farhad heydari ∗

Hospitals play a vital role in disaster management and their function must be maintained during crises. Isfahan province is susceptible to major crises and disasters at any time of the year. The study aimed to investigate the hospital safety index (HSI) in hospitals in Isfahan province. 

This cross-sectional study was conducted using the HSI questionnaire of the world health organization. The safety of all 55 hospitals in Isfahan province was evaluated with the Persian version of the questionnaire from 2017 to 2022. In this study, all hospitals were evaluated by a group of experts from the emergency operations center (EOC) of Isfahan University of Medical Sciences, and the checklists were completed with the cooperation of the hospital disaster committee, visiting the hospitals, and interviewing the personnel. 

The safety level of hospitals has improved from 2017 to 2022 so in 2022, 38 hospitals (69.09%) had a high safety level, and 17 hospitals (30.91%) had a medium safety level. This increase in safety has happened in all three components of safety (functional, non-structural, and structural safety). There was no significant difference in the overall hospital safety score between academic-educational, non-academic governmental, social security and military, and private and charity hospitals (P<0.05). 

Although the safety in the hospitals of Isfahan province has improved due to the continuous disaster prevention and preparedness activities, hospitals still need to improve to achieve higher levels of safety. The HSI shows how well a hospital can maintain its organization and performance during disasters. This index will be useful for decision-making and policy-making to prioritize administrative and civil interventions.

Recently, high-flow nasal cannula (HFNC) oxygen therapy has been implicated in the treatment of patients with acute respiratory failure. In this study, the effect of this treatment on COVID-19 patients was investigated. This was a prospective, randomized, single-blind clinical trial on patients with COVID-19 referred to the emergency department. COVID-19 patients who had peripheral oxygen saturation (SpO2) ≤90% despite receiving nasal oxygen (up to 6 L/min) were included in the study and randomized to HFNC or conventional oxygen therapy (COT). Then the patients were compared in terms of vital signs, SpO2, need for endotracheal intubation, and need for intensive care unit admission. The sample size was calculated at 35 patients in each group. Variables were compared using the chi-square test, Student’s t-test, or the Mann-Whitney U test. 87 patients with a mean age of 65.3±14.8 (62.1% male) were included. The two groups were similar in terms of age, sex, time interval from onset to diagnosis, and underlying diseases (hypertension, diabetes, coronary artery disease, etc.) (P<0.05). No statistically significant difference was reported between SpO2 and PaO2/FiO2 vital signs at the beginning of treatment between the two groups. One hour after treatment, respiratory rate, SpO2, and PaO2/FiO2 were better in the HFNC group compared to the COT group (P<0.05). Also, there was no significant difference between the two groups in terms of the need for endotracheal intubation, the need for ICU admission, and in-hospital mortality. Early use of HFNC oxygen therapy in patients with COVID-19 can improve SpO2, respiratory rate, and PaO2/FiO2 levels. Therefore, it has high clinical value.

Recognizing and determining severe trauma is essential for choosing the appropriate treatment strategy. The aim of this study was to find the predictive value of the quick sequential organ failure assessment (qSOFA) score for in-hospital mortality in adult trauma patients. This prospective observational study was conducted on adult patients with multiple trauma presenting to the emergency department. The qSOFA score was calculated according to the initially recorded variables. The primary outcome was in-hospital mortality. The predictive value of qSOFA was evaluated using the Area Under Receiver Operating Characteristic (AUC) analysis. Finally, 775 multiple trauma patients with a mean age of 38.68±18.74 were admitted. Of these, 34 people (4.39%) died and 741 subjects were discharged from hospital. The mean qSOFA score was 0.41±0.64, significantly higher in the survived patients than in the non-survived patients (P < 0.001). The AUC of qSOFA score to predict in-hospital mortality was 0.878 (95% confidence interval: 0.853-0.900); thus, qSOFA was a good predictor of in-hospital mortality in multiple trauma patients. The qSOFA score can be considered a simple and rapid screening tool for identifying multiple-trauma patients.

COVID-19 disease began to spread all around the world in December 2019 until now; and in the early stage it may be related to high D-dimer level that indicates coagulation pathways and thrombosis activation that can be affected by some underlying diseases including diabetes, stroke, cancer, and pregnancy and it also can be associated with Chronic obstructive pulmonary disease (COPD). The aim of this article was to analyze D-dimer levels in COVID-19 patients, as D-dimer level is one of the measures to detect the severity and outcomes of COVID-19. According to the results of this study, there is a higher level of D-dimer as well as concentrations of fibrinogen in the disease onset and it seems that the poor prognosis is linked to a 3 to 4-fold increase in D-dimer levels. It is also shown that 76% of the patients with ≥1 D-dimer measurement, had elevated D-dimer and were more likely to have critical illness than those with normal D-dimer. There was an increase in the rates of adverse outcomes with higher D-dimer of more than 2000 ng/mL and it is associated with the highest risk of death at 47%, thrombotic event at 37.8%, and critical illness at 66%. It also found that diabetes and COPD had the strongest association with death in COVID-19. So, it is necessary to measure the D-dimer levels and parameters of coagulation from the beginning as well as pay attention to comorbidities that can help control and management of COVID-19 disease.

Endotracheal intubation is the basic method of providing a safe cross‑sectional airway area and the incorrect placement can be dangerous and causes complications. So this study aimed to access the diagnostic value of color Doppler epigastric ultrasound and linear probe suprasternal notch ultrasound in comparison with standard capnography in confirmation of endotracheal tube (ETT) placement after intubation.

This diagnostic value study was conducted on 104 patients requiring intubation who were referred to the Emergency Department. After the intubation, color Doppler epigastric ultrasound and suprasternal notch ultrasound as well as the standard capnography were used to confirm the placement ETT.

The sensitivity and specificity of color Doppler epigastric ultrasound were 97.96% and 100%, for suprasternal notch ultrasound were 98.98% and 66.67%, and for combination of the both methods were 96.94% and 100% respectively that showed the significant diagnostic value in the confirmation of ETT placement (P < 0.001). The mean of elapsed time to confirm the ETT placement by the standard capnography method (17.95 ± 2.45 s) was significantly more than the two methods of epigastric ultrasound (10.38 ± 4.65 s) and suprasternal notch ultrasound (5.08 ± 4.45 s) as well as the combined method with the mean of 15.46 ± 8.31 s (P < 0.001).

The results of this study showed that although ultrasound is a potentially accurate, fast, and reliable method to confirm the endotracheal tube placement, but suprasternal notch ultrasound is considered to be a more appropriate diagnostic technique due to its higher sensitivity and less detection time compared to epigastric ultrasound and combined method.

Traumatic brain injury (TBI) is one of the major health and socioeconomic problems in the world. How clinicopathological features of TBI differ by age is unclear. The present study evaluated the epidemiology of TBI and identified any variable that differs among pediatric, middle‑aged, and elderly patients.

The descriptive cross‑sectional study was conducted on patients with TBI from April 2019 to April 2021. The study population consisted of all patients with TBI who were admitted to the Emergency Department. The inclusion criteria were all TBI patients who were a candidate for head computed tomography (CT) scans. The patients’ clinicopathological parameters were recorded.

Among 3513 patients with TBI who underwent CT scans, 212 patients died (6.0%). The mean age of subjects was 30.67 ± 19.42, and 69.2% of the patients (2430 cases) were male. Motor vehicle accidents (48.4%) were the most prevalent mechanisms of injury. Intracranial lesions were seen on the head CT scan in 509 (14.5%) patients. The highest mortality rate was shown in elderly patients and the lowest in children (P < 0.001). Falls were the most common mechanism of injury in the elderly subjects (65.2%), while motor vehicle accidents were the most common in the children and middle‑aged groups (40.9% and 54.0%). The incidence of intracranial lesions and moderate‑to‑severe head injuries was significantly higher in the elderly subjects (P < 0.001). Subdural hematoma and subarachnoid hemorrhage were the most common CT findings in elderly patients (13.3% and 11.3%). Brain contusion and skull fracture were the most common findings in the children (6.0% and 4.3%).

The present study found that the clinicopathological parameters were significantly different among children, middle‑aged patients, and elderly patients.

Traumatic injuries have become a health problem worldwide, especially in low‑ to middle‑income countries. Therefore, this study was conducted to identify predicting factors of death in adult severe multiple trauma patients.

This retrospective cross‑sectional study was performed on 1397 adult multiple trauma patients referred to the emergency department(ED) of Poursina Hospital between June 2019 and August 2021. The demographic characteristics, on admission clinical parameters, laboratory tests, the need for packed red blood cell transfusion, and the need for endotracheal intubation were recorded. The revised trauma score (RTS) was calculated according to the physiological variables collected on admission to ED. The primary outcome was 1‑day mortality after admission.

The mean age of subjects was 37.12 ± 13.61 (18–60) years, and 1250 (89.5%) subjects were male. The 1‑day mortality was 339 patients (24.3%). Initial RTS score and the mean Glasgow coma scale (GCS) scores were significantly higher in the survived group than in the nonsurvived group (6.6 ± 1.2 vs. 4.9 ± 1.0, 10.2 ± 3.7 vs. 4.9 ± 2.4, P < 0.001). The multivariate analysis resulted in low GCS (odds ratio [OR] = 1.527, 95%CI 1.434–1625, P < 0.001), low O2 saturation (OR = 1.023, 95%CI 1.003–1.043, P = 0.022), and need for intubation in the ED (OR = 0.696, 95%CI 0.488–0.993, P = 0.046) as predictors of 1‑day mortality. The area under the curves receiver operating characteristics of RTS and GCS scores to predict mortality were 0.853 (95% CI: 0.831–0.874) and 0.866 (95% CI: 0.846–0.887), respectively.

Multiple factors associated with 1‑day mortality were reduced GCS score, decreased oxygen saturation, and need for intubation in the ED. The RTS and GCS scores are good predictors of mortality survival in multiple trauma patients.

In addition to heart disease, ECG also changes in non-heart disease, which due to its similarity, can lead to misdiagnosis of heart disease in patients. ECG changes in brain lesions such as ischemic and hemorrhagic strokes, brain traumas, etc. and have been studied in many articles, but the effects of brain midline shift on ECG changes have not been studied. In this study, we want to examine these changes.

This is a prospective cross-sectional descriptive study. Patients with brain tumors who were referred to Al-Zahra and Kashani hospitals in Isfahan from April 2019 to March 2021 were selected. Patients with a history of heart disease, patients receiving medications that cause ECG changes, patients with ECG changes due to non-cardiac and cerebral causes, and individuals under 15 years of age were not included in the study. Patients whose ECG changes were due to electrolyte disturbances or acute heart problems were also excluded from the study. After obtaining informed consent from patients, a CT scan or brain MRI was taken and patients were divided into two groups with and without midline shift. Then the ECG was taken and ECG changes (T wave, ST segment, QTc Interval, QRS prolongation) were compared in two groups of brain tumors with and without midline shift.

136 patients were included in the study. Of these, 69 patients were in the without midline shift group and 67 patients were in the midline shift group. In the midline shift group, 3% of patients had ST segment changes and 23.9% had T wave changes, which were 1.4% and 10.1% in the without midline shift group, respectively. The mean QTc Interval in the two groups without and with midline shift was 338.26 (4 28.438) and 388.66 (37.855), respectively, and the mean QRS in the without midline shift group was 86.09 (88.9.88) ms and in the midline shift group was 94.63 (±12.83) ms.

Brain midline shifts can cause QRS widening, QTc interval prolongation, and T-wave changes in patients' ECGs.

Acute kidney injury (AKI) is an independent risk factor in critically ill patients. This study aimed to evaluate the prevalence of AKI in resuscitated cardiac arrest (CA) patients, its potential risk factors, and outcomes of AKI in cardiac arrest survivors. 

A hundred and forty-nine cases of post-CA that survived for at least 24 hours, were admitted to three hospitals between 2016 and 2020, were studied. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss, and End-stage) criteria. Baseline demographic data, resuscitation variables, the prevalence of AKI, in-hospital and six-month mortality were collected. Logistic regression evaluated the factors associated with AKI occurrence and mortality. 

AKI occurred in 59 (39.6%) of the patients. Of these, nine patients (15.3%) required renal replacement therapy (RRT) during their hospital stay. There were 47 (52.2%) in-hospital mortality in patients without AKI and 41 (69.5%) in patients with AKI (P=0.036). Post-CA AKI was significantly associated with six-month mortality (OR 1.65 [1.39-2.88]; p = 0.029). Older age, the higher cumulative dosage of epinephrine during cardiopulmonary resuscitation, post-CA shock, in-hospital CA, PEA/asystole rhythm, longer duration of cardiac arrest, as well as higher admission creatinine and lactate levels were independently associated with AKI, in contrast, higher admission Base Excess level was negatively associated with AKI. 

AKI occurred in nearly 40% of CA patients. AKI was associated with a higher in-hospital and six-month mortality rates.

Previous studies have shown that several factors affect the outcome of cardiopulmonary resuscitation. In this study, we have evaluated the factors associated with the outcome of resuscitation in in-hospital cardiopulmonary arrest patients (IHCA) 002E.

This cross-sectional non-probability study was performed on patients with in-hospital cardiopulmonary arrest between 2015 and 2020 in the emergency department (ED) of Al-Zahra Hospital, Isfahan, Iran. Data were then collected from medical records to describe patient characteristics, arrest profile, and survival details. Factors associated with the dependent variable were examined Logistic regression.

Among 848 in-hospital cardiopulmonary arrests, 18 patients (2.1%) survived and were discharged from the hospital. The mean age of patients was 62.74±21.17 years, 583 (68.8%) were male, and 265 (31.2%) were female. The mean age of patients with successful resuscitation and those with unsuccessful resuscitation was 62.33±21.79 (6 to 116 years) and 61.58±21.20 (1 month to 108 years) years, respectively. The rate of unsuccessful resuscitation increased with increasing age (P=0.04). Also, the rate of unsuccessful resuscitation increased if there was an underlying disease (P=0.01). In frequency analysis of resuscitation services, emergency medicine with 633 (57.3%) resuscitation is in the first place in the number of resuscitations, of which 22.9% of them have been successful (ROSC). In the anesthesia service, of 2 resuscitations performed, both were successful. In the general surgery service, 36.5% of 63 resuscitations were successful, and the success rate for the neurosurgery service was 32.4% of 102 resuscitations. Analyzing the duration of successful and unsuccessful resuscitation has great importance. In successful resuscitation, the average time was 18.98 minutes and in unsuccessful resuscitation was 39.20 minutes. Also, the maximum and minimum time for successful resuscitations was 63 and 1 minutes. The maximum and minimum time for unsuccessful resuscitations was recorded as 60 and 10 minutes.

The results showed that several factors were influential in cardiopulmonary resuscitation. Increasing age and underlying disease reduced the success of cardiopulmonary resuscitation.

The use of point-of-care ultrasonography (POCUS) for identifying medial collateral ligament(MCL) tears has increased in recent years. This study aimed to evaluate the diagnostic accuracy of POCUS inthe diagnosis of acute MCL tears of the knee.

This prospective cross-sectional study was performedon patients with suspected MCL tear of the knee in the emergency department (ED). After history taking andprimary physical examination, radiographic imaging of the knee was done. If there was no fracture in the kneeX-ray, the POCUS examination was done. All of the patients were asked to refer to an orthopedic clinic, 7-10 daysafter discharge from ED, for Magnetic Resonance Imaging (MRI) evaluation. The second POCUS was done in theorthopedic clinic. Finally, the findings of POCUS and MRI were compared in diagnosing MCL injury.

Two hundred and fifty patients with a mean age of 25.05 ± 9.12 years were analyzed (86.8% male). Accordingto the MRI findings, as the gold standard, 55(22.0%) patients had MCL injury. The sensitivity, specificity, pos-itive and negative predictive values (PPV and NPV ), and accuracy of ultrasound in detection of MCL injury, incomparison with MRI were 83.64 (95% CI, 71.20 to 92.23), 94.36% (95% CI, 90.13 to 97.15), 80.70% (95% CI, 69.95to 88.25), 95.34% (95% CI, 91.83 to 97.38), and 92.00% (95% CI, 87.92 to 95.05), respectively. The area under thereceiver operating characteristic (ROC) curve of POCUS was 0.890 (95% CI, 0.844 to 0.926).

It seemsthat POCUS can be applied in screening patients with MCL tears following blunt knee trauma.

Seizure and syncope have similar clinical symptoms but different etiologies. Hence, differential diagnosis is crucial prior to intervention. This study evaluates the diagnostic importance of neuron specific enolase (NSE), creatine phosphokinase (CPK), and serum lactate dehydrogenase (LDH) for admitting patients with seizure medical history to emergency department (ED) in order for differential diagnosis between syncope and seizure.

Patients with a short‑lasting loss of consciousness admitted to the ED were recruited. All patients with a short‑lasting loss of consciousness were eligible and EEG was conducted several times and was taken over a long period. Patients were then divided into two groups of seizure and syncope. The biochemical markers levels of all the eligible patients were measured by a reputable laboratory.

In order to define specificity and sensitivity of different levels of biomarkers and the optimal cut‑off points, ROC curves for each biomarker of syncope and seizure patients admitted to ED were performed. AUC for NSE, CPK, and LDH were 0.973 ± 0.023, 0.827 ± 0.047, and 0.836 ± 0.043 respectively in 95% confidence level. Cut‑off points for NSE, CPK, and LDH were determined 25.12, 218.09, and 193.88 respectively.

It was concluded that NSE, CPK and LDH levels were different significantly in seizure patients compared to syncope ones. The seizure group showed an increase in NSE, CPK and LDH level. Determining biomarkers level for differential diagnosis of seizure and syncope can be applied as a supplementary test in addition to tests like EEG.

Physiological scoring systems could potentially aid emergency department (ED) trauma triage, and allowed clinicians to focus on treating the most severe patients first. This study aims to compare Modified Early Warning Score (MEWS), Worthing Physiological Scoring System (WPSS), National Early Warning Score (NEWS), and Rapid Emergency Medicine Score (REMS) in predicting inhospital mortality for multiple trauma patients.

This prospective descriptive study was performed on adult multiple trauma patients referred to the ED of Al-Zahra and Kashani hospitals, Isfahan, Iran during 2019-2020. The primary outcome was inhospital mortality. Receiver operating characteristic (ROC) curve analysis was used to evaluate and compare the performances of four scores.

Of the 771 patients included in this study, 738 patients (95.7%) survived after 24 h of admission. The mean age of patients was 38.66 ± 18.67 years, and the majority of patients were male (79.1%). To predict inhospital mortality, the area under the ROC curve (AUC) of REMS, MEWS, NEWS, WPSS, and Injury Severity Score (ISS) were 0.944, 0.889, 0.768, 0.754, and 0.869, respectively. Results showed that REMS was more successful than other scores in predicting in-hospital mortality for multiple trauma patients. AUC of REMS was significantly better than NEWS, WPSS, and ISS in predicting inhospital mortality.

The findings of this study reveal that REMS is an excellent predictor of in-hospital mortality and MEWS, NEWS, WPSS, and ISS are good predictors of in-hospital mortality.

 Healthcare workers (HCWs) are among the highest groups impacted by the COVID-19 pandemic. This study aimed to analyze professional quality of life (ProQOL) and its association with emotional well-being in HCWs during the pandemic. 

 This cross-sectional study was conducted on HCWs being in close contact with COVID-19 patients in Iran. The questionnaires assessing ProQOL, emotional well-being, and demographic and occupational characteristics were recruited via email or social media. The ProQOL was used to measure compassion fatigue (CF), burnout (BO) and compassion satisfaction (CS). 

 Among the respondents, 705 HCWs were enrolled, including a higher proportion of physicians 449 (63.7%), females 452 (64.1%), and married 486 (68.9%). The mean of participants’ work experience was 8.41 ± 8.91 years. Almost all of HCWs showed moderate to high levels of CS (98.3%). Also, most of HCWs showed a moderate level of CF (96.3%), and the majority of them (76.6%) had a moderate level of BO. There were significant differences in the duration of contact with COVID-19 patients for all three components of ProQOL and emotional well-being score. Women had a higher level of BO than men (P=0.003). CS was significantly higher in married HCWs than in singles (P=0.007). Pearson correlation coefficient showed that CS had a negative relationship with CF and BO. However, there was a direct correlation between emotional well-being and the CS. 

 During the COVID-19 pandemic, Iranian HCWs showed to have moderate to high levels of CS, and a moderate level of both CF and BO, and showed that emotional well-being had a direct correlation with CS.

Ketamine has been a safe and effective sedative agent commonly used for painful pediatric procedures in the emergency department (ED). This study aimed to compare the effect of dexmedetomidine (Dex) and propofol when used as co‑administration with ketamine on recovery agitation in children who underwent procedural sedation.

In this prospective, randomized, and double‑blind clinical trial, 93 children aged between 3 and 17 years with American Society of Anesthesiologists Class I and II undergoing short procedures in the ED were enrolled and assigned into three equal groups to receive either ketadex (Dex 0.7 μg/kg and ketamine 1 mg/kg), ketofol (propofol 0.5 mg/kg and ketamine 0.5 mg/kg), or ketamine alone (ketamine1 mg/kg) intravenously. Incidence and severity of recovery agitation were evaluated using the Richmond Agitation‑Sedation Scale and compared between the groups.

There was no statistically significant difference between the three groups with respect to age, gender, and weight (P > 0.05). The incidence of recovery agitation was 3.2% in the ketadex group, 22.6% in the ketofol group, and 22.6% in the ketamine group (P = 0.002, children undergoing short procedures were recruited). There was a less unpleasant recovery reaction (hallucination, crying, and nightmares) in the ketadex group compared with the ketofol and ketamine groups (P < 0.05). There was no difference in the incidence of oxygen desaturation between the groups (P = 0.30).

The co‑administering of Dex to ketamine could significantly reduce the incidence and severity of recovery agitation in children sedated in the ED.

Stroke is one of the most common debilitating diseases. Although effective treatment is available, a golden time has been defined in this regard. Therefore, prompt action is needed to identify patients with stroke as soon as possible, even in the pre-hospital stage. In recent years, several clinical scales have been introduced for this purpose. We performed the present study to examine the accuracy of eight clinical scales in terms of stroke diagnosis.

This multicenter diagnostic accuracy study was conducted in 2019. All patients older than 18 years who were admitted to the emergency department (ED) and underwent brain magnetic resonance imaging (MRI) for a suspected stroke were eligible. All data were gathered through a pre-prepared checklist consisting of three sections, using the clinical records of the patients. The first section of the checklist included basic characteristics and demographic data. The second part included physical examination findings of 19 items related to the 8 scales. The third part was dedicated to the final diagnosis based on the interpretation of brain MRI, which was considered the gold standard for the diagnosis of acute ischemic stroke (AIS) in the current study.

The data from 805 patients suspected of stroke were analyzed. In all, 463 patients (57.5%) were male. The participants’ age was 6-95 years with a mean age of 66.9 years (SD = 13.9). Of all the registered patients, 562 (69.8%) had an AIS. The accuracy of screening tests was 63.0% to 84.4%. The sensitivity and specificity were 71.9% to 95.7% and 46.5% to 82.8%, respectively. Among all the screening tests, Los Angeles Pre-Hospital Stroke Screening (LAPSS) had the lowest sensitivity, and Medic Prehospital Assessment for Code Stroke (Med PACS) had the highest sensitivity. In addition, PreHospital Ambulance Stroke Test (PreHAST) had the lowest specificity and LAPSS had the highest specificity.

Based on the findings of the present study, highly sensitive tests that can be used in this regard are Cincinnati Prehospital Stroke Scale (CPSS), Face-Arm-Speech-Time (FAST), and Med PACS, all of which have about 95% sensitivity. On the other hand, none of the studied tools were desirable (specificity above 95%) in any of the examined cut-offs

In recent years, several scoring systems have been developed to assess the severity of traumaand predict the outcome of trauma patients. This study aimed to compare Rapid Emergency Medicine Score(REMS), Modified Early Warning Score (MEWS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) inpredicting the in-hospital mortality of trauma patients.

This diagnostic accuracy study was done onadult patients admitted to the emergency department (ED) between June 21, 2019, and September 21, 2020,following multiple trauma. Patients were followed as long as they were hospitalized. The REMS, MEWS, GCS,and ISS were calculated after data gathering and comprehensive assessment of injuries. Receiver operatingcharacteristics (ROC) analysis was performed to examine the prognostic performance of the four different tools.

Of the 754 patients, 32 patients (4.2%) died and 722 (95.8%) survived after 24 hours of admission. Themean age of the patients was 38.54 ± 18.58 years (78.9% male). The area under the ROC curves (AUC) of REMS,MEWS, ISS, and GCS score for predicting in-hospital mortality were 0.942 (95% CI [0.923-0.958]), 0.886 (95% CI[0.861-0.908]), 0.866 (95% CI [0.839-0.889]), and 0.851 (95% CI [0.823-0.876]), respectively. The AUC of REMSwas significantly higher than GCS (p=0.035). The sensitivities of GCS≤11, ISS≥13, REMS≥4, and MEWS≥3 scores for in-hospital mortality were 0.56, 0.97, 0.81, and 0.94, respectively. Also, the specificities of GCS, ISS,REMS, and MEWS scores for in-hospital mortality were 0.93, 0.82, 0.81, and 0.85, respectively.

Itseems that REMS is more accurate than GCS, ISS, and MEWS in predicting in-hospital mortality≥24 hours ofmultiple trauma patients.

Various methods of analgesia can be used to reduce or prevent procedural pain in emergencydepartment (ED). This study aimed to evaluate the effectiveness of topical lidocaine-diclofenac combinationcompared to lidocaine-prilocaine combination (Xyla-P) in reduction of the pain during central venous catheter(CVC) insertion.

In this randomized clinical trial, 100 adult patients requiring CVC insertion in the EDwere enrolled. These patients were randomly divided into two groups. The site of CVC insertion was coveredwith 2 g of topical Xyla-P cream in the first group, and 2 g of topical lidocaine-diclofenac cream in the secondgroup. The primary outcome was the pain during CVC implantation. The secondary outcomes were physiciansatisfaction and the incidence of side effects.

On the visual analog scale (VAS), the pain score duringCVC insertion was significantly lower in the second group (p = 0.027). However, there was no difference in painscores during lidocaine injection between the two groups (p = 0.386). Also, there was no significant differencein the rate of side effects between the two groups (p = 1.0). The physician’s satisfaction with the first groupwas significantly lower than the second group (p = 0.042).

Although the CVC insertion pain wassignificantly lower in patients who received the topical combination of Lidocaine plus Diclofenac, there wasno clinically important difference between the two groups and both topical anesthetics were effective and safein reducing pain intensity. Also, lidocaine-diclofenac combination cream was more cost-effective than Xyla-Pcream.

Ultrasonography (US) has been suggested as an integral part of resuscitation to identify poten-tially reversible causes of cardiac arrest (CA). This study aimed to evaluate the association between cardiac ac-tivity on ultrasonography during resuscitation and outcome of patients with non-shockable rhythms.

We conducted a prospective, observational study on adult patients presenting with CA or experiencing CA inthe emergency department (ED), and initial non-shockable rhythm. US examination of the sub-xiphoid regionwas performed during the 10-second interval of rhythm and pulse check and the association of US findings andpatients’ outcomes was evaluated.

151 patients with the mean age of 65.32 ± 11.68 years were evaluated(76.2% male). 43 patients (28.5%) demonstrated cardiac activity on the initial US. The rate of asystole in initialrhythm was 58.9% (n=89). Return of spontaneous circulation (ROSC) was achieved in 36 (23.8%) patients, twenty(13.2%) survived to hospital admission and seven (4.6%) survived to hospital discharge. When the cardiac stand-still duration increased to six minutes, no patient survived hospital discharge. Potentially reversible causes weredetected in 15 cases (9.9%), and four of them survived to hospital discharge. Cardiac activity on first scan wasassociated with ROSC (OR: 6.86, 95%CI: 2.92-16.09; p < 0.001), survival to hospital admission (OR: 17.80, 95%CI:3.95–80.17; p < 0.001), and survival to hospital discharge (OR: 17.35, 95%CI: 2.02–148.92; p = 0.001).

Conclusion:

In non-traumatic cardiac arrest patients with non-shockable rhythms, bedside US is of great importancein predicting ROSC. The presence of pulseless electrical activity (PEA) rhythm and cardiac activity on initial USwere associated with ROSC, survival to hospital admission, and hospital discharge. When the cardiac standstillduration increased to six minutes, no patient survived hospital discharge.

Andsberg et al. have recently introduced a novel scoring system entitled “PreHospital Ambulance Stroke Test (PreHAST)”, which helps to early identification of patients with acute ischemic stroke (AIS) even in prehospital setting. Its validity has not been assessed in a study yet, and the purpose of this study was to assess this scoring system on a larger scale to provide further evidence in this regard.

This was a cross-sectional multi-center accuracy study, in which, sampling was performed prospectively. All patients over 18 years of age admitted to the emergency department (ED) and suspected as AIS cases were included. All required data were recorded in a form consisting of 3 parts: baseline characteristics, neurological examination findings required for calculating PreHAST score, and the ultimate diagnosis made from interpretation of their brain magnetic resonance imaging (MRI).

Data from 805 patients (57.5% men) with the mean age of 67.1 ± 13.6 years were analyzed. Of all the patients presenting with suspected AIS, 562 (69.8%) had AIS based on their MRI findings. At the suggested cut-off point (score ≥ 1), PreHAST had a specificity of 46.5% [95% confidence interval (CI): 40.1%-53.0%) and a sensitivity of 93.2% (95% CI: 90.8%-95.2%).

According to the findings of our study, at the suggested cut-off point (score ≥ 1), PreHAST had 93.2% sensitivity and 46.5% specificity in detection of patients with AIS, which were somewhat different from those reported in the original study, where 100% sensitivity and 40% specificity were reported for this scoring system.

 Acute pain management is a core ethical commitment to medical practice. However, there is evidence to suggest that sometimes infiltrative lidocaine (IL) is not used prior to thoracentesis and abdominocentesis due to the belief that two needles cause greater pain than one. However, topical anesthetics like lidocaine-prilocaine cream (LPC) are painless, easy to use, and have less systemic side effects. Therefore, LPC can be a suitable substitute for medical procedures.

 This study was designed to compare the analgesic effects of LPC with IL in thoracentesis and abdominocentesis.

 Patients were divided into two study groups, including individuals seeing a physician for a thoracentesis (N = 36) and those seeing a physician for an abdominocentesis (N = 33). Patients were randomly assigned to the IL (N = 35) or LPC (N = 34) groups for diagnostic and/or therapeutic purposes. The IL group received 100 mg of 2% lidocaine 5 minutes prior to their procedure, whereas the LPC group received 2.5 g of lidocaine-prilocaine cream. The cream was spread over a 20 - 25 cm2 area and occluded with dressing plaster for 30 minutes prior to the procedure. In both study groups, the thoracentesis and abdominocentesis were ultrasound-guided.

 The findings suggest a non-significant difference between overall pain perception in LPC and IL groups generally, as well as specifically in abdominocentesis and thoracentesis groups. Furthermore, the result remained the same after controlling for confounding variables. The number of attempts to perform successful abdominocentesis was significantly higher in the LPC than IL (P-value = 0.003) group but was not significant in the thoracentesis group (P-value = 0.131). The level of patient satisfaction in the LPC and IL groups were not significantly different (P-value > 0.05).

 Overall, LPC appears to be an appropriate alternative to IL in reducing pain during thoracentesis and abdominocentesis, but it seemed to increase unsuccessful medical procedure attempts.

Tubular feeding is used, in patients who cannot take food through their mouths, but their digestive system is able to digest food. This method is safe and affordable for the patient and results in maintaining the function of the digestive system and reducing the risk of infection and sepsis. 

The purpose of this study was to compare the three methods of the NG tube placement in intubated patients in the emergency department. 

This study is a randomized, prospective clinical trial conducted between 2016 and 2018. 75 patients who had been referred to the emergency department were enrolled in the study and divided into three groups, to have their NG tube insertion using either the conventional method (Group C), or using brake cable (Group B) or applying Rusch intubation stylet (Group S) for highwayman's hitch or draw hitch. 

The mean duration of NG tube insertion was not significant between three groups (p=0.459), but the mean duration of NG tube insertion in group B was 18.43 ± 2.71 seconds and less than the other groups. NG tube insertion by first attempt in the group B was associated with the highest success rate. There was no significant difference, however, in the success rate in NG tube insertion on first and second attempts (p=0.376, p=0.353). 

The use of brake cable as a guide wire during insertion of a nasogastric tube increases the success rate on first attempt. No meaningful difference, however, was noted in the overall success rate in NG tube insertion on first and second attempts.

Ultrasonography (US) is not the method of choice for the diagnosis of calcaneal fractures. The aim of this study was to compare the diagnostic accuracy of US with plain radiography in the diagnosis of calcaneus fractures following blunt ankle and foot trauma. In this cross-sectional study, 214 patients (over 18 years) presenting to the emergency department (ED) with suspicion of traumatic calcaneus fracture following acute blunt trauma, were enrolled. Bedside ultrasonography was performed and interpreted by emergency physicians. After that, plain radiography was performed. Furthermore, all the patients were assessed by computed tomography (CT) scan as the gold standard. Finally, 193 patients were enrolled with a mean age of 29.4±15.7 years (85.5% male). Fractures in the calcaneus were detected in 49 patients. The sensitivity and specificity of ultrasonography in the detection of calcaneal fractures were 83.6%, (confidence interval (CI), 69.7 –92.2) and 100% (95% CI, 96.7 –100), while the sensitivity and specificity of X-ray were 87.7% (95% CI, 74.5 –94.9) and 100% (95% CI, 96.7 –100). There was no false positive result for X-ray and US. Our findings suggest that bedside US with an acceptable sensitivity and specificity can be used as a promising alternative for the diagnosis of calcaneal fracture in ED.

Urgent restlessness is a common condition following ketamine anesthesia in the emergency. The aim of this study was to compare the effects of intravenous midazolam, oral melatonin, and placebo in controlling of ketamine-induced agitation in adult patients undergoing minor emergency surgery.

 In a randomized clinical trial study, 96 patients in the emergency department who needed ketamine for sedation were divided into three groups of 32 cases. Prior to administration of ketamine, the first group received intravenous midazolam plus oral placebo, the second group received intravenous placebo and oral melatonin, and the third group received oral placebo plus intravenous placebo. The time of re-consciousness and recovery time were determined and compared in the three groups.

The mean score of restlessness was significantly lower in the midazolam and melatonin groups than in the control group (P = 0.020); but there was no difference between the midazolam and melatonin groups (P > 0.999).

 According to the findings of the study, oral melatonin, as intravenous as midazolam, appears to be effective in reducing ketamine-induced agitation in anesthesia for minor emergency surgeries.

The continuing-to-grow number of older adults with traumatic brain injury (TBI) presenting to emergency departments (EDs) and hospitals necessitates the investigation of TBI in these patients.

The present study was conducted to investigate the epidemiology of TBI and the factors affecting intracranial lesions and patient outcomes in older adults.

The present retrospective cross-sectional study was performed between March 2016and March 2018. The study population comprised all TBI patients with a minimum age of 60 years presenting to the ED. The eligible candidates consisted of patients presenting to the ED within 24 hours of the occurrence of traumas and requiring head CT scanas part of their examination. The patients’ baseline information was also recorded.

A total of 306 older adult patients with a mean age of 70.61±8.63 years, of whom 67.6% were male, underwent CT scan for TBI during the study period. Falls were the major cause of head injuries, and intracranial lesions were observed in 22.9% (n=70) of the patients. Subdural hematoma (SDH) was observed as the most prevalent injury in 27.6% of the patients, 22.9% (n=16) were transferred to the operating room, and 7.5% (n=23) died. Moreover, the severity of trauma was significantly different between the two genders (P=0.029). Midline shift, SDH, subarachnoid hemorrhage (SAH) and moderate-to-severe head injuries were also significantly associated with poor outcomes (P<0.05).

Death from TBIs was more likely in the patients with SDH, SAH and midline shift or in those with an initial Glasgow coma scale (GCS) of below 13. These predictions are clinically relevant, and can help improve the management of older adults with TBI.