Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 08 11 e1 e1 Katayuon Jahangiri Department of Health in Disasters and Emergencies, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran Nourollah Rostami Expert of Disasters Risk Reduction in Health deputy of Ilam University of Medical Sciences, Ilam, Iran Ali Sahebi Department of Health in Disasters and Emergencies, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2019 07 25 2019 08 11 As important infrastructures in every community, hospitals and healthcare centers are required to continue their operation during normal and disastrous situations and respond to the situation and provide services for the injured. In 2008, the hospital safety index (HSI) was proposed by the Pan American Health Organization (PAHO) for evaluating the safety of hospitals and healthcare facilities in potential hazardous situations. The hazards threatening these facilities can be identified using a checklist, and categorized as structural, non-structural and functional vulnerability while considering their likelihood of occurrence, frequency, harmful outcomes and numerical estimate of damage. In 2016, risk and safety assessments in disasters were performed in 280 healthcare centers affiliated to Ilam University of Medical Sciences, Ilam, Iran, including 204 medical homes, 66 comprehensive urban and rural health centers and 10 district health centers. The present research was conducted using the hazard assessment guidelines developed by the Iranian Ministry of Health. The results revealed that geologic hazards, climatologic threats, epidemics and traffic accidents were respectively the most frequent hazards threatening healthcare centers in Ilam province. Moreover, the levels of the structural, non-structural and functional safety of the healthcare centers were respectively found to be 20.34%, 27.67% and 21.53%. The overall safety of the health centers was also estimated at 22.79%. In fact, the safety level received a score of 3 out of 10.  Hatami et al. obtained a safety index of 4 out of 10, and found the level of functional safety to be 51.48%, that of structural safety 33.97%, that of non-structural safety 54.82% and that of overall safety 43.72%. Moreover, an evaluation of the safety level of Iranian health centers in the face of disasters in 2015 reported a functional safety level of 29%, a structural safety level of 36%, a non-structural safety level of 21% and an overall safety level of 29%. The safety levels of healthcare centers in Ilam province were therefore lower than those reported as the national mean safety indices. In addition, the present results were expressed through their root cause analysis. The unsatisfactory preparedness level of healthcare centers in Ilam province on a national scale based on the hazard assessment guidelines developed by the Ministry of Health can be attributed to the following factors: • The very old building structures of the health centers contributing to lower safety and higher risks • Failing to complete the checklists according to the instructions provided for national assessment tools; the checklists should have been completed by skilled, well-educated experts who were informed of how to use the instruments and how to complete the checklists. • The invalidity of the obtained results associated with completing the checklists by experts of the Deputy of Health and subsidiary units, who lacked knowledge about structural engineering and building architecture. In fact, the intrinsic features of some of the instruments required asking for assistance from engineering experts such as architects, civil engineers and urban engineers to complete the checklists; nevertheless, financial limitations prevented the use of specialist expertise. • Failing to take the necessary measures to promote the safety and efficiency of the healthcare centers despite the neglect reflected in the annually-completed preparedness assessment tools; the annual status of safety and preparedness of healthcare centers in Ilam was reported to be unsatisfactory. • As a major component of management, control is a combination of actions required for identifying strengths, weaknesses, threats and opportunities through monitoring and evaluating the processes and solving the system problems by performing appropriate intervention. The improvement of the status quo is not guaranteed unless controls lead to interventions. The results obtained through assessing the preparedness and safety of hospitals appear to have not affected the strategic programs, policies and procedures of the health system authorities in a way that safety levels are enhanced in healthcare facilities. The policy makers are therefore recommended to revise the methods used to take advantage of this information. https://fem.tums.ac.ir/index.php/fem/article/view/227 https://fem.tums.ac.ir/index.php/fem/article/download/227/204

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 06 18 e2 e2 Seyedhossein Seyedhosseini-Davarani Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Elham Hesari Department of Emergency Medicine, Imam Khomeini Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran Mohammad Afzalimoghadam Pre-Hospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran. Javad Seyedhosseini Pre-Hospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran. Nader Tavakoli Department of Emergency Medicine, Rasool-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran Hooman Hossein-Nejad Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran 2019 01 29 2019 02 06 Introduction: In 2010, a national triage train-of-trainer (TOT) workshop was held in Tehran, Iran. Objective: The present study aimed to assess the validity of the triage performed by the nurses educated by those who participated in TOT workshop. Method: This cross-sectional study was carried out in 6 teaching hospitals from 4 universities in Iran. Inter-rater and intra-rater reliability of performed triage by participations was measured. Thirteen nurses were randomly selected. Thereafter, at the end of each working shift, patient data recorded in the daily data registry forms were collected. Then, duration of hospital stay, number of cases admitted to general wards or intensive care units, number of cases discharged from the ED within 12 hours and mortality rate were compared with the triage level determined by the nurse. Results: In total, 30 nurses with a mean age of 28.4 ± 3.7 years were enrolled. In this study, 1491 triage cases (61.6% male) were evaluated, of which 4.2% were triaged as level 1, 18.3% as level 2, 37.1% as level 3, 20.4% as level 4 and 20.0% as level 5. The following outcome was observed: 3.64% were discharged, 6.29% were hospitalized, 3% died and 2.3% were discharged against medical advice without completing treatment. The correlation of determined triage level and patients’ duration of hospitalization was significant based on one-way ANOVA test (p = 0.000). The outcome of the patients significantly correlated with the level of triage determined by the study nurses (p = 0.000). Conclusion: Based on the findings, it appears that triage performed by the study nurses educated by those who participated in TOT workshop through cascade training system had perfect validity. https://fem.tums.ac.ir/index.php/fem/article/view/127 https://fem.tums.ac.ir/index.php/fem/article/download/127/188

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 07 11 e3 e3 Soraya Siabani School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran Ali Soroush School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran Maryam Babakhani School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran Sina Siabani School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran Zahra Naghibifar School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran Hadis Karami School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran Mitra Ghahremani School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran 2019 05 22 2019 06 18 Introduction: Identifying the death reasons amongst elderly, may help prioritizing the research projects and interventions. Objective: This study purpose was to determine the death pattern and causes, and also its likely associated factors, in a mega hospital in western Iran. Method: This retrospective cross-sectional study, conducted on elderly died from April 2011 to March 2016, in Imam Reza hospital in Kermanshah, Iran. The data were collected about the demographic characteristics, medical information, and the main death causes. The causes-of-death was classified adopting the International Classification of Diseases, Tenth Revision (ICD–10). The relationships between outcome and predicting variables were assessed by using Chi-square and Tukey's test in SPSS. Results: Totally, 2415 died elderly were registered during the study period. The participants mean age at the time of their death was 75.35±9.15 years old. The diseases of circulatory system (dominancy of stroke), infectious diseases (leading by septicaemia and septic shock, respectively), and respiratory system diseases were the most common death causes, respectively. Age was the most important associated factor for the all-cause mortality related to the cardiovascular diseases (p=0.001). Conclusion: The majority of deaths were the premature, which requires paying more attention. Although, cardiovascular diseases were the leading death causes and that is predictable, but the fatality of infectious diseases is still causing concerns. https://fem.tums.ac.ir/index.php/fem/article/view/162 https://fem.tums.ac.ir/index.php/fem/article/download/162/194

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 08 11 e4 e4 Azimeh Jahanipour Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran Leila Asadabadi Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Mehdi Torabi Department of Emergency Medicine, Kerman University of Medical Sciences, Kerman, Iran Moghadameh Mirzaee Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran Elham Jafari Pathology and Stem Cell Research Center, Kerman University of Medical Sciences, Kerman, Iran. 2019 06 18 2019 07 24 Introduction: Electrolyte disorder is a prevalent complication in multiple trauma patients; nevertheless, the role of chloride has been rarely addressed in literature when evaluating serum electrolytes. Objective: The present study was conducted to determine the correlation between serum chloride changes and hospital mortality in multiple trauma patients. Method: The present cross-sectional study measured serum chloride levels in 100 multiple trauma patients upon their admission to the emergency department and 24 hours later. All these patients were followed up in terms of hospital mortality using their medical records. Exact logistic regression was used to measure the effects of independent variables on hospital mortality in the patients. Results: Hospital mortality was found to be 15 (15%), and the mean serum chloride level to be 106.37±4.53 mmol/l upon admission and 112.18±6.16 mmol/l 24 hours later. Although the univariate analysis suggested that serum chloride levels were independently associated with mortality 24 hours after admission (P=0.005), this correlation was insignificant in the multivariate analysis. Conclusion: The present study rejected the hypothesis suggesting the potential role of serum chloride levels in predicting hospital mortality in multiple trauma patients. https://fem.tums.ac.ir/index.php/fem/article/view/197 https://fem.tums.ac.ir/index.php/fem/article/download/197/205

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 10 10 e5 e5 Sushma Shriyan Department of Emergency Medicine, Bharati Hospital, Maharashtra, India Utsav Mani Department of Emergency Medicine, Bharati Hospital, Maharashtra, India Firdaus Bhot Department of Emergency Medicine, Bharati Hospital, Maharashtra, India Elizabeth Sada Department of Emergency Medicine, Bharati Hospital, Maharashtra, India Rajesh Ursekar Department of Emergency Medicine, Bharati Hospital, Maharashtra, India Digvijay Adake Department of Emergency Medicine, Bharati Hospital, Maharashtra, India 2019 08 11 2019 10 10 Introduction: Bull injuries are common in India. An injury by a bull is more common in rural and agriculture dependent regions of the country. The incident causing injury by a bull can be sports related or work related. Work related injuries are almost mostly seen in farmers. Case presentation: We would like to present six cases of bull injury over a period of three years who reported to our EM. All six patients were admitted. Five out of six patients survived the hospital stay. Conclusion: Trauma sustained due to being hit by a large animal should be treated akin to a high velocity trauma and such a patient definitely warrants a period of observation even if the injuries are not life threatening. A high index of suspicion is needed for suspecting occult injuries. Fluid resuscitation and age of the patient are important considerations. https://fem.tums.ac.ir/index.php/fem/article/view/244 https://fem.tums.ac.ir/index.php/fem/article/download/244/237

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 10 03 e6 e6 Farzaneh Rashidi-Fakari Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran Masoumeh Simbar Midwifery and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Saeed Safari Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Shahrzad Zadeh-Modares Department of Gynecology & Obstetric, Shahid Beheshti University of Medical Sciences, Tehran, Iran Hamid Alavi-Majd Department of Biostatics, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2019 08 11 2019 08 11 Introduction: There is no consensus on what the bases and criteria are for the dynamic process of maternity triage. Properly performing the maternity triage process requires reliable data to ensure the correct implementation of this process and the identification of existing deficiencies, and find strategies to modify, improve and enhance the quality of this process. Objective: The present study was conducted to explain the quality of the maternity triage process. Methods: The present qualitative study performed a directed content analysis on 19 maternity triage service providers and key informants selected through purposive sampling. The data were collected through semi-structured interviews in 2018 and analyzed using directed content analysis based on the Donabedian’s model. The accuracy and rigor of the qualitative data were then investigated and confirmed. Results: The participants identified the most important factors affecting the quality of the services provided in maternity triage as two categories of measures and care, and interactions and communication. The category of measures and care included two subcategories of examinations and obtaining a medical history. Conclusion: The present study comprehensively identified different dimensions of the quality of maternity triage services at different levels. The participants identified the quality of the maternity triage process as a multi-dimensional and important concept. Different dimensions of the maternity triage process are recommended that be addressed when designing and implementing maternity triage guidelines and instructions so as to maintain the quality of this process and satisfy their needs. https://fem.tums.ac.ir/index.php/fem/article/view/242 https://fem.tums.ac.ir/index.php/fem/article/download/242/231

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 08 17 e7 e7 Sepideh Paybast Neurology Department, Bouali Sina Hospital, Qazvin University of medical sciences and health, Qazvin, Iran Ali Ashraf Clinical Research Development Unit, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran Hakimeh Sarshad Clinical Research Development Unit, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran Maryam Shakiba Department of Health Education and Services, School of Health, Guilan University of Medical Sciences, Rasht, Iran Yaser Moadabi Department of Neurology, School of Medicine, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran 2019 06 02 2019 06 11 Introduction: Currently, the most available treatment for acute ischemic stroke (AIS) is thrombolytic therapy with recombinant tissue plasminogen activator (r-TPA). A challenge in r-TPA therapy is the prediction of recovery in each case. Objective: The aim was to find a possible relationship between the cerebral oximetry indexes and the clinical outcome of r-TPA therapy to assess the cerebral oximetry as a non-invasive monitoring agent for therapy. Methods: The inclusion criteria were all patients with AIS who received r-TPA. The neurologic status was evaluated based on the national institutes of health stroke scale (NIHSS) score at arrival, and after a period of 24 hours. In addition, the levels of brain oxygenation in both hemispheres were measured before and continuously over the first 24 hours after r-TPA injection, using an oximetric sensor in the frontal lobes. The clinical success was defined as a 4-point improvement from the baseline NIHSS. Results: Total 44 patients with the mean age of 58.2 ± 2.18 years were enrolled, of whom 68.18% were male. Twenty-eight patients remained clinically unimproved and 16 patients were improved. A significant difference was found in the mean surface area under the brain oximetric curve in the 24 hour, in the affected hemisphere in the improved group, compared to the unimproved group (P = 0.007). There was a significant difference between the mean increase in brain oxygenation within 24 hours in the improved and unimproved groups (P = 0.002). Conclusion: The cerebral oximetry could contribute to predict the likelihood of r-TPA prognosis in patients with AIS. https://fem.tums.ac.ir/index.php/fem/article/view/174 https://fem.tums.ac.ir/index.php/fem/article/download/174/207

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 06 06 e8 e8 Ashok Uppiretla Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Gangalal G M Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Suhas Rao Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Donnel Don Bosco Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Shareef S M Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Vivek Sampath Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India 2019 05 04 2019 05 12 Introduction: The association between chest compression fraction (CCF) and return of spontaneous circulation (ROSC) has been a controversial issue in literature; and both positive and negative correlations have been reported between CCF and survival rate. Objective: The present study was conducted to determine the relationship between the rate and outcomes of chest compression and between CCF and ROSC in patients with cardiac arrest. Method: The present prospective observational study was conducted during 2018 on patients with cardiac arrest aged 18-80 years. Participants with end-stage renal diseases, malignancies and grade IV heart failure were excluded. A stop watch was set upon the occurrence of a code blue in the emergency department, and time was recorded by the observer upon the arrival of the code blue team leader (a maximum permissible duration of 10 minutes). The interruptions in chest compressions were recorded using a stopwatch, and CCF was calculated by dividing the duration of chest compression by the total duration of cardiac arrest observed. Results: Totally, 45 participants were enrolled. Most of the patients had non-shockable rhythms and underwent CPR based on related algorithm. Hypoxia and hypovolemia were the two probable etiology of cardiac arrest; and coronary artery disease was the most prevalent underlying disease. All patients with ROSC had CCF more than 70%. A CCF below 70% was observed in 21 cases (46.7%), and a fraction of at least 70% in 24 cases. All patients with ROSC had CCF more than 70%. A CCF below 70% was observed in 21 cases (46.7%), and a fraction of at least 70% in 24. A significantly higher duration and fraction of chest compression was observed in the participants who attained ROSC (P<0.001). Conclusion: Based on the findings of current study, it seems that significantly higher chest compression durations and fractions were found to be associated with ROSC, which was achieved in the majority of the participants with a CCF of at least 80%. https://fem.tums.ac.ir/index.php/fem/article/view/147 https://fem.tums.ac.ir/index.php/fem/article/download/147/184

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 12 01 e9 e9 Pouya Entezari Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran Mohammad Jalili Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Javad Seyedhosseini Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Amin Doosti-Irani Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran Hadi Mirfazaelian Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran 2019 10 16 Context: This meta-analysis of clinical trials was conducted to compare the diagnostic accuracy of ultrasound in comparison to plain radiography in shoulder dislocation. Evidence acquisition: MEDLINE, Cochrane Database of Systematic Reviews, clinicaltrials.gov, Google scholar, and Scopus were searched for clinical trials. Diagnosis of shoulder dislocation and confirmation of shoulder reduction were the outcomes of interest. Sensitivity, specificity, positive predictive value and negative predictive value of included clinical trials were calculated.  Results: Seven studies met our inclusion criteria and were analyzed. All included studies except two had a sensitivity and specificity of 100% for ultrasound (one with a sensitivity of 54% and one with a specificity of 60%). Conclusion: It can be suggested that ultrasound can be used as a reliable alternative diagnostic method for detection of both dislocation and reduction in shoulder joint. This may decrease the delay in treatment, cost, radiation exposure, and need for repeated sedation. https://fem.tums.ac.ir/index.php/fem/article/view/285 https://fem.tums.ac.ir/index.php/fem/article/download/285/238

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 08 25 e10 e10 Seyed-Mohammad-Kazem Aghamir Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran Mehdi Ebrahimi Department of Internal Medicine, Faculty of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran Iran Fatemeh Khatami Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran 2019 07 16 2019 07 24 Context: An emergency is any medical problem that could cause death or permanent injury if not treated quickly. In some occasions, the kind of urgent intervention depends on patient’s exact genetic background. Unfortunately, the importance of genes in medical emergencies has been forgotten in recent decades.  Evidence acquisition: In order to find relevant articles, we searched two databases of Pubmed and Embase. The exact words of “genes”, “genetics”, “epigenetics”, “DNA”, and “emergency” were used alone and in combination. All studies like randomized clinical trials (RCT), case/controls, case series, case reports, and review articles were studied to find the related data. No time limitation was considered for the studies. Results: Several aspects of genetic testing are newly considered in emergency departments including cell-free DNA (cfDNA) for disease diagnosis, pharmacogenetics for decreasing the adverse drug effects, and personalized medicine for exact emergency interventions in diseases like Vascular Ehlers-Danlos syndrome (vEDS). Data from genetic testing and genome wide association studies have yielded promising results to make medical emergency interventions more beneficial in the near future.  Conclusion: Taking everything into consideration, several advanced genetic and epigenetic alteration technologies can change emergency medicine for the better. Personalized genetic data of patients can turn emergency medicine to personalized medicine. https://fem.tums.ac.ir/index.php/fem/article/view/216 https://fem.tums.ac.ir/index.php/fem/article/download/216/212

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 07 01 e11 e11 Hossein Zabihi Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran. Pezhman Farshidmehr Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran. Reza Hajebi Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran. Ehsan Rahimpour Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran. Payam Vezvaei Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran 2019 06 14 2019 06 26 Introduction: Various strategies could be considered dealing with penetrating thoracic injuries. Thoracoscopy is much less invasive than routine thoracotomy approach for managing such cases in which the sharp object remains in the body. The case presented in this article was managed with thoracoscopy for a penetrating dorsolateral thoracic injury. Case Presentation: A 35-year-old man with a penetrating dorsolateral thoracic injury referred to the emergency department. Despite an elevated pulse rate, the patient has proper blood pressure and O2 saturation. Considering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy. At thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space. There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications. Conclusion: Our experience of removing a retained knife by thoracoscopy showed that it can be an appropriate alternative for patients with penetrating thoracic injury who are hemodynamically stable and have appropriate conditions for thoracoscopy. https://fem.tums.ac.ir/index.php/fem/article/view/185 https://fem.tums.ac.ir/index.php/fem/article/download/185/193

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 10 31 e12 e12 Dalton Norwood Hospital de Occidente, Santa Rosa de Copan, Honduras Lucia Dominguez Hospital de Occidente, Santa Rosa de Copan, Honduras Ricardo Dominguez Hospital de Occidente, Santa Rosa de Copan, Honduras Walter Winders Department of Emergency Medicine, Medical University of South Carolina, Charleston, USA 2019 10 23 2019 10 27 Introduction: Bidirectional ventricular tachycardia (BVT) is a rare arrhythmia characterized by QRS complexes with an axis in the frontal plane alternating polarity in the precordial leads and right bundle branch block (RBBB) morphology. To the best of our knowledge, there is no previous report in dilated cardiomyopathy or in the context of a probable peripartum cardiomyopathy. Case Presentation: A 26-year-old, 9-month female patient, with no significant past medical history (the patient denies medication intake, herbs like aconite, trouble during delivery, any heart issues or family history of sudden death or cardiomyopathies) who presents to the emergency room due to 11 days of dyspnea, exacerbated by daily activities, orthopnea, and paroxysmal nocturnal dyspnea. She presented with ventricular bigeminy and systolic dysfunction with left ventricular ejection fraction (LVEF) <20%. The patient later developed a stable ventricular tachycardia (VT) treated with amiodarone, which resulted in hemodynamic instability and BVT rhythm with VT paroxysms. Without the possibility of ablation, the use of high dose beta blockers and an implantable cardioverter defibrillator resulted in the same rhythm with a lower heart rate, better NYHA functional class, and less episodes of VTs. Conclusion: BVT is a rare type of tachycardia that can be present in dilated cardiomyopathy. In the absence of ablation capabilities, decreasing the heart rate with beta-blockers may reduce the rate of paroxysmal VTs. https://fem.tums.ac.ir/index.php/fem/article/view/287 https://fem.tums.ac.ir/index.php/fem/article/download/287/239

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 08 11 e13 e13 Mohammad Ashouri Department of Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Payam Vezvaei Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran Alireza Kazemeini Department of Surgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Alborz Sherafati Department of Cardiology, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Hadi Mirfazaelian Department of Emergency Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran 2019 06 15 2019 07 19 Introduction: Acute gastric dilation following trauma is an unusual event that can occur in different settings, and can cause gastric necrosis as a rare though fatal condition. The present report involves a case of acute gastric dilation following multiple traumas, which caused gastric necrosis and total gastrectomy. Case presentation: A 19-year-old morbid obese male presented to the emergency department (ED) following a motor vehicle accident. He had a left lower extremity crash injury. In his serial examinations, he was complaining of upper abdominal pain with epigastric tenderness. After nasogastric tube (NGT) reinsertion, due to detecting coffee ground secretions in the drained fluid, the patient was transferred to the operating room. A midline laparotomy was performed that revealed dilation and discoloration of the stomach. Gastric decompression was performed. All the discoloration then disappeared except for that of certain suspicious areas, which necessitated evaluations. On the following day, given the lack of improvement in the patient`s condition, he was transferred to the operating room for a second laparotomy. Conclusion: The present report emphasized on the importance of NGT insertion in multiple-trauma patients, which is, however, neglected in many cases. Moreover, acute gastric dilation is recommended to be considered in the differential diagnosis of patients with multiple or abdominal trauma and complaints of vomiting or abdominal pains. https://fem.tums.ac.ir/index.php/fem/article/view/192 https://fem.tums.ac.ir/index.php/fem/article/download/192/203

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 09 18 e14 e14 Suhas Rao Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Anoop Chakrapani Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Ashok Uppiretla Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India Donnel Don-Bosco Department of Emergency Medicine, Kerala Institute of Medical Sciences, Trivandrum, India 2019 07 22 2019 07 28 A 14-year-old girl presented to the emergency department (ED) with a history of three episodes of seizure-like activity and no comorbidities at 2 am. The first episode had occurred at 6 am, the second at 12 pm and the third two hours before presenting to the ED. Each episode lasting less than 5 minutes, was associated with the limb and spinal rigidity and extension, the up-rolling of eyeballs and urinary incontinence. The patient reported no history of fever, recent trauma, previous febrile seizures, prodromal symptoms, tongue bite, headache or physical excretion before the episodes. No postictal confusion or tonic-clonic movements and significant family history were also reported. The initial examination found her to be conscious, oriented and hemodynamically stable, and the results of her systemic examinations were normal without any significant positive findings. Evaluation of the patient initiated with the provisional diagnosis of new-onset seizures, followed by performing a computed tomography (CT) scan of the head, which was normal and ruled out any intra-cranial pathology. The results of the blood test involving serum electrolytes, calcium and magnesium were also normal. Abrupt polymorphic ventricular tachycardia (VT) was identified on the monitor (figure 1) as a few second-episodes of posturing and stretching of the body with no peripheral and central pulses during the examination in the ED. The patient came around after undergoing cardiopulmonary resuscitation immediately followed by defibrillation at 200 J and reverting the rhythm to sinus. The patient had recurrent episodes of pulseless polymorphic VT, which required ten times of defibrillation for one hour and antiarrhythmic drug therapy with IV bolus of 300 mg and then again 150 mg amidaraone, and then infusion of 1 mg of magnesium sulfate diluted in 10 ml of D5W and also administration of 1 mg/kg of lidocaine. The patient was electively intubated and ventilated under deep sedation, and transferred to the cardiac care unit (CCU). The two-dimensional echocardiography findings were revealed normal-sized heart chambers and good left ventricular function. Blood levels of high-sensitivity troponin I and CK-MB were also in their normal range. Despite performing repeated defibrillation and anti-arrhythmic therapy, the patient showed repeated episodes of pulseless VT. She was therefore referred to a higher-level center to be administered with left stellate ganglion block (LSGB). She withstood the procedure, and discharged from the hospital after a ten-day follow-up. An implantable cardioverter-defibrillator (ICD) was later planned for the patient, and she continued with taking oral antiarrhythmic drugs. https://fem.tums.ac.ir/index.php/fem/article/view/221 https://fem.tums.ac.ir/index.php/fem/article/download/221/217

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 4 1 2019 11 27 e15 e15 Ahmed Negida Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt 2019 11 27 In the previous educational articles, we explained how to calculate the sample size for a rate or a single proportion, for an independent cohort study, for an independent case-control study, for a diagnostic test accuracy study, and for a superiority clinical trial. In this article, we will explain how to calculate the sample size for a non-inferiority or equivalence clinical trial. https://fem.tums.ac.ir/index.php/fem/article/view/302 https://fem.tums.ac.ir/index.php/fem/article/download/302/245