journal of emergency practice and trauma

Abstract
Cisplatin was the first of the platinum drugs. Second-generation platinum derivative was carboplatin that its efficacy in the treatment of many malignancies is equal to cisplatin, and its toxicity profile is more favorable. Here we report on a 50-year-old woman with a history of cervix cancer who developed a severe hypersensitivity reaction (HSR) to carboplatin. She was admitted to the emergency department (ED) with shortness of breath, tachypnea, restless, agitation, and lethargy. On arrival, the patient was hemodynamically unstable; we initiated treatment immediately with hydration, oxygen therapy with mask, hydrocortisone, midazolam, and adrenalin. After 1 hour, BP and O2 sat improved to 100/70 mm Hg and 92% respectively, but there was not any significant improvement in tachycardia as well as tachypnea and she was still lethargic and agitated. Her symptoms improved gradually after 18 hours of admission. She was discharged after 36 hours. HSRs to cisplatin and carboplatin can be potentially life-threatening. The symptoms can range from a mild rash to severe anaphylaxis. Doctors should be aware of these reactions, determine appropriate treatment, and know the cross-reactivity among these drugs.
Keywords: Cisplatin, Carboplatin, Cross-reactivity, Cancer, Anaphylaxis

Abstract
Wasp sting is a relatively common arthropod assault. This usually results in pain and mild allergic reactions, but sometimes may cause severe systemic reaction and multiorgan dysfunction including rhabdomyolysis, hemolysis, coagulopathy, hepatic, renal and cardiac complications. Along with several other pathomechanisms, rhabdomyolysis is a distinguished cause of acute kidney injury (AKI) in patients with wasp sting. We herein report a case in which the patient developed rhabdomyolysis followed by AKI due to multiple wasp stings. The offending wasp was brought to the hospital and the species was confirmed by a zoologist (Vespa affinis).
Keywords: Acute kidney injury, Rhabdomyolysis, Wasp venom
Citation: Ullah P, Chowdhury A, Isha IT, Mahmood S, Chowdhury FR, Zeesan-ul-Abir M, et al. Wasp stings (Vespa affinis) induced acute kidney injury following rhabdomyolysis in a 25-year-old woman. Journal of Emergency Practice and Trauma 2016; 2(2): 55-57. doi: 10.15171/jept.2016.08

Abstract
Objective: To evaluate the association of base deficit (BD) with mortality in traumatized children, and to assess this association in a subgroup of patients with traumatic brain injury (TBI).
Methods: In this cross-sectional study performed prospectively on a convenience sample of patients under 16 years of age with trauma presenting to an academic level ІІ trauma center, we obtained venous BD values initially and followed the patients for in-hospital mortality. Initial vital signs were measured and injury severity score (ISS), randomized trauma score (RTS), and pediatric trauma score (PTS) were calculated.
Results: A total of 102 patients were included, with 48 patients diagnosed with TBI. Nine patients (8.8%) died during admission, of which 6 were diagnosed with TBI. Based on the univariate analysis, BD was associated with mortality in the whole group (P = 0.01), but not in the TBI subgroup (P = 0.08). In multivariable analysis, RTS was the only variable independently associated with mortality (P = 0.001, odds ratio [OR] = 0.197). Linear regression model showed that BD was predictive of ISS, RTS, and PTS. Receiver operating characteristics (ROC) curve showed a cutoff point of -7 mmol/L for BD, below which there is a 12 fold increased risk for mortality.
Conclusion: BD is a useful parameter in mortality prediction in pediatric trauma like in adult age group, but this predictive role in TBI patients is not supported by our results.
Keywords: Base deficit, Mortality, Pediatric traumaamount of base in millimoles per liter (mmol/L) required for buffering 1 liter of whole blood to a pH of 7.4 in the following conditions: temperature of 37 degrees of Celsius, full oxygen saturation, and an arterial pressure of CO 2 (PaCO 2) of 40 millimeters of mercury (mm Hg). BD is usually measured by blood gas analysis and normal values are defined as-2 to +2 mmol/L (8). A BD of-6 mmol/L or less is shown to be an indicator for the extent of injury, amount of blood transfusion required, and mortality (9). BD is introduced as a reliable physiologic

Objective: Acute mesenteric ischemia (IMA) is a vascular emergency with broad variability of clinical presentations and non-specific laboratory findings. Therefore, there is a significant need for reliable serological markers of ischemia. Various laboratory studies may be performed for suspected AMI, but in general, such studies will not establish the diagnosis.
Methods: In a prospective, non-interventional study, from October 2012 to October 2013, we investigated 70 patients with probable diagnosis of AMI. Blood samples were taken from patients and analyzed for complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), urea, creatinine (Cr), sodium (Na), potassium (K), D-dimer, lactate, amylase, PH, partial pressure of carbon dioxide (PCO2), and bicarbonate (HCO3). Finally the results were compared with AMI diagnosis confirmed by computed tomography (CT) angiography.
Results: Seventy patients with acute severe abdominal pain were studied. Thirty-nine patients (55.7%) were male and 31 patients (44.3%) were female. The average age was 68.01 ± 14.67 (±SD). Based on CT-angiography results, 27 (38.6%) patients had AMI and 43 (61.4%) patients did not have AMI. Chi-squire test showed P values of 0.606 and 0.986 for relations between sex and risk factors with AMI correspondingly. One-sample Kolmogorov-Smirnov revealed white blood cell (WBC), hemoglobin (Hb), platelets (Plt), urea, Cr, Na, K, PCO2 and HCO3 as normally distributed parameters (P > 0.05). Moreover PT, PTT, INR, D-dimer, lactate, amylase, and PH were non-normally distributed (P < 0.05).
Conclusion: We found a significant relation between increased serum lactate level and definitive AMI diagnosis. We recommend rising serum lactate as a finding in AMI.
Keywords: Mesenteric ischemia, Fibrin fragment D, Lactate, Early diagnosis

Objective: There are many communities at risk by a series of air pollution episodes. Tehran is one of the most polluted cities in the world. The presence of one or more air pollutants with a certain concentration in a particular period of time can cause several adverse effects on human and animals’ well-being that can cause much morbidity. There are several pollutants in the air but some of them can cause severe adverse effects on the lungs and air ways.
Methods: In this retrospective cross-sectional study 1958 patients with exacerbation of chronic obstructive pulmonary disease (COPD) who were admitted in the emergency department (ED) of Rasol Akram hospital between March 2004 and March 2006 entered the study. Data such as number of admissions, air pollution particles (CO, SO2, O3, NO2, PM10) according to available documents were analyzed.
Results: From 1958 patients who enrolled in this study, 887 (53.5%) were male and 771 (46.5%) were female. According to statistical analysis, we could observe a significant correlation between the concentration of Co, PM10, So2 with ED admission rate of COPD exacerbation (P: 0.031, 0.008, and 0.001 respectively). The effect of PM10, So2 and Co was more significant respectively in logistic regression on ED admission.
Conclusion: There was significant correction between concentrations of air pollutants with number of ED admission for COPD exacerbation.
Keywords: Air Pollution, So2, No2, Co, PM10, O3, COPD

Abstract
Objective: Most previous retrospective studies failed to show a consistent association between pre-hospital time intervals and mortality in trauma patients, bringing the recommendation of “transport fast to increase survival” under question. The aim of this study was to evaluate the association of response time, scene time, and transport time with 24-hour in-hospital mortality.
Methods: In this cross-sectional study data were collected In the emergency department (ED). Time intervals were obtained from emergency medical service (EMS) central system. All traumatized patients presented to an urban academic hospital by EMS with Emergency Severity Index (ESI) levels 1 or 2 were included in the study. Exclusion criteria were age under 16 or above 65, being transported from outside of the city, severe underlying medical illness, life threatening intoxications, and randomized trauma score (RTS) of more than 10. Patients were followed in the hospital for 24-hour mortality.
Results: A total of 2884 patients were enrolled in the study. Response time, scene time, transport time, and total out of hospital time were all associated with mortality in univariate analysis (P = 0.02, 0.01, <0.001, and 0.001, respectively). In multivariate regression analysis, transport time was associated with 24-hour mortality (P < 0.001, OR [95% CI]: 1.20 [1.16-1.24]).
Conclusion: Although time intervals in most previous studies did not show association with mortality, there is no recommendation such as “pre-hospital time intervals in traumatized patients should not be limited,” since limiting time intervals for taking a traumatized patient to the hospital still seems to be prudent. Our findings support the recommendation of decreasing the transportation and total out of hospital time in the present condition in Kerman city EMS system.
Keywords: Prehospital Emergency Care, Time-to-Treatment, Trauma, Transportation, Emergency medical service

Objective: Trauma is one of the main causes of losing effective life among the populations. Knowing the pattern of trauma in each country can be considered as the first step in planning preventive programs to reduce trauma injuries. This study was conducted to evaluate the epidemiological status of trauma in Shahid Bahonar hospital in Kerman.
Methods: This retrospective, descriptive cross-sectional study was conducted in 2014. The study population consisted of all traumatic patients who referred to Shahid Bahonar hospital. All patients entered the study based on census sampling. In order to collect data, the medical record of each patient was scrutinized and the demographic information, causes of trauma, and the anatomical location of trauma were extracted. All data were entered into the SPSS version 20 software. For data analysis, we used descriptive tests (frequency and mean) as well as analytical tests (chi-square).
Results: 7803 (76.8%) traumatic patients were male and 2358 (23.2%) were female. Of all causes of trauma, accidents had the most frequency among women and men at 1208 (23.9%) and 3846 (76.1%) correspondingly. Other causes of trauma in both groups were related to falling (1538), violence (1720), occupation (1181), sports (663), and self-harm (5). The age group of 15-24 with 2576 patients had the highest amount of trauma (25.4%). In terms of location, limbs and thorax had the highest and the lowest amount of injury at 4527 (44.6%) and 653 (6.4%) respectively. We could observe a significant relationship between the cause of trauma with sex and the age variables (P < 0.0001).
Conclusion: Males are more susceptible to traumatic problems than females regarding the nature of their jobs . Moreover, accidents are the main cause of trauma. Improving the quality of vehicles, roads safety, and establishing driver training courses to follow the rules are highly recommended.
Keywords: Wounds and injuries, Epidemiology, Shahid Bahonar hospital, Kerman

Abstract
Objective: One of nonsteroidal anti-inflammatory drugs (NSAIDs) named as ketorolac is frequently used to relieve acute pain. Current study was conducted with the aim of ketorolac efficacy measurement as a pain killer agent for controlling the primary headache in emergency departments.
Methods: In this study, we enrolled 50 patients with primary headache who received 60 mg ketorolac intravenously as a slow infusion in about 10 minutes. Pain scores were evaluated with visual analog scale (VAS) on arrival and also 1 hour and 2 hours after ketorolac infusion. Statistical analysis was performed on collected data by using Wilcoxon and Mann-Whitney tests to assess the differences in VAS pain scores.
Results: Decreasing the VAS more than 3 points from the arrival until 1 hour (P < 0.001), and more than 5 points from the arrival until 2 hours after ketorolac administration (P < 0.001) were seen. Those with history of analgesic use before admission in emergency department in comparison with the others did not accompany with more decline in pain score after 1 hour (P = 0.34) or 2 hours (P = 0.92).
Conclusion: It seems that ketorolac is assured, safe and well tolerated agent for pain control in patients presented with primary headache to the emergency departments. Based on the results achieved in this study, ketorolac illustrates its perceptible effects within 1 hour after administration that even more prominent after 2 hours.
Keywords: Ketorolac, Headache, Pain management, Emergency medicine

Abstract
Objective: Patient satisfaction is one of the most important indicators for measuring the quality of emergency services and health care. The purpose of this study was to evaluate the patients’ satisfaction in the emergency department (ED) of Sina hospital.
Methods: This descriptive, cross-sectional study was performed during one month in Sina hospital in 2014. Data were collected by a questionnaire which its validity and reliability were confirmed in previous studies. The questionnaire consisted of 2 parts. Part 1 included the demographic characteristics and part 2 encompassed the scales of satisfactory. Data analysis was conducted by SPSS version 15.
Results: Totally, 425 patients participated in this study. The mean age of patients was 41.6±17.6 years. The mean total score of patient satisfaction was 17.43±1.56. The maximum satisfaction was related to the knowledge of physicians and the minimum satisfaction was related to the remaining period in the ED. Additionally, there was a desirable satisfaction for nurses’ performances. In terms of satisfaction regarding the physical environment and the workflow of the ED, the results were moderate. There was a significant statistical difference regarding nurses and physicians behavior in the ED during different working shifts, vacation days, and workdays.
Conclusion: Based on the results obtained, patients had good satisfaction for the received services in the ED. It is necessary to develop physical spaces and improve the workflow of patients in the ED.
Keywords: Patient Satisfaction, Emergency Service, Hospital

Abstract
Objective: Low back pain is the most common skeletal disorder worldwide that 50% to 80% of people experience it at least once in their lifetime. Physical and psychological factors in the work environment can relatively contribute to low back pain. In this study, we examined the prevalence of low back pain and influential factors in its development among nursing staff.
Methods: In this cross-sectional study we assessed the prevalence of low back pain among nurses working in Poursina hospital, Rasht, Iran, during March and April 2012. Demographic data and information on the status of skeletal pain, as well as, associated factors were collected using a pre-designed check list. Data were analyzed using SPSS version 16.
Results: A total of 350 nurses with a mean age of 32.00 ± 8.24 years (minimum 22 and maximum 56 years) were studied (90.3% female). 246 participants (70.3%) had a history of low back pain. There was no significant difference between gender and the incidence of low back pain, (P = 0.286). 96 participants (27.4%) aged 27 to 31 had the highest rate of low back pain and 11 participants (3.1%) aged 52 to 56 were the least frequent age group. Low back pain significantly differed by age (P = 0.001), body mass index (BMI) (P = 0.222), and physical activity (P = 0.050).
Conclusion: The results of this study showed a prevalence of 70% for low back pain among nurses working in Poursina hospital in Rasht, in Gilan province. Age, BMI, and physical activity were significantly associated with the prevalence of low back pain. However, gender, occupation, marital status, smoking, family history, frequency of lifting heavy things, work experience, and workplace did not show a significant relationship.
Keywords: Low back pain, Nurses, Prevalence, Risk factors

Abstract
In order to equip medical students with all the necessary skills in dealing with patients to provide optimal treatment, the need for the use of real patients in educational settings has become prominent. But all the required skills cannot be practiced on real patients due to patients’ safety and well-being. Thus, the use of standardized patients (SPs) or simulated patients (SiPs) as a substitute for real patients signifies their importance in simulation-based medical education. One question raised in regard to using SPs or SiPs in order to enhance medical students’ tangible and intangible skills in a safe controlled environment is whether these two terminologies are the same or different? Various studies use these terms interchangeably and do not consider a difference between them. Based on our literature review, there seems to be differences between these two modalities. We also try to highlight the advantages of these modalities in clinical encounters.
Keywords: Standardized patient; Simulated patient; Education, Medical

Abstract
Objective: To evaluate the capability of ascitic fluid dipstick results for pH, glucose, and protein in order to predict a low serum-ascites albumin gradient (SAAG) at the bedside of the patient in the emergency department (ED).
Methods: This prospective cross-sectional study was conducted during one year in the ED of Afzalipour hospital in Kerman, Iran. All patients with diagnostic or therapeutic paracentesis of ascitic fluid were considered as eligible patients. Exclusion criteria included clinical suspicion for spontaneous bacterial peritonitis (SBP), any contraindications to paracentesis, and patients’ refusal to participate in the study. Dipstick values were obtained at the bedside, and SAAG was calculated after the determination of serum and ascitic fluid albumin by laboratory. A low SAAG ascitic fluid was defined as the study outcome. We also used our study population as a test group to evaluate an equation proposed in one previous study: K = 0.012 Protein−0.012 Glucose−3.329 pH+23.498
Results: A total of 50 patients were enrolled in the study. Based on multivariate regression analysis, dipstick values for protein and glucose were independently predictive of a low SAAG ascitic fluid (P = 0.23, OR = 1.04; and P = 0.001, OR = 0.81, respectively). The formula proposed in one of the previous studies was tested by our data set, with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at 84%, 83%, 84%, and 80%, respectively.
Conclusion: Dipstick test of ascitic fluid for pH, glucose, and protein has an acceptable sensitivity and specificity as a point of care test, but it cannot be recommended as a substitute for SAAG determination based on the current findings.
Keywords: Serum-asictes albumin gradient, Ascitic fluid, Dipstick tes

Abstract
Objective: Renal colic is a common cause of emergency room visits. Due to the spontaneous passage of more than 90% of kidney stones, treatment in the emergency department (ED) is limited to pain control. Analgesics currently used are selected based on physician experiences and various theories from different sources. The aim of this study was to compare the common drugs (pethidine and diclofenac) used for renal colic in Iran.
Methods: In this single-blinded randomized clinical trial, 90 patients with renal colic who referred to the ED of Imam Reza hospital in Kermanshah were randomly assigned to each of 3 treatments including pethidine suppository (50 mg, iv), diclofenac suppository (50 mg), and a combination of pethidine and diclofenac suppository. In this regard, the response to treatment and duration of hospitalization were compared.
Results: The best medicine to relieve pain intensity in patients under 25 years was diclofenac suppository. In patients in the age range of 25-45 years, pethidine and diclofenac were the best choice. Conversely, in patients older than 45 years, pethidine was the best treatment. We could also observe a decrease in the length of hospitalization in patients who received pethidine.
Conclusion: It can be concluded that morphine is more appropriate to control pain and reduce the length of hospitalization in patients with renal colic.
Clinical Trial Registration: irct.ir, Identifier: IRCT20101214538
Keywords: Renal colic, Emergency department, Pain Relief Unit

Ingestion and inhalation of phosphine are 2 forms of toxicity and their clinical manifestation is extremely wide. A 22-year-old girl was admitted with complaints of nausea, vomiting and epigastric pain after eating lunch. She had a history of celiac disease. On arrival, she was alert and hemodynamically stable. There was not any abdominal tenderness or guarding. Food poisoning treatment initiated but after 1 hour her condition deteriorated with hypotension, tachycardia, and epigastric pain. Venous blood gas (VBG) showed severe metabolic acidosis. She denied any drug ingestion again. New Electrocardiogram (ECG) showed extensive inferolateral ST elevation myocardial infarction (STEMI). Bicarbonate plus dopamine was initiated. After 8 hours of admission, rhythm became ventricular fibrillation (VF) and cardiopulmonary resuscitation (CPR) began. Peritoneal dialysis was performed. Next morning frequent VF occurred again but CPR was unsuccessful. Family found aluminum phosphide (AIP) tablets in her purse. Early diagnosis and supportive treatment may be effective but the most important factor is the dose of ingestion.
Keywords: Aluminum phosphide, Poisoning, Survival, Prevention and control

Abstract
Organ donation is an integral part of the health care system. Many patients who have had an accident or have undergone a progressive disease are in need of an organ transplant and if they do not receive the required organ they would die. It is important to know that the most important source of organ donation is the brain death patients. It is highly essential to determine the pivotal factors that have an effect on organ donation. The aim of this study was to determine factors influencing decisions on organ donation in brain death patients. This study was conducted in 2014 and was based on a literature review both in English and Persian databases. In addition, some relevant books were scrutinized. Overall, 2 categories were identified as factors associated with the acceptance of organ donation and factors associated with the refusal of organ donation. Based on the results obtained, these factors have an effect organ donation and policy makers and management authorities should consider these factors to increase the likelihood of organ donation.
Keywords: Organ donation, Brain death, Factors

Objective: Road traffic injuries (RTIs) are the second leading causes of death in Iran. One of the most important steps in the prevention of traffic-related trauma and its consequences is gaining insight into the epidemiology of injuries. We conducted this study to describe the characteristics of RTIs and to find strategies for its prevention.
Methods: This was a prospective cross-sectional study on consecutive road traffic trauma patients admitted to the emergency department (ED) of the second largest trauma center in the northeast of Iran, during July to September 2013. Demographic characteristics, type of vehicle, and injured area of the body were documented for each patient.
Results: Of 666 included patients, 562 (84.4%) were male and 104 (15.6%) were female, with a mean age of 28.89 ± 16.62 years. Most of the patients were uneducated. The highest frequency of RTIs was related to motorcyclists with an attributed risk of RTIs for motorcycles at 75.8%. The most common traumatized area was head, face, and lower extremities.
Conclusion: The largest number of traumatized patients was among motorcyclists and uneducated population underscores the importance of public training about motorcycle usage and security and increase social awareness about reasons behind traffic law.
Keywords: Trauma, Injury pattern, Road traffic injury, Iran

Objective: Congestive heart failure (CHF) has become one of the most important health care problems in western countries. This article focuses on the outpatient diagnosis and management of heart failure. We want to compare the outcome of patients who were treated with high dose diuretics in the emergency department (ED) without admission with patients who were admitted to hospital for standard treatment.
Methods: This was a randomized prospective clinical trial study. The patients who came to the ED from March 20, 2008 up to August 20, 2008 were divided into two groups randomly. The length of ED stay in the experimental group was documented. Also, readmission and mortality in 6 months and satisfaction in both groups were taken into consideration. All data were analyzed using SPSS 15.0.
Results: In experimental group, the rate of recurrent admission, expiration, discharge, clinic visit, and clinic admission was 8%, 4%, 29%, 18%, and 0% respectively. On the other hand, in control group it was 16%, 40%, 18%, 22%, and 2% respectively. Additionally, there was a significant difference between these groups (P = 0.00).
Conclusion: This study is the first regional prospective trial to comprehensively examine the therapeutic management in patients with CHF. This study, comparing the high dose diuretic efficacy in the decreasing of hospital stay and readmission; and decreasing mortality rate with routine therapy, showed that there was a significant difference between these two strategies in the mortality rate, readmission, and length of hospital stay (P = 0.00).
Keywords: Aggressive therapy, Congestive heart failure, Diuretics

Objective: Trauma is a major health problem worldwide regardless of regional socioeconomic and healthcare status. As a leading cause of death, trauma results in severe socioeconomic damages, which could be highly prevented by optimal care. As nurses are the major professional groups involved in patient care, improvement of their knowledge and practical skill leads to more qualified healthcare staff. Nowadays, traditional methods of education cannot meet students’ needs and modern methods of training are recommended to be applied. This study, therefore, aimed to compare the effects of two methods of teaching (electronic education and teacher-based education) on students’ learning and the efficacy rate of each method on the knowledge of fourth year students of nursing and midwifery faculty in Tabriz University of Medical Sciences.
Methods: In this study, the participants were randomly assigned into 2 educational groups of electronic (experimental group) and teacher-based (control group) method. All participants took a pre-test. Then each group attended the same course in a different method. Finally, post-test was taken by the participants and data were analyzed.
Results: A comparison of the mean knowledge score of both groups showed that electronic education was more effective than teacher-based education.
Conclusion: The electronic training will result in more effective learning in comparison to teacher-based method and can be applied as an appropriate and efficient method of education.
Keywords: Electronic education, Teacher-based education, Level of knowledge, Nursing students, Trauma patients

Aluminum phosphide (ALP) is a potent lethal substance, that use for agriculture purpose, as a pesticide. this substance may use for suicide, and it will kill the patient rapidly. we want to report a patient who use ALP for suicide purpose and was managed quickly in the emergency department and he became alive.
Keywords: Aluminum phosphide, Suicide, Outcome

Acute chest pain is an important and frequently occurring symptom in patients. Chest pain is often a sign of ischemic heart disease. Chest pain due to suspected Acute Coronary Syndrome (ACS) is responsible for a large and increasing number of hospital attendances and admissions. Current practice for suspected ACS involves troponin testing 10–12 hours after symptom onset to diagnose Myocardial Infarction (MI). Patients with a negative troponin can be investigated further with Computed Tomographic Coronary Angiography (CTCA) or exercise Electrocardiography (ECG).
A review of cardiac biomarkers as screening test in acute chest pain over 15 years was conducted. Separate searches were under taken for biomarkers. We Searched electronic databases up to 2004-2014, reviewed citation lists and contacted experts to identify diagnostic and prognostic studies comparing a relevant index test (biomarker, CTCA or exercise ECG) to the appropriate reference standard. We classified studies to two part early rise biomarkers, high sensitivity biomarkers.
Conclusion: Although presentation troponin has suboptimal sensitivity, measurement of a 10-hour troponin level is unlikely to be cost-effective in most scenarios compared with a high sensitivity presentation troponin. Measurement of cardiac troponin using a sensitive method was the best test for the early diagnosis of an Acute Myocardial Infarction (AMI). Measurement of myoglobin or Creatine Kinase-MB (CK-MB) in addition to a sensitive troponin test is not recommended. Heart-type Fatty Acid-Binding Protein (H-FABP) shows promise as an early marker and requires further study.
Keywords: Risk factor, Acute myocardial infarction, Emergency department, Troponin

Background: Potassium, as an extracellular ion, plays an important role in the electrophysiologic function of the myocardium and any change in extracellular concentration of this ion might have a marked impression upon myocyte electrophysiologic gain. High serum potassium levels are thought to impair pulse conduction in Purkinje fibers and ventricles more than that in the Atrioventricular (AV) node. Therefore, although complete AV block can occur, it is a rare initial presentation.
Case Report: We describe a 62-year-old man with a history of diabetes mellitus, ischemic heart disease and previous Coronary Artery Bypass Graft (CABG), who came to our emergency department due to generalized weakness starting 2 days before admission. The patient also had decreased force in lower limbs, exacerbating from the morning, and was finally diagnosed as a hyperkalemia-induced Complete Heart Block (CHB). It should also be noted that the patient responded dramatically to the administration of 10 mL of 10% calcium gluconate along with external pacing until potassium level correction became effective.
Conclusion: In spite of the fact that Hyperkalemia can be associated with frequent Electrocardiogram (ECG) abnormality, advanced heart blocks (second- and third-degree AV blocks) are usually found only in patients with pre-existing heart failure, conduction abnormalities, or other cardiac diseases. Institution of effective treatment rapidly and forgiveness of traditional non-effective, time consumptive and sometimes risking full-adjustment modalities, such as sodium bicarbonate infusion or exchange resins that prevent their use in the emergent phase, can help minimize patient morbidity and mortality.
Keywords: Hyperkalemia, Complete heart block, External pacing

Introduction: Emergency department is the most important part of a hospital and it seems that 24-hour presence of emergency medicine specialist can be effective in improving the performance of this ward. Therefore, the present study was performed with the aim of studying the effect of 24-hour presence of emergency medicine specialists in the emergency department of Shahid Bahonar hospital, Kerman/Iran.
Methods: In this mixed methods study, data collection was done through studying various related documents and semi-structured interview. Data analysis was performed using descriptive statistics and qualitative content analysis.
Results: The presence of emergency medicine specialists resulted in a decrease in waiting time, hospital’s revenue growth, increase in number of requested laboratory tests, improvement of decision-making for patients and decrease of first 24-hour mortality rate. Economic benefits, improvement of the quality of services and emergency department management were among qualitative results of the present study.
Conclusion: In whole, 24-hour presence of emergency medicine specialists in the emergency department of Kerman Shahid Bahonar hospital has been effective in improving the performance and quality of services.
Keywords: Emergency medicine specialists, Emergency, Hospital, Emergency medicine’s presence, Specialists

Introduction: There are major differences in neonatal and obstetrics outcomes of labour among different ethnicities. The present study compared the neonatal and obstetrics outcomes of labour between the Iranian and Afghan ethnicities.
Methods: Neonatal and obstetrics problems were evaluated in Iranian and Afghan pregnant women, who had referred to Arash Educational/Treatment Center for labour during a year.
Results: 3020 (93.7%) Iranian and 202 (63%) Afghan women were evaluated. There were no significant differences between the two ethnicities in relation to a need for Neonatal Intensive Care Unit (NICU), the rate of live births, infant birth weight, congenital anomalies and premature births (P>0.05). The rate of Caesarian section was higher in Iranian women (P=0.001).
Conclusion: It seems that the differences in neonatal problems and outcomes of labour obstetrics between Iranians and Afghans can be attributed to different cultural, economic, and social conditions in comparison to different ethnicities.
Keywords: Neonatal problems, Outcomes of labour, Ethnic differences

Objective: This study aimed to determine the association of cardiac risk factors and the risk of Acute Myocardial Infarction (AMI) in Emergency Department (ED) patients with non-diagnostic ECG changes.
Methods: This cross-sectional study was conducted in the ED of Imam Hossein Hospital during a period of one year. In this study, patients with symptoms suggestive of AMI including chest pain, dyspnea, palpitation, syncope, cerebrovascular incidents, nausea, vomitting, dizziness and loss of consciousness were included. The demographic data and risk factors, such as age, gender, history of diabetes, Hypertension (HTN), Hyperlipidemia (HLP), renal failure, positive family history of Coronary Artery Disease (CAD), smoking, substance abuse, alcohol consumption within the past 24 hours and cocaine use within the past 48 hours were recorded. Non-diagnostic ECG included: normal, non-specific, abnormal without ischemic symptoms such as old bundle branch block, Left Ventricular Hypertrophy (LVH), etc. The final diagnosis of AMI was determined by Creatine Phosphokinase-MB (CPK-MB) serum markers and Troponin I. The data were analyzed by using SPSS V. 20 and the level of statistical significance was considered to be P< 0.05.
Results: HTN, HLP, family history of heart disease were significantly higher in those who had non-diagnostic ECG (P< 0.05). However, the ischemic heart diseases were significantly lower in those with non-diagnostic ECG. History of diabetes, stroke, renal failure, alcohol or opium and menopause showed no significant association with non-diagnostic or diagnostic ECG.
Conclusion: Overall, the risk factors are limitedly associated with the occurrence of Myocardial Infarction (MI) in cases where ECG is not diagnostic and it is better to use other criteria to diagnose AMI.
Keywords: Risk factor, Acute myocardial infarction, Emergency department, Electrocardiogram