Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 2 4 2018 07 14 e40 e40 Nur Hafizhah Widyaningtyas Master of Nursing Student, University of Brawijaya, Malang, Indonesia. Retty Ratnawati Lecturer of Faculty of Medicine, University of Brawijaya, Malang, Indonesia. Asti Melani Astari Lecturer of Faculty of Medicine, University of Brawijaya, Malang, Indonesia. 2018 07 07 2018 07 14 About 95% of the two billion airlines passengers suffered from health issues (1). Furthermore, a call center in North Carolina noted that there were 16 in-flight emergency cases for every 1 million airlines passengers (2). Cardiac arrest is one of these cases, which is a cause for mortality for about 1000 people during the flights (3). Cardiopulmonary resuscitation (CPR) can be demonstrated by the medical professionals or trained people such as flight attendants. Commercial flights usually do not have official medical staffs on board. Hence, whenever there are in-flight medical emergency cases, flight attendants should be trained to manage such cases. Flight attendants themselves are laymen who are trained to do basic medical emergency interventions, that is, even if they intervene in such cases, they cannot take an appropriate decision as the medical professionals. During in-flight cardiac arrest, the flight attendants are mainly responsible to immediately contact the ground staff and voluntary medical professionals on board; besides, they also have a right to perform CPR (4). Certain airlines such as Air Canada and Scandinavian Airlines have policies related to medical supervision. They apply emergency telemedicine that involves emergency specialists as the commander (5). Furthermore, the specialists will assign some instructions for the flight attendants who manage the in-flight medical emergencies (5). In contrast, in Indonesia, in case of any in-flight medical emergency, the flight attendants would announce on call asking for the presence of any medical professionals on board; however, no official medical professionals are recruited on board by the airlines for any medical casualties or emergency. Attendant expressed that the rescuer had many senses while helping people with in-flight medical emergency like shocked while looking at the victim. Contrary, the rescuer also determined to take her responsibility as a cabin crew by helping the victim. Furthermore, she had to manage her dilemma before doing that. The flight attendant has already expressed her suggestion on having in-flight medical professionals so that she can focus on her responsibility as a cabin crew. NBAA (2016) declares that commercial airlines are suggested to make policies that involve medical professionals in managing in-flight medical emergency (6). These will make flight attendants feel comfortable in serving the passengers. Consequently, the flight attendant needs medical companionship while performing CPR on board. Hence, in-flight medical emergency management, which is part of prehospital management, can be guaranteed https://fem.tums.ac.ir/index.php/fem/article/view/96 https://fem.tums.ac.ir/index.php/fem/article/download/96/79

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 2 4 2018 07 15 e41 e41 EN Ozlem Karagun Department of Emergency Medicine, School of Medicine, Baskent University, Adana, Turkey Hasan Yesilagac Department of Emergency Medicine, School of Medicine, Baskent University, Adana, Turkey Betul Gulalp Department of Emergency Medicine, School of Medicine, Baskent University, Adana, Turkey Yuksel Gokel Department of Emergency Medicine, School Of Medicine, Cukurova University, Adana, Turkey 2018 06 28 2018 07 15 Introduction: In recent years, patients' satisfaction with emergency medical services provided to them has been one of the main criteria in the evaluation of the quality of these services. Objective: The goal of our study was to determine the factors that affect the satisfaction of patients admitted to the emergency department (ED) and to provide new regulations. Method: This prospective and descriptive study included 341 patients who utilized the ED services of a university hospital between October 1, 2004, and June 30, 2005. The patients' demographic and visit characteristics, waiting times, and the total duration of stay in the ED were noted in the prepared questionnaire. In addition, all patients were asked to indicate their level of satisfaction with the care received in the ED based on a five-point Likert scale. The results were analyzed using ANOVA, chi-square, and logistic regression tests. Results: Of the 341 patients, 219 (64.2%) were satisfied with the care they had received in the ED. Factors such as doctor and nurse behavior, medical information, the frequency of doctors and nurses visits, the ease of access to personnel, the cleanliness of the ED, and the availability of technical equipment had a statistically significant effect on the overall satisfaction of the patients (p < 0.05). Conclusion: The quality of patient care provided and the features of the ED determine the patients’ satisfaction with the ED services. https://fem.tums.ac.ir/index.php/fem/article/view/94 https://fem.tums.ac.ir/index.php/fem/article/download/94/80

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 2 4 2018 10 01 e42 e42 Farhad Heydari Emergency Medicine Research Center, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. Nasim Golestani Department of Emergency Medicine, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran Mehrdad Esmailian Emergency Medicine Research Center, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. 2018 07 25 Introduction: A clinical practice guideline (CPG) is developed with the aim of improving the quality of health care and reducing unnecessary interventions, hospitalization time, and related costs. Objective: This study attempted to design a standard protocol for gastrointestinal bleeding (GIB) patients. Method: This was a cross-sectional study conducted during 2013 and 2014 in an educational medical center in Isfahan, Iran. A checklist containing questions about waiting time for the services, hospitalization time, and costs was completed for the GIB patients. After this primary data gathering, a CPG was designed, codified, underwent several revisions, and finally implemented. Thereafter, the checklist was completed by GIB patients and compared with the previous ones. Result: Fifty patients in each of the two phases were included. The mean age and sex of the studied patients were not different. The time from emergency departments (ED) arrival until the first visit (14 ± 9.8 Vs. 19.4 ± 13.4 minutes; p = 0.03), hospitalization (73.7 ± 49.2 Vs. 116.2 ± 7.2 hours; p=0.003) and costs (1.3 ± 0.81 Vs. 3.68 ± 3.51 million rials; p < 0.001) were significantly reduced following the CPG implementation. The time from admission until conducting endoscopy was not different in the two study periods (16.5 ± 7.8 Vs. 23.9 ± 24.5 hours, p = 0.89). Conclusion: The implementation of the CPG for the management of GIB patients in the ED resulted in a reduction in the waiting time for the services and, further, reduction of hospitalization time and related costs. https://fem.tums.ac.ir/index.php/fem/article/view/97 https://fem.tums.ac.ir/index.php/fem/article/download/97/81

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 2 4 2018 09 02 e43 e43 Sahar Mirbaha Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Amin Saberinia Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Sepide Ghesmati School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Mohammadmehdi Forouzanfar Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2018 09 02 2018 09 02 Introduction: Epidemiologic evaluation generally starts with recording the raw data regarding mortality, and healthcare managers should have a national plan executed for this purpose. Objective: The present study was planned and performed with the aim of epidemiologically evaluating mortality cases among patients admitted to the emergency department (ED) of a major hospital in Tehran, Iran in order to plan and provide proper equipment for decreasing the mortality of patients. Method: This cross-sectional study was performed in Shohadaye Tajrish Hospital, Tehran, Iran. All cases of mortality, recorded in the ED of the studied hospital from 20 March 2016 until 21 June 2016, were included in the study. A checklist was prepared for gathering data and the clinical profiles of all the considered patients were reviewed. Using this checklist, demographic data, chief complaint, history of underlying disease, pathologic findings of imaging modalities, and cause of death were extracted from the patients’ profiles. Result: Over the mentioned period of time, in total, the data of 8420 admissions to the ED were recorded. Out of these patients, 76 (0.9%) had died, the mean age of whom was 67.66 ± 21.40 years. Based on these findings, among patients who had presented to the ED, 42.1% died due to the complications of heart attack and 13.2% died from complications caused by cancer. Conclusion: Based on the findings of the present study, cardiovascular complications were the most leading cause of mortality in the studied ED and complications resulting from malignancy were in the second place. Trauma and accidents leading to intracranial hemorrhage were in the next places. https://fem.tums.ac.ir/index.php/fem/article/view/105 https://fem.tums.ac.ir/index.php/fem/article/download/105/86

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 2 4 2018 09 04 e44 e44 Mani Mofidi Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran. Roghayeh Rouhi Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran. Babak Mahshidfar Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran. Saeed Abbasi Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran. Peyman Hafezimoghadam Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran. Mahdi Rezai Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran. Davood Farsi Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran. 2018 08 17 2018 08 30 Introduction: Painful surgical procedures require adequate sedation and analgesia. A vast array of medications can be used for Procedural Sedation and Analgesia (PSA) in Emergency Departments (EDs). Objective: The present study was conducted to compare Propofol-Ketamine (PK) and Propofol-Fentanyl (PF) compounds in patients undergoing closed reduction in EDs. Methods: This randomized, double-blind, clinical trial was conducted on 110 consecutive patients who required sedation for closed reduction. The patients were randomly divided into two groups of equal sizes. The PK group received an intravenous bolus of 1 mg/kg of propofol plus 0.5 mg/kg of ketamine, and the PF group received an intravenous bolus of 1 mg/kg of propofol plus 1 µg/kg of fentanyl. The analgesic effect and success rate were the primary outcomes under study. Results: The PK group achieved more effective analgesia at the end of the experiment. The success rate was almost the same in both groups Shivering (p=0.005) and a drop in oxygen saturation to below 92% (p=0.048) were two side effects that were more prevalent in the FK group . The mean recovery time was significantly shorter in the PK group (p<0.001). The patients in the PK group were more satisfied. Conclusion: In comparison with the PF compound, the use of KP leads to better pain relief and greater patient satisfaction and shorter sedation time in PSA. https://fem.tums.ac.ir/index.php/fem/article/view/102 https://fem.tums.ac.ir/index.php/fem/article/download/102/85

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 2 4 2018 06 24 e45 e45 Ali Abdolrazaghnejad Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Mohsen Banaie Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Nader Tavakoli Trauma and Injury research center, Iran university of medical sciences, Tehran, Iran. Mohammad Safdari Department of Neurosurgery, Khatam-Al-Anbia Hospital, Zahedan University of Medical Sciences, Zahedan, Iran Ali Rajabpour-Sanati Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran 2018 06 24 Context: The aim of this review is to recognizing different methods of analgesia for emergency medicine physicians (EMPs) allows them to have various pain relief methods to reduce pain and to be able to use it according to the patient’s condition and to improve the quality of their services. Evidence acquisition: In this review article, the search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane for emergency pain management methods were reviewed. Among the findings, high quality articles were eventually selected from 2000 to 2018, and after reviewing them, we have conducted a comprehensive comparison of the usual methods of pain control in the emergency department (ED).  Results: For better understanding, the results are reported in to separate subheadings including “Parenteral agents” and “Regional blocks”. Non-opioids analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of acute pain. However, the relief of acute moderate to severe pain usually requires opioid agents. Considering the side effects of systemic drugs and the restrictions on the use of analgesics, especially opioids, regional blocks of pain as part of a multimodal analgesic strategy can be helpful. Conclusion: This study was designed to investigate and identify the disadvantages and advantages of using each drug to be able to make the right choices in different clinical situations for patients while paying attention to the limitations of the use of these analgesic drugs. https://fem.tums.ac.ir/index.php/fem/article/view/93 https://fem.tums.ac.ir/index.php/fem/article/download/93/78

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 2 4 2018 04 21 e46 e46 Suha Aloosi Department of Oral and Maxillofacial Surgery,found to be 22.59±7.32 in the case group and 21.97±8.16 in the controls (P>0.05). Conclusion: According to the obtained results, platelet indices do not increase in PTE. They cannot be therefore used to diagnose PTE in suspected patients. https://fem.tums.ac.ir/index.php/fem/article/view/137 https://fem.tums.ac.ir/index.php/fem/article/download/137/172

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 05 22 e28 e28 Nicholas Gallagher Department of Emergency Medicine, Arnot Ogden Medical Center, Elmira, New York, USA Frank Edwards Department of Emergency Medicine, Arnot Ogden Medical Center, Elmira, New York, USA 2019 05 15 2019 05 16 Context: This review discusses the range of clinical presentations seen with poisonings by the major toxic alcohols--methanol, ethylene glycol, and isopropyl alcohol. It outlines a straightforward diagnostic strategy and discusses in detail the current treatment recommendations. Evidence acquisition: The authors conducted a literature search of primary and secondary sources related to the topic. For treatment recommendations, search restrictions included articles published between 2008 and 2019. For background information, search restrictions included articles written from 1990 – present. Results: This review discusses in detail how the diagnosis can be made via clinical signs, symptoms, and laboratory values as well as the most recent treatment recommendations. This paper will also discuss the limitations of the emergency department workup and how the absence of particular laboratory findings does not necessarily rule out the diagnosis. Conclusion: Poisoning with methanol, ethylene glycol, and isopropanol present diagnostic and therapeutic challenges to emergency physicians. Toxic alcohol poisonings lead to an elevated osmolar gap and, with the exception of Isopropanol, a metabolic acidosis. In order for the timely initiation of life-saving treatment, emergency physicians need a solid understanding of the pathophysiology, clinical presentation, laboratory workup, and treatment. Laboratory assays for these compounds are send-out tests in most hospitals and are therefore of no value in the acute clinical setting. https://fem.tums.ac.ir/index.php/fem/article/view/153 https://fem.tums.ac.ir/index.php/fem/article/download/153/179

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 04 06 e29 e29 Mohammad Reza Mashhadi Department of Health, Rescue and Treatment of IR Iran Police Force, Applied Research Center, Tehran, Iran Mostafa Shahabinejad Department of Health, Rescue and Treatment of IR Iran Police Force, Applied Research Center, Tehran, Iran 2019 02 20 2019 03 22 Introduction: Unintentionally retained foreign bodies (RFBs) can be accompanied with acute reactions such as inflammatory responses, infections and abscesses within a few days or weeks after surgery with adverse consequences for patients and surgeons. Case Report: An 84-year-old woman was admitted to hospital with weakness, lethargy and infectious secretions of the umbilicus. The patient had undergone hysterectomy 21 years before. Clinical examinations and accurate umbilicus explorations found a 0.5-mm fibrin and smelly umbilical secretions. Dragging found the fibrin to be a surgical gauze thread. The patient was therefore identified as a candidate for laparotomy, which revealed a long gauze attached to a band and a metal ring in the umbilicus and hypogastric regions as well as a large abscess containing 200 ml of infectious secretions, severe adhesions of the intestines to each other and to the abdominal wall, a 10×10 cm cavity and an approximately 1-cm fistula or laceration in the Ileum due to the foreign body (long gauze). The patient was discharged from the hospital in good health conditions after the final surgery. Conclusion: Given the possibility of leaving foreign bodies in the surgery site, surgical teams are required to precisely control surgical instruments after surgery. https://fem.tums.ac.ir/index.php/fem/article/view/139 https://fem.tums.ac.ir/index.php/fem/article/download/139/170

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 06 09 e30 e30 Marco Nastasi Division of Cardiology, University of Catania, Catania, Italy 2019 05 17 2019 05 29 Introduction: We describe a patient without a history of cardiovascular diseases as an example of Wellens’ syndrome (WS). Case Report: A 65-year-old man presented to emergency department due to intermittent chest pain. Physical examination and chest x-ray were unremarkable. Electrocardiogram (ECG) showed biphasic T-wave in precordial leads V1-V4. Primary cardiac serum biomarkers including high-sensitive cardiac troponin T (hs-cTnT) and CK-MB were slightly elevated, that further assessment did not show any increases; while ECG recorded during a pain period revealed T-wave pseudo-normalization. The patient underwent coronary angiography that revealed a proximal left anterior descending artery lesion. Conclusion: WS is a diagnostic and management challenge and serial ECG evaluation is still essential for a possible acute coronary syndrome. Having knowledge of all subtle features of this syndrome, could avoid improper discharge of high-risk patients. Definitely, accurate risk stratification, and prompting these patients to an early coronary angiogram and treatment are mandatory to avoid development of a massive anterior myocardial infarction. https://fem.tums.ac.ir/index.php/fem/article/view/155 https://fem.tums.ac.ir/index.php/fem/article/download/155/187

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 05 25 e31 e31 Somayeh Karimi Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Sepideh Babaniamansour School of Medicine, Islamic Azad University of Medical Sciences, Tehran, Iran Ehsan Aliniagerdroudbari School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2019 05 22 2019 05 25 A 34-year-old pregnant woman was referred to our emergency ward, complaining of intensification of skin lesions which had started six days earlier. Initially, vesicular lesions had started from head and face accompanied by fever which turn to generalized pustular lesions expanded to the whole body within four days (figure 1). By investigating the patient's personal contact history, we found that same symptoms were detected in her 9-year-old child 19 days prior to admission which was diagnosed as chickenpox. The patient also had mentioned previous history of chicken pox infection at her age of seven. She was ill but not toxic and was conscious with a blood pressure of 98/59 mmHg, respiratory rate of 18 breaths per minute, heart rate of 100 beats per minute and oral temperature of 37.2 °C in physical examination. She didn't have respiratory distress, dyspnea, meningism symptoms (Kernig Sign, Brudzinksi, and Nuchal Rigidity), ataxia or sensory defect and her all other physical examinations were normal. Upon diagnosis of chickenpox, intravenous (IV) acyclovir 750 mg three times a day and also IV clindamycin 900 mg TDS in combination with IV fluid were administered and finally the patient was admitted in Infectious diseases ward. https://fem.tums.ac.ir/index.php/fem/article/view/163 https://fem.tums.ac.ir/index.php/fem/article/download/163/180

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 04 27 e32 e32 Mehran Sotoodehnia Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Atefeh Abdollahi Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Maryam Khodayar Imam Hossein Center for Education, Research and Treatment, Shahroud University of Medical Sciences, Shahroud, Iran 2019 04 27 An 85-year-old female patient was brought to emergency department (ED) from a nursing home with altered mental status (GCS: 12/15) and hypotension (90/60 mmHg). Bilateral fine crackles in lungs and severe cachexia were obvious in her physical examination. The ECG showed only sinus tachycardia. Several attempts at peripheral vein cannulation failed due to poor visualization of severely atrophied and contracted subcutaneous veins. Therefore, on two attempts, a central venous catheter (CVC) was inserted into the right internal jugular vein (IJV) using the Seldinger technique. After securing and taping the central line, fluid infusion started with no difficulty and a portable chest x-ray was ordered. https://fem.tums.ac.ir/index.php/fem/article/view/144 https://fem.tums.ac.ir/index.php/fem/article/download/144/173

Tehran University of Medical Sciences Frontiers in Emergency Medicine 2717-3593 3 3 2019 05 19 e33 e33