of the journals to be in contact with scholars from Iran for political reasons (or excuses), including sanctions. With the successful experience of the first Iranian emergency medicine journal, the emergency department of Tehran University of Medical Sciences decided to launch a journal that matches the high standards of this old and outstanding university. We hope that this endeavor will provide the scholars of the emergency medicine discipline as well as other investigators with an opportunity to publish their manuscripts and benefit from the input of other colleagues. We also hope to promote the position of this journal to a well-known academic journal in the region. In doing so, the editorial board will eagerly wait for the constructive feedback of our esteemed audience.  https://fem.tums.ac.ir/index.php/fem/article/view/13 https://fem.tums.ac.ir/index.php/fem/article/download/13/13

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 12 e11 e11 Shervin Farahmand Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran 2017 10 25 https://fem.tums.ac.ir/index.php/fem/article/view/16 https://fem.tums.ac.ir/index.php/fem/article/download/16/12

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 29 e9 e9 EN Atousa Akhgar Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Mohammad Taghi Talebian Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Mohamad Ashouri Department of Surgery, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Shora Ghorbani Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Hadi Mirfazaelian Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran 2017 10 29 2017 10 29 Introduction: The possibility of intestinal injury for all patients presenting to emergency department (ED) with blunt abdominal trauma, despite minimal physical signs should be considered. To highlight the patient management, hear, we report a case of hollow viscus injuries resulting from blunt abdominal trauma referring to a teaching hospital in Tehran, Iran. Case presentation: A 30-year-old man presented to the ED after “falling into a hole” with his back and had direct blunt abdominal trauma by a heavy bag of cement. In physical examination, there was a mild abdominal tenderness on right upper quadrant. On bedside ultrasonography, there was small free fluid in his Morison’s pouch without hypotension. So abdominal CT scan was performed which revealed free fluid in pelvic, perihepatic, and perisplenic spaces. Mural hematoma of proximal part of jejunum with mural wall hypodensity in mid jejunal loop were also revealed. The patient underwent surgery, and there was damage to the colon serosa and jejunal perforation which was primarily repaired. Conclusion: The presented case highlights the importance of obtaining history and physical exam and paying attention to the nature and mechanism of injury. Emergency physicians should be aware of hollow viscus injury in traumatic patients. Any delay in diagnosis and operative management are associated with an increase in mortality. https://fem.tums.ac.ir/index.php/fem/article/view/22 https://fem.tums.ac.ir/index.php/fem/article/download/22/18

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 13 e3 e3 Javad Seyedhosseini Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. Mojtaba Ahmadi Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Amir Nejati Department of Emergency Medicine, Imam Khomeini Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran. Ali Ardalan Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Mohammadhossein Ghafari Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Elnaz Vahidi Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. 2017 10 13 2017 10 13 Introduction: Emergency physicians should secure Endotracheal tubes (ETT) properly in order to prevent unplanned extubation (UE) and its complications. Despite various available endotracheal tube holders, using bandages or tape are still the most common methods used in this regards. Objective: This study aimed to compare adhesive tape (AT) versus fixing bandage (FB) method in terms of properly securing ETT. Methods: This was an observational longitudinal trial. All patients older than 15-years-old admitted to the ED who had indication for ETT insertion were eligible. Patients were randomly assigned to one of the two groups in which AT or FB was applied. All patients were observed thoroughly in the first 24 hours after intubation. Using a pre-prepared checklist, encountered UE rate and other data were recorded. Results: Seventy-two patients with the mean age of 55.98 ± 18.39 years were finally evaluated of which 38 cases (52.8%) were male. In total, 12% of patients in our study experienced unplanned extubation. Less than 12% of the patients experienced complete UE; there was no statistically significant difference between the two groups (p = 0.24). Comparison of UE with age showed no significant difference (p = 0.89). Male patients experienced more UE, but this was not statistically significant (p = 0.44). Conclusion: It is likely that whether the AT method or FB was applied for securing the ETT in emergency departments, there was no significant difference in rates of unplanned extubation. https://fem.tums.ac.ir/index.php/fem/article/view/6 https://fem.tums.ac.ir/index.php/fem/article/download/6/7

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 18 e4 e4 Anita Sabzghabaei Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Majid Shojaee Department of Emergency Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Marzieh Amiri Department of Emergency Medicine, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran. Neda Akhoundzadeh Department of Emergency Medicine, Poorsina Hospital, Guilan University of Medical Sciences, Rasht, Iran. Saeed Safari Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2017 10 18 2017 10 18 Introduction: Troponin test is one of the methods for diagnosing acute coronary syndrome, but the overuse and misuse of this test has increased the costs imposed on the health system and the patients. Objective: The present study was conducted to investigate the veracity of troponin test requests for patients presenting to an emergency department with chest pain and examine the effectiveness of training emergency medicine assistants in reducing unnecessary and inappropriate requests in emergency departments. Methods: This clinical audit was conducted in the emergency department of Imam Hossein Hospital, Tehran, Iran, in 2014. Sampling was carried out using the census method and all the cases presenting to the emergency department for whom a troponin test was requested by the emergency medical assistants were included in the research. First, the veracity of the current troponin test requests was assessed; then, training was given to the personnel, and the veracity of the troponin test requests was once again verified after the training was completed. The rate of veracious troponin requests for the patients was measured based on two factors, including the interval between the patients’ admission and the troponin test request, and the interval between the onset of pain and the troponin test request. The veracity of the troponin test request was compared before and after training using the Phi test and Cramer’s V test in IBM SPSS-21. Results: This study examined a total of 500 patients (250 before training and 250 after), who had a mean age of 57.65±18.15 years, including 51.6% men. Significant differences were observed between the mean time of the patients’ admission and the overall and post-training troponin test results (P=0.000), and also between the mean time of the onset of pain and the overall and post-training troponin test results (P=0.000). The number of positive troponin test results did not differ significantly between the patients in either of the two stages (P=0.39). Conclusion: Unnecessary troponin test requests reduced significantly after this clinical audit in the examined emergency department. https://fem.tums.ac.ir/index.php/fem/article/view/8 https://fem.tums.ac.ir/index.php/fem/article/download/8/9

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 21 e5 e5 Shervin Farahmand Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Omid Shabestari Health Informatics at Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Canada Meghdad Pakrah Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Hooman Hossein-Nejad Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Mona Arbab Massachusetts General Hospital, Harvard Medical School, MA, USA Shahram Bagheri-Hariri Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran 2017 10 21 2017 10 21 Introduction: Artificial intelligence (AI) is the development of computer systems which are capable of doing human intelligence tasks such as decision making and problem solving. AI-based tools have been used for predicting various factors in medicine including risk stratification, diagnosis and choice of treatment. AI can also be of considerable help in emergency departments, especially patients’ triage. Objective: This study was undertaken to evaluate the application of AI in patients presenting with acute abdominal pain to estimate emergency severity index version 4 (ESI-4) score without the estimate of the required resources. Methods: A mixed-model approach was used for predicting the ESI-4 score. Seventy percent of the patient cases were used for training the models and the remaining 30% for testing the accuracy of the models. During the training phase, patients were randomly selected and were given to systems for analysis. The output, which was the level of triage, was compared with the gold standard (emergency medicine physician). During the test phase of the study, another group of randomly selected patients were evaluated by the systems and the results were then compared with the gold standard. Results: Totally, 215 patients who were triaged by the emergency medicine specialist were enrolled in the study. Triage Levels 1 and 5 were omitted due to low number of cases. In triage Level 2, all systems showed fair level of prediction with Neural Network being the highest. In Level 3, all systems again showed fair level of prediction. However, in triage Level 4, decision tree was the only system with fair prediction. Conclusion: The application of AI in triage of patients with acute abdominal pain resulted in a model with acceptable level of accuracy. The model works with optimized number of input variables for quick assessment. https://fem.tums.ac.ir/index.php/fem/article/view/11 https://fem.tums.ac.ir/index.php/fem/article/download/11/10

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 12 e6 e6 Sahar Mirbaha Department of Emergency Medicine, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Hossein Delavar-Kasmaei Department of Neurology, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Erfan Shafiee Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2017 10 21 Introduction: Headache is a common reason for visiting emergency departments, and pain control is a major therapeutic goal in patients with headaches. Objective: The present study was conducted to examine the effectiveness of the concurrent intravenous administration of dexamethasone and metoclopramide in pain control in patients presenting to emergency departments with complaints of primary headache. Methods: This quasi-experimental study examined patients with moderate to severe headache attacks presenting to emergency departments. An 8-mg dose of dexamethasone and a 10-mg dose of metoclopramide were intravenously administered to the patients. The degree of headache was measured and recorded using the Numeric Rating Scale (NRS) upon admission and one hour and two hours after the injection. Results: A total of 51 patients with a mean age of 38.3±10.5 years participated in the study. The patients’ mean pain score was 8.4±1.3 upon admission and reduced to 6.2±2.3 one hour after the administration of the medication and to 3.1±2.9 two hours after the administration, suggesting significant reductions on both occasions (P<0.05). The therapeutic success was 39.2% one hour after the administration of the medication and 84.3% two hours after the administration. Conclusion: Based on these findings, the concurrent administration of dexamethasone and metoclopramide appears to affect the control of headache intensity in patients with primary headaches presenting to emergency departments. https://fem.tums.ac.ir/index.php/fem/article/view/12 https://fem.tums.ac.ir/index.php/fem/article/download/12/11

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 1 1 2017 10 12 e7 e7 Alireza Abootalebi Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Sepideh Khazaei Student Research Committee, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Mohammad Minakari Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Mohammad Nasr-Isfahani Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Mehrdad Esmailian Emergency Medicine Research Center, Department of Emergency Medicine, Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran. Farhad Heydari Emergency Medicine Research Center, Department of Emergency Medicine, Al-Zahra Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran. 2017 10 28 Introduction: Large-volume paracentesis is one of the usual treatments for cirrhotic patients with tense ascites, which may cause different complications including decreased cardiac preload, suppressed renin angiotensin system, inactivation of sympathetic nervous system, electrolyte imbalances, etc. Objective: The aim of this study was to compare the effects of administrating hydroxyethyl starch (HES) and albumin in cirrhotic patients with tense ascites in order to reduce the paracentesis complications. Methods: In the present randomized clinical trial, 108 cirrhotic patients with tense ascites were enrolled. The patients were randomly divided into 3 groups. In group A, albumin 20% with 5 g/L dose of paracentesis fluid, in group B, HES 6% dissolved in saline were administered, and in group C, a combination of albumin 20% and HES 6% with half the dosage administrated to two other groups were prescribed. Then biochemical panel, and liver function tests and renal and electrolyte complications were compared between the groups. Results: The results obtained after intervention did not show significant differences between the groups regarding weight (p=0.102), heart rate and platelet count (both p=0.094), hematocrit (p=0.09), creatinine (p=0.421), serum sodium (p=0.743) and potassium (p=0.147), total bilirubin (p=0.375) and urine volume (p=0.421). Additionally, we concluded that mean arterial pressure of patients who had received albumin was higher than the other 2 groups (p < 0.001). Conclusion: The results of the present study showed the similar effects of HES and albumin in cirrhotic patients with tense ascites undergoing large-volume paracentesis. https://fem.tums.ac.ir/index.php/fem/article/view/17 https://fem.tums.ac.ir/index.php/fem/article/download/17/15