Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 01 22 e13 e13 Serdar Özdemir Department of Emergency Medicine, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey İbrahim Altunok Department of Emergency Medicine, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey Abdullah Algın Department of Emergency Medicine, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey 2022 10 02 2022 12 27 Objective: This study was conducted to reveal the relationship of the hematological inflammatory index (HII) and systemic immuno-inflammation index (SII) with short-term and prolonged hospitalization in cases of acute pancreatitis. Methods: This single-center cross-sectional study was conducted in the emergency department (ED) of an educational hospital. The study population contained cases who untaken to the ED with acute pancreatitis between August 15, 2021, and May 15, 2022. Cases discharged from the ED, those referred to another center for hospitalization, and those with absent information were excluded from the study. The patients were grouped according to the length of hospital stay (expected and prolonged) and short-term mortality (survivor and died). We constructed a receiver operating characteristic (ROC) curve for short-term mortality and prolonged hospitalization and obtained the area under the curve (AUC) values for SII and HII. Results: One hundred seventy-seven patients were included in the study. There was no significant difference between the expected and prolonged hospitalization groups in the terms of SII and HII (P=0.649 and P=0.084, respectively). There was also no significant difference between the survivor and died groups in the terms of these indexes (P=0.070 for HII and P=0.138 for SII). The AUC values for the SII and HII in the prediction of 30-day mortality were 0.616 and 0.642, respectively. The AUC values for the SII and HII in the prediction of prolonged hospitalization were 0.580 and 0.642, respectively. Conclusion: The outcomes of the present study showed no significant difference among the expected and prolonged hospitalization groups or the survivor and died groups in the terms of SII and HII. We recommend the validation of our results in multicenter studies with larger samples. https://fem.tums.ac.ir/index.php/fem/article/view/1083 https://fem.tums.ac.ir/index.php/fem/article/download/1083/440

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 12 31 e12 e12 Ennio Licheri Department of Emergency Medicine, University of Modena and Reggio Emilia, Modena, Italy 2023 02 05 The Emergency Medicine school in Italy is relatively young. It was founded in 2008, and the first specialists were trained 5 years later, in 2013. The school was created to give relevance to the role of the emergency doctor and try to obtain highly specialized and trained figures in managing, quickly and effectively, the various situations that can occur in an emergency department. Before the creation of the school, many colleagues believed that anyone could go to work in an emergency room (ER), even without a specific traineeship for that. In reality, the school was created to try to equate the level of training of Italian first aid doctors to the standards of other western countries, in which the school of emergency medicine had already been established. After a somewhat sluggish start, over the years the emergency and urgency medicine (MEU) school has gained its importance and more and more people have enrolled in what is the most adrenaline-filled and varied training school of all. With the neospecialists there has been a gradual filling of the ERs with highly trained figures in the management of various medical emergencies and equipped with various diagnostic-therapeutic skills. Unfortunately, the situation has changed in recent years. In fact, since 2020 our national health system (SSN, Servizio Sanitario Nazionale) has deteriorated significantly in terms of services and quality. Even before the 2020 various critical issues could have been noticed, such as the lack of staff in many departments, the overcrowding of hospitals, the lack of an effective territorial health support system, it is with the COVID-19 epidemic that our public SNN has really started to falter. Italy, as some may already know, was one of the European countries to suffer the most from the pandemic especially due to the large number of elderly people in Italy. Hospitals, and ERs in particular, were always under pressure and those who worked there were subjected to exhausting shifts. Unluckily, among the consequences of the emergency situation there has been an important departure of doctors from the national health system towards either the free profession or even abroad. Needless to say, among the most abandoned departments in recent times, there are the critical area and intensive care departments and the ER. This led to a major health crisis to which a real solution has not yet been found. Almost all Italian ERs are now understaffed and the doctors who work there have to face exhausting working days and take on many responsibilities. Waiting times in most Italian ERs are getting longer and longer, and episodes of physical and verbal aggression carried out by patients against doctors and healthcare staff are now very so much common. Sadly, the prospect of a life of so many sacrifices has led to a slump in enrollment in graduate school of emergency medicine, with more than 60% of the places available each year vacant. Various ERs have closed and others will be closed if the situation does not improve. In this moment, no effective proposals to solve the problem have been presented by the Italian government. However, there are many doctors who claim their rights and who work with passion every day in often difficult environments. More and more demonstrations and protests are being organized which demand an improvement in working conditions, a higher wage in line with European standards, a reduction in working hours and an increase in annual days off. It goes without saying that emergency medicine doctors are at the forefront of all of this. There are those who say that only by improving the working conditions in the Italian ERs could it be possible to recover the Italian public health system from its serious crisis which forces the Italian government to hire doctors from other foreign states and conversely, Italian doctors to emigrate to other countries that guarantee greater attention to the rights of health professionals, that I cannot be agree with those. https://fem.tums.ac.ir/index.php/fem/article/view/1163 https://fem.tums.ac.ir/index.php/fem/article/download/1163/434

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 02 16 e18 e18 Amirhossein Nasiri-Valikboni Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran Yazdan Baser Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran Hamzah Ramawad Department of Emergency Medicine, NYC Health & amp; Hospitals, Coney Island, New York, USA Reza Miri Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mahmoud Yousefifard Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2022 12 05 2023 01 17 Objective: In this study, we investigate the diagnostic value of the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) tool in the diagnosis of large vessels occlusion (LVO) in a systematic review and meta-analysis. Methods: We conducted a search in Medline (PubMed), Embase, Scopus and Web of Science databases until the 21st of September 2022, as well as a manual search in Google and Google scholar to find related articles. Studies of diagnostic value in adult population were included. Screening, data collection and quality control of articles were done by two independent researchers. The data were entered and analyzed in STATA 17.0 statistical program. Results: The data from 30 articles were entered. The best cut-off points for FAST-ED were 3 or 4. The sensitivity and specificity of FAST-ED at cut-off points 3 were 0.77 (95% CI: 0.73-0.80) and 0.76 (95% CI: 0.72-0.80), respectively. These values ​​for cut-off point 4 were 0.72 (95% CI: 0.65-0.78) and 0.79 (95% CI: 0.75-0.82), respectively. Meta-regression showed that the sensitivity and specificity of FAST-ED performed by a neurologist was more accurate compared to emergency physician (p for sensitivity=0.01; p for specificity<0.001) and emergency medical technicians (p for sensitivity=0.03; p for specificity<0.001). Finally, it was found that the sensitivity of FAST-ED performed by the emergency physician and the emergency medical technician has no statistically significant difference (p=0.76). However, the specificity of FAST-ED reported by the emergency physician is significantly higher (p<0.001). The false negative rate of this tool at cut-off points 3 and 4 is 22.5% and 28.8%, respectively. Conclusion: Although FAST-ED has an acceptable sensitivity in identifying LVO, its false negative rate varies between 22.5% and 28.8%. A percentage this high is unacceptable for a screening tool to aide in the diagnosis of strokes considering it has a high rate or morbidity and mortality. Therefore, it is recommended to use another diagnostic tool for the stroke screening. https://fem.tums.ac.ir/index.php/fem/article/view/1123 https://fem.tums.ac.ir/index.php/fem/article/download/1123/435

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 02 23 e21 e21 EN Tooraj Zandbaf Department of General Surgery, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran Mohammad Ebrahim Kalantari Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran Soheil Ahmadyar Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran Ali Esparham Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran 2023 01 29 2023 02 02 A 30-year-old married woman with a history of infertility was referred to the general surgery department with complaints of occasional and intermittent left lower abdominal and left inguinal pain. Abdominal examination was normal and there was no obvious bulging in the left inguinal region. Routine laboratory tests were normal. Abdominal and pelvic ultrasonography revealed a left inguinal hernia with a defect of 15 millimeters (mm) and did not report any other pathological points. The patient was a candidate for laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. During the operation, pneumoperitoneum was performed through the umbilical region using a Veress needle, and after inserting a 10 mm umbilical port and exploring the abdomen, blood was seen in the pelvis. It was determined that the bleeding was from the mesentery of the small intestine (a known iatrogenic complication caused by Trocar or Veress needle). Two more 5 mm ports were inserted, the mesenteric bleeding was ligated using a ligature, and it was decided to continue the surgery laparoscopically. No obvious hernia was seen in the exploration of the inguinal area. After intra-abdominal blood suction, it was determined that there was a retroperitoneal hematoma in zone one. The patient's vital signs were still stable. After some patience, it became clear that the hematoma was expanding, so a decision was made to perform a laparotomy. Zone one was explored, and it was found that there was a perforation in front of the inferior vena cava, and there was heavy bleeding, so after controlling the proximal and distal vein, the perforation site was repaired using Prolen threads. In pelvic exploration, there was extensive adhesion in the region of the ovaries, fallopian tubes, and uterus, but there was no mass in the ovaries. Full abdominal exploration was performed. There was a mass in the small intestine 15 centimeters (cm) from the ileocecal valve, which caused an almost complete obstruction. Considering the patient's stable vital signs, a decision was made to resect the mass, and anastomose of the small intestine. At the end of the surgery and after washing the abdomen, the opened peritoneum was repaired on the vein, and two drains were placed in the pelvis. On the third day of surgery and after bowel habits returned, a liquid diet was started. On the fifth day, the patient had a good general condition, so the drains were removed and she was discharged. The histopathology examination of the small intestine mass showed endometriosis. The patient was referred to a gynecologist for consultation and treatment. https://fem.tums.ac.ir/index.php/fem/article/view/1160 https://fem.tums.ac.ir/index.php/fem/article/download/1160/439

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 03 11 e19 e19 Ayman Alhadheri Department of Emergency Medicine, McLaren Oakland Hospital/Michigan State University, Pontiac, Michigan, USA Sadia Alam SUNY Downstate College of Medicine, Brooklyn, New York, USA Saad Ahmed SUNY Downstate College of Medicine, Brooklyn, New York, USA Mohammed Alsabri Department of Emergency Medicine, Al-Thawra Modern General Teaching Hospital, Sana’a City, Yemen 2023 02 15 2023 03 11 It would be inaccurate to state that Yemen’s difficulties began with the current civil war in September of 2014. While the war brought about its own list of insurmountable tribulations, it also exacerbated already present disasters. This article explores the many dynamics that have led to what has been referred to as the world’s worst humanitarian crisis (1). These include war, internal displacement, economic disaster, healthcare collapse, outbreaks in refugee camps, vaccination concerns, malnutrition, food insecurity, water sparsity, and infectious disease catastrophes. Along with accurate depictions of what is happening on the ground, this article suggests a few potential solutions worth investigating further, ranging from national and international efforts. With an ever-changing climate, this article serves to provide the most up to date impression of the current crisis and disasters. https://fem.tums.ac.ir/index.php/fem/article/view/1171 https://fem.tums.ac.ir/index.php/fem/article/download/1171/438

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 02 16 e22 e22 Hamzah A. Ramawad New York Health & Hospital, South Brooklyn Health. Brooklyn, New York, USA Adam Rhodes New York Health & Hospital, South Brooklyn Health. Brooklyn, New York, USA 2023 01 15 2023 02 16 A 11-year-old boy was seen at our pediatric emergency department (PED) for evaluation of a swollen and painful penis. He had placed a glass ring over his penis fourteen days prior.  This resulted in straining with micturition and a fleshy circumferential non healing wound at the base of the penis with serosanguinous discharge. The glass ring eroded into the deep subcutaneous layer of the skin at the base of the penis. The distal penis was swollen and tender with no changes in skin color, texture or blurring of sensation. The glans was viable with appropriate capillary refill. Urine stream was unaffected, and the amount of serosanguinous discharge was not related to the act of voiding. Emergency measures were conducted including administration of analgesia, antiemetics, active immunization against tetanus, systemic antibiotic therapy (cefazolin), and urology consultation. Due to extensive damage, urology deferred ring removal in the PED and recommended removal in the operating room to control the probable damages better, post removal of ring. The patient was transferred as our facility did not have an inpatient unit for post operative management. The ring was successfully removed using a bone cutter under general anesthesia. Surgical exploration revealed minimal erosion into the cavernosal bodies without any injuries to the dorsal veins, dorsal and deep artery, and nerves. Intra-op cystoscopy showed no injuries to the urethra. Primary closure was done circumferentially in two layers (Buck’s fascia and skin) with an absorbable vicryl 5-0 interrupted suture, followed by pressure bandage. The case was presented to a social worker considering the clinical features of the case. The social service experts and providing physicians were reassured there was no concerns for child abuse, sexual abuse, neglect, behavioral or psychiatric disorders. The patient was discharged with Bactrim and analgesics for one week after he was able to void independently. One month follow up at the urology clinic revealed that the patient had good skin preservation, wound healing, and micturition. The patient had no difficulties with anxiety, depression, or post-traumatic stress at his follow up appointments with a behavioral health therapist. https://fem.tums.ac.ir/index.php/fem/article/view/1157 https://fem.tums.ac.ir/index.php/fem/article/download/1157/436

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 03 10 e20 e20 Wajeeha Musharraf Star Hospitals, Banjara Hills, Hyderabad, Telangana, India Sudhir Mane SVS Medical College and Hospital, Mahabubnagar, Telangana, India Habeeba Musharraf Shadan Institute of Medical Sciences, Peeramcheru, Hyderabad, Telangana, India 2023 02 08 2023 03 09 Workplace violence in hospitals, specifically in emergency departments (ED), has become a growing concern in recent years. This violence can come from patients, their families, or visitors and can take the form of verbal or physical attacks. Preventing violence in EDs can be achieved through design modifications with minimal personnel and infrastructure requirements. Infrastructure design plays a crucial role in reducing the risk of violence. Private lockers should be available at the ED entrance to limit dangerous objects being brought into the department. Furnishings should be fixed to prevent them from being used as weapons, and evacuation should be facilitated through open rows of seating. Positive distractions, such as gardens or natural areas visible through windows, can reduce stress in patients and lower aggression. Ligature points should be eliminated and tamper-resistant items should be provided to reduce dangers in the built environment. The triage desk should be positioned in a secure area with access control and panic buttons available for staff. Hidden exits should be provided in case of violence and emergency exits should open outward and be lockable only from the outside. It seems that preventing violence in EDs requires a combination of management, technology, planning, and physical design. Proper infrastructure design can play a crucial role in reducing the risk of violence, and healthcare professionals, administrators, and architects should be aware of best practices in ED design. https://fem.tums.ac.ir/index.php/fem/article/view/1164 https://fem.tums.ac.ir/index.php/fem/article/download/1164/437

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 12 31 e14 e14 Shirin Madadian School of Medicine, Tehran University of Medical Sciences, Tehran, Iran Mojgan Rahimi Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Peyman Saberian Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Parisa Hasani-Sharamin Tehran Emergency Medical Service Center, Tehran, Iran Amirhossein Orandi Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Alireza Jalali Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Seyed Khalil Pestechi Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran Sepideh Aarabi Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Mahshid Faghani Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran 2023 04 19 Objective: There are several methods for teaching emergency medical technicians (EMTs) cardiopulmonary resuscitation (CPR); but choosing the most effective option depends on several factors. This study was designed to compare the effectiveness of three different CPR training methods, including traditional, peer, and virtual methods, for EMTs. Methods: This study was a pretest-posttest study, which was performed from March to September 2020 in Tehran, Iran. Participants were EMTs working in the operations department of the EMS center. In the first step, for the pretest evaluation, an Objective Structured Clinical Evaluation (OSCE) exam was held for all participants. Thereafter, the subjects were divided into 3 groups including master-centered traditional collective education, peer training, and virtual courses. Then the participants underwent educational intervention and after that, another OSCE exam was held about 1 week after the sessions to evaluate the effect of interventions. Results: At first, 156 volunteers entered the study and participated in the pretest OSCE exam, of which 125 volunteers participated in the posttest OSCE exam. Of these, 51 volunteers participated in the peer education group, 35 volunteers were in the virtual education group, and 39 volunteers in the classic education group. The mean score of the participants in all 4 assessed skills, including endotracheal intubation, laryngeal mask airway insertion, basic life support, and advanced life support, increased significantly after educational intervention in all 3 groups (p<0.05); and this increase was higher in the virtual group compared to the other two groups (p<0.05). Conclusion: We found that virtual training was more effective than classic and peer training for CPR training of EMTs. https://fem.tums.ac.ir/index.php/fem/article/view/1201 https://fem.tums.ac.ir/index.php/fem/article/download/1201/441

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 04 22 e15 e15 Khalid Almulhim Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia Ali Mobarki College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia Abdulelah Aljasir College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia. Abdullah Almulhim College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia. Ibrahim Almulhim College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia. 2022 12 25 2023 04 20 Objective: This study aims to understand students' skills based on their self-assessment and their perceptions regarding emergency medicine (EM) physicians, EM patients, and choosing EM as a future career. Methods: This study employed prospective observational design. It was conducted from 2 October to 2 November 2022 in Saudi Arabia. The study participants were senior medical students at King Faisal University. Senior students who finished a four-week EM rotation were involved as post-cases, and senior students who had not finished their EM rotation were involved as pre-cases. An online survey was administrated to all students who met out criteria. Results: A total of 161 students were included in the study; 65.2% had not yet done their EM clerkship, while 34.8% had completed their EM clerkship. Among them, 48.4% were male, and 51.6% were female. On average, post-EM clerkship students showed greater confidence in their skills of conducting an initial assessment of a patient (p=0.027), developing a management plan (p=0.007), explaining the principles of EM to others (p<0.001), presenting patient cases formally (p=0.049), interpreting electrocardiogram (p=0.006), and applying medical resuscitation (p=0.041). No significant differences were found between the average confidence in the skills and abilities of male and female students. Post-EM clerkship and male students were more likely to choose EM as a career when compared with pre-EM clerkship (p<0.001) and female students (p=0.006). Conclusion: It seems that, after completing a four-week rotation, students exhibited significant advances in knowledge, illness management, and procedural skills. It is likely that the EM clerkship significantly improved students' perceptions of the EM specialty. https://fem.tums.ac.ir/index.php/fem/article/view/1142 https://fem.tums.ac.ir/index.php/fem/article/download/1142/443

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 04 26 e16 e16 Kiumarth Amini Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran Mojtaba Mojtahedzadeh Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran Atabak Najafi Department of Anaesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Hamidreza Sharifnia Department of Anaesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Aliasghar Tabatabaei Mohammadi Urmia University of Medical Sciences, Urmia, Iran 2022 12 13 2023 01 16 Objective: Sepsis is one of the leading causes of mortality in intensive care unit. Despite advances in its management, its mortality rate remains high. Recently, high dose of vitamin C in sepsis treatment has attracted the attention of researchers. In the current study, the impacts of 25 mg/kg of vitamin C every 6 hours as a bolus for 3 days were assessed in septic patients in intensive care unit (ICU). Methods: This was a prospective cohort study that was performed on adult patients with diagnosis of sepsis. Patients were assigned to control group (administration of placebo) or intervention group, i.e., those receiving a 25 mg/kg dose of vitamin C every 6 hours as a bolus for 3 days. Clinical data were recorded before and after the experiment. Also, plasma levels of antithrombin III, syndecan-1, fibrin degradation product (FDP), D-dimer, and C-reactive protein (CRP) were measured at 0, 24, 48, and 72 hours. Results: In septic patients receiving vitamin C, a significant upregulation of antithrombin III and significant decreases in the levels of syndecan-1 (at 48 hours; P-value=0.046 and at 72 hours; P-value=0.007), D-dimer and CRP were observed compared to the control. Reductions in sequential organ failure assessment (SOFA) score, in-hospital mortality, and ICU length of stay were seen in septic patients receiving vitamin C. Conclusion: Prescribing high dose of intravenous vitamin C can reduce the mortality of sepsis patients and reduce the length of stay in the ICU. https://fem.tums.ac.ir/index.php/fem/article/view/1131 https://fem.tums.ac.ir/index.php/fem/article/download/1131/442

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 7 2 2023 04 27 e17 e17 Alireza Zemestani Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran. Iran Amir Kavousi Department of Epidemiology, School of Public Health and Safety, Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Homayoun Sadeghi-Bazargani Road Traffic Injury Prevention Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Hamid Soori Department of Epidemiology, School of Public Health and Safety, Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2023 01 03 2023 01 22 Objective: Vehicle safety plays a key role in reducing the number of road traffic deaths and serious injuries. This study aims to investigate the effect of vehicle safety on the severity of traffic crashes in Iran using structural equation modeling (SEM). Methods: This was a comparative cross-sectional study of all imported vehicles with Aras free trade zone license plate as well as all domestic vehicles (cars produced in Iran) commuting on Tabriz-Jolfa road. The study population included drivers who had accidents on Tabriz-Jolfa road over a period of one year from September 22, 2020 to September 21, 2021 and were injured or  their vehicles had been damaged (n=652). Data was collected using set of questionnaires with 10 sections. The effect of independent variables, as exogenous latent variables (human, vehicle, and environmental factors), on a dependent variable, as an endogenous latent variable (crash severity) was measured using SEM. All data were analyzed using Mplus 8.0 software. Results: In the structure part of the model with foreign vehicles group, the effect sizes of three exogenous variables, i.e., human, environmental, and vehicle factors, on the dependent variables were found to be 0.412, 0.396 and 0.358, respectively. The effect sizes in the model with domestic vehicles were found to be 0.312, 0.702 and 0.820, respectively. Conclusion: Vehicle factors (variables related to car safety) had a high impact on crash severity in the national license plate and domestically manufactured vehicle group, indicating the necessity of improving vehicle safety. https://fem.tums.ac.ir/index.php/fem/article/view/1150 https://fem.tums.ac.ir/index.php/fem/article/download/1150/444