Journal of Emergency Practice and Trauma

Abstract With the increasing prevalence of chronic diseases such as asthma, epilepsy, diabetes, anaphylaxis, and cystic fibrosis
among students, the empowerment of school nurses has become more critical than ever . One of the main tasks of
school nurses is to support students with chronic diseases and help them effectively manage these conditions .
Medication management in schools, especially for chronic diseases, is vital because it allows students to participate
fully in educational and social activities. This directly impacts improving academic outcomes and students’ overall health.Empowering school nurses in Iran with greater authority, including the ability to prescribe essential medications
alongside proper training and resources, is crucial for strengthening school health services. Such measures will
enhance medication safety, foster a supportive learning environment, and safeguard student well-being. The
Iranian government and educational authorities should prioritize these reforms through comprehensive policies
and sustained investment to ensure healthier, safer schools for future generations.

Abstract Objective: When dealing with patients with possible traumatic brain injury, prehospital emergency
personnel must make decisions quickly with very little data. Determining the amount of risk that
threatens patients can lead to making correct treatment decisions. The present study aimed to
determine and compare the diagnostic accuracy of early warning scores in prehospital care for the
diagnosis of traumatic brain injury.
Methods: This prospective study was conducted from December 2023 to January 2025 at hospitals
affiliated with Tehran University of Medical Sciences. Sampling was performed purposefully, and
non-randomly and 250 trauma patients were enrolled in the study. Data collection was carried out
utilizing a demographic questionnaire and various scoring systems, including the National Early
Warning Score (NEWS2), Modified Early Warning Score (MEWS), Triage Early Warning Score (TEWS),
and Modified Emergency Medical Score (MEMS). The data were analyzed using SPSS software.
Results: The mean age of the patients was 40.90±15.78. Accident (56.8%) was the most common
mechanism of trauma, and multiple trauma (56%) was the most common type of trauma. The
National Early Warning Score 2 showed the highest diagnostic accuracy with sensitivity of 82.2%,
specificity of 81.1%, and area under the curve of 0.889(. The results of the independent t-test
showed that the mean score of the NEWS2 in prehospital care for patients with an initial diagnosis of
traumatic brain injury after 72 hours (12.3±29.4) was significantly lower compared to other patients
(08.3±73.7) (P<0.001).
Conclusion: While all four early warning scores were good at detecting ICU admission, there were
significant differences in their performance measures. The higher diagnostic accuracy of the National
Early Warning Score 2 makes it a valuable tool in identifying patients with traumatic brain injury.

Abstract Background: Active teaching is widely used in medical education to engage students and promote active learning. However, there is a paucity of research on how active teaching strategies can be applied to English Language learning in a Medical Education context. This study aimed to evaluate the effects of flipped classroom, and team-based learning on knowledge, and learning satisfaction of health sciences students.  
Methods: This quasi-experimental study was undertaken with 82 students who were divided into 3 groups, Flipped Group (FG), Team-based Learning (TBL), and Lecture Group (LG) at Sirjan School of Medical Sciences in 2023. Prior to study, the Oxford Quick Placement Test (OQPT) of 50 items was administered to homogenize students. To compare knowledge, a researcher-made knowledge test of English was administered at the baseline and after the intervention. Students’ satisfaction and their perspectives were obtained through a survey. Data were analyzed by Chi-squared, one-way ANOVA, Post hoc Tukey test, and Kruskal-Wallis H tests using SPSS software version 26, and content analysis for the open-ended responses.
Results: Of the 117 students participating in the OQPT, 82 (70.10%) entered the study. They included, 21 (25.60%) males, and 61 (74.40%) females with the mean age of 19.57±1.52 years old. In the post-intervention, the FG scored significantly higher (56.71±16.48) than TBL (51.00±14.23), and the LG (39.41±11.45) (p<0.001). Satisfaction levels were highest in the FG. Students’ perspectives varied and were classified into two categories: advantages and challenges, corresponding to each teaching approach.  
Conclusions: The FG and TBL approaches significantly enhanced learning and student satisfaction compared to LG. These findings underscore the importance of active engagement in medical education, suggesting that innovative teaching strategies can effectively improve student experiences and academic success.

Abstract Objective: While PCI achieves high procedural success rates, persistent risks such as periprocedural thrombosis, inflammatory cascades, and myocardial hypoperfusion contribute to a bimodal pattern of early and late complications, underscoring gaps in current risk prediction models. This research focuses on identifying the risk factors contributing to recurrent coronary events, particularly stent thrombosis and in-stent restenosis, in patients admitted to the cardiac emergency department.
Methods: A retrospective cohort study was conducted on 204 patients at Shahid Rajaei Hospital to analyze their clinical records, including demographic data, cardiovascular risk factors, and treatment history. Data collection utilized a structured checklist encompassing demographics, cardiovascular risk factors, treatment history, procedural details, and outcomes. Statistical analyses (PRISM version 9.0) included descriptive statistics and multivariable logistic regression to assess predictors of outcomes.
Results: Multivariate logistic regression analysis revealed that for same-artery re-involvement, the duration after first myocardial infarction was significantly associated with increased risk (P < 0.0001, OR = 3.666). Regarding stent thrombosis, multiple factors including duration after myocardial infarction (P < 0.001), not taking Plavix (P = 0.033), MI type (P = 0.001), diabetes mellitus (P = 0.002), cigarette smoking (P = 0.029), and absence of family history (P = 0.03) all demonstrated significant effect. For in-stent restenosis, only the absence of diabetes (P = 0.018, OR = 0.432) was significantly associated with decreased likelihood of this outcome.
Conclusion: The study also emphasizes the importance of early detection, regular follow-ups, and effective management strategies, such as pharmacological intervention and lifestyle changes, to reduce the risk of adverse cardiac outcomes. Additionally, it was found that a prolonged duration since the initial myocardial infarction significantly elevates the risks of same-artery re-occlusion and stent thrombosis.

Abstract Objective: Acute exacerbation of chronic obstructive pulmonary disease (COPD) is a significant
healthcare burden. This study aimed to compare three risk assessment tools in predicting the
outcomes of COPD exacerbation.
Methods: This prospective cohort study was conducted between October 2023 and November
2024 at five hospitals in Iran (three in Tehran, one in Shahr-e-Rey, and one in Nehbandan). A total of
392 patients admitted with acute exacerbation of COPD were enrolled using consecutive sampling.
The predictive accuracy of the Ottawa COPD Risk Scale (OCRS), DECAF, and BAP-65 for adverse
outcomes (ICU admission, mechanical ventilation, and mortality) was assessed. The area under the
receiver operating characteristic curve (AUC-ROC) and performance metrics (sensitivity, specificity,
predictive values, and likelihood ratios) were calculated for each score. AUCs were compared using
paired sample ROC analysis with significance set at P<0.05.
Results: The AUCs for OCRS, DECAF, and BAP-65 in predicting cumulative adverse outcomes (CAO)
were 0.78 (95% CI: 0.73–0.83), 0.79 (95% CI: 0.74–0.83), and 0.79 (95% CI: 0.74–0.83), respectively
(P<0.05). For CAO, DECAF and BAP-65 demonstrated the most balanced performance at optimal
cutoff, with sensitivities of 69.8% (95% CI: 61.9–75.4) and 68.2% (95% CI: 59.7–75.6) and specificities
of 78.7% (95% CI: 0.74.5–0.81.8) and 78% (95% CI: 72.5–82.5). OCRS had a sensitivity of 61.2% (95%
CI: 52.6–0.77) and a specificity of 84.8% (95% CI: 80.3–89.5). No significant confounding or effect
modifications from demographics, lifestyle factors, or comorbidities were found except for age with
DECAF, which performed better in younger patients.
Conclusion: DECAF and BAP-65 showed the most balanced performances in predicting CAO
amongst the three tools. Paired with a clinician’s judgment, these tools offer valuable insights for
better triage and clinical decision-making in managing acute COPD exacerbation.

Abstract Objective: Trauma-related deaths are among the top 10 causes of mortality, with an average of
three deaths from traffic accidents every hour in Indonesia. In 2012, there were 117,949 traffic
accidents resulting in 29,544 deaths (25.04%). In 2021, there were 103,645 accidents with 25,266
deaths (24.37%). Despite efforts to record trauma cases in Indonesia, existing scoring systems from
developed countries face limitations. This study aims to propose a new, locally adapted scoring
system to improve the management of multiple trauma cases, particularly at Saiful Anwar General
Hospital (RSSA), Malang.
Methods: This observational analytic study with a retrospective cohort design was conducted at
RSSA, Malang, Indonesia, from January 2021 to December 2022. A total of 506 multiple trauma
patients from the RSSA Emergency Department were included, selected through purposive
sampling. Data analysis involved the use of the t-test or the Mann-Whitney U test for numerical
and ordinal data, the chi-square or Fisher’s test for nominal data, followed by multivariate logistic
regression to establish a scoring system.
Results: Logistic regression through backward elimination identified 15 significant predictors of
in-hospital mortality: age (P=0.000, OR=0.967), pulse rate (P=0.006, OR=0.981), GCS (P=0.000,
OR=1.381), intracerebral hemorrhage (P=0.105, OR=0.966), subdural hemorrhage (P=0.001,
OR=0.875), infratentorial hemorrhage (P=0.000, OR=0.151), subfalcine herniation (P=0.038,
OR=0.871), transtentorial herniation (P=0.050, OR=0.038), mandibular fracture (P=0.004,
OR=0.235), etc. GCS was the strongest predictor (Wald=50.54). Although intracerebral hemorrhage
and lung tissue injury (P>0.05) were retained due to clinical relevance, the model showed excellent
discriminatory power, with an area under the curve (AUC-ROC) of 0.917 and a 95% confidence
interval of 0.886–0.948.
Conclusion: The MTPS scoring system developed in this study can predict the prognosis of multiple
trauma patients with strong discrimination (0.917) and is expected to improve the quality of trauma
care in accordance with WHO guidelines at RSSA Malang.

Abstract Objective: Orthostatic hypertension (OH) is one of the most common symptoms of autonomic
nervous system disorder in patients with type 2 diabetes. This study aimed to determine the
percentage of OH among Vietnamese older adults with type 2 diabetes and its influencing factors.
Methods: A cross‐sectional descriptive study was conducted using convenience sampling to recruit
96 older adults with type 2 diabetes who received care at a large hospital in central Vietnam between
November 2020 and June 2021. Data were collected using a demographic and health-related
questionnaire and Omron electronic sphygmomanometers for blood pressure (BP) measurement.
OH was diagnosed according to the 1996 diagnosis criteria of the American Autonomic Society
and the American Academy of Neurology. Descriptive statistics, independent t-test, chi-square,
and univariable and multivariable logistic regression were used for analysis, with p-value≤0.05
considered significant.
Results: The relative frequency of orthostatic hypotension (OH) among older adults with type 2
diabetes was 46.9%. Multivariable logistic regression identified gender, HbA1C level, and duration
of diabetes as significant predictors of OH. Specifically, females had 5.44-fold higher odds of
developing OH compared to males (OR=5.44; 95% CI: 1.94–15.25; P=0.001). Each one-unit increase
in HbA1C was associated with a 1.33-fold increase in the odds of OH (OR=1.33; 95% CI: 1.002–
1.77; P=0.049). Additionally, longer diabetes duration was linked to higher odds of OH, with an
8.3% increase in odds for each additional year of diabetes (OR=1.08; 95% CI: 1.01–1.16; P=0.018).
Although stroke history and kidney failure showed elevated odds ratios, their associations with OH
were not statistically significant (P>0.05).
Conclusion: Orthostatic hypotension (OH) is highly prevalent among older adults with type 2
diabetes, particularly in females with prolonged disease duration and poor glycemic control
(high HbA1C). Clinically, these findings highlight the need for healthcare providers to prioritize
routine screening and tailored management strategies for this high-risk group, aiming to prevent
complications such as falls, cardiovascular events, and decreased quality of life

Abstract Introduction: Snakebite envenoming is a significant public health problem in rural tropical regions, often resulting in disability and death. Timely hospitalization and prompt administration of antivenom are crucial for survival. However, factors such as limited awareness, poor access to healthcare, antivenom therapy, and reliance on traditional healers contribute to delays in seeking medical care, thereby increasing complications and adverse outcomes.
Methods:  This cross-sectional analytical study aimed to evaluate pre-hospital delay, its associated factors, and related complications among patients with snake envenomation presenting to the emergency department of a tertiary care public center in South India, from August 2023 to May 2024. This study included 100 adult participants with confirmed snakebite characteristics. Participants were selected through consecutive sampling, and data collection focused on details of the snakebite incident, time of hospital presentation, causes of delay, and complications. The data were analysed using mean ± standard deviation, median (interquartile range), and associations were tested using the Chi-square test, Fisher’s exact test, and the Mann-Whitney U test.
Results:  In our study, 18% of participants arrived at the hospital more than 4 hours after envenomation, with a median arrival time of 90 minutes. Among the study participants, prehospital practices included washing the bite site with soap and water (n = 19, 19%) and application of native concoctions (n = 17, 17%). Lack of awareness and knowledge regarding snakebite contributed to delayed hospital arrival. On the first day of admission, the most common complications were leukocytosis (83%), dyselectrolytemia (n =70, 70%) hepatic dysfunction (n = 56, 56%) renal dysfunction (n = 57, 57%), haematuria (n = 48, 48%), and metabolic acidosis (n = 45, 45%). Delayed presentation was significantly associated with higher rates of complications like hematuria (p = 0.003), renal dysfunction (p = 0.008),  metabolic acidosis (p = 0.047)
Conclusion: The current study revealed that traditional practices, combined with a lack of awareness about bites, socioeconomic constraints, and the absence of a guardian, often lead to delayed medical care. These delays result in longer hospital stays, increased morbidity, and higher mortality. Early hospitalization can significantly reduce complications, disability, and mortality in patients with snake envenomation.

Abstract Objective: Platelet-rich plasma (PRP), derived from the patient’s own blood and containing a high
density of bioactive compounds, is an emerging therapeutic option for the management of spinerelated disorders. This study aimed to evaluate the short-term efficacy of PRP therapy in managing
chronic discogenic low back pain compared with conventional treatment.
Methods: In the present randomized controlled trial, 32 participants were enrolled from the
Neurosurgery Ward at Shahid Bahonar Hospital in Kerman; all patients had a diagnosis of chronic
discogenic low back pain. The subjects were randomly assigned to a PRP treatment group (n=15)
and a control group (n=17). PRP was prepared using a standardized protocol and injected into the
affected disc under fluoroscopic guidance. Control group participants underwent conventional
treatment, specifically physical therapy and analgesics. Pain intensity (VAS), functional disability
(ODI), analgesic use, and adverse events were monitored at baseline and at 1, 4, and 12 weeks, and
at 6 months post-treatment.
Results: The PRP and control groups had mean ages of 47.5 (±9.2) and 49.8 (±8.8) years,
respectively (P=0.487). The PRP intervention resulted in significantly improved VAS scores as
early as 1 week post-treatment, with improvements persisting at weeks 4 and 12 and at month 6
(P<0.05). The PRP group showed greater reductions in ODI scores at both the 12-week and 6-month
follow-ups (P<0.05).
Conclusion: PRP therapy significantly alleviates pain and improves function in patients with low
back pain. This makes it a promising alternative to conventional treatment approaches

Abstract Introduction: This study aimed to investigate the diagnostic accuracy of serum levels of lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) in evaluating the risk of Acute Kidney Injury (AKI) following traumatic rhabdomyolysis.
Methods: A systematic review and meta-analysis were conducted by searching Medline, Embase, Scopus, and Web of Science for relevant studies up to June 2025, considering terms such as ‘‘Crush Syndrome,’’ ‘‘Crush Injury,’’ ‘‘Rhabdomyolysis,’’ AND ‘‘Serum Glutamic Oxaloacetic Transaminase,’’ ‘‘SGOT,’’ or ‘‘Aspartate Transaminase.’’ Studies that compared LDH or AST levels in traumatic rhabdomyolysis patients with and without AKI were included. The pooled effect size was evaluated using the standardized mean difference (SMD), and a 95% confidence interval (CI) was calculated. A random-effects model was employed to handle the heterogeneity. Subgroup analyses were conducted based on age group (adults and pediatrics). All analyses were performed using the statistical program STATA 17.0.
Results: For AST, the initial database search identified a total of 5,120 articles (2362 duplicates). Initially, 2,758 studies were screened by title and abstract, 52 articles were selected for full-text assessment, and finally, six articles were included in the quantitative analysis. In the case of LDH, the initial database search identified 4,044 articles (1471 duplicates). The initial 2,573 articles were screened by title and abstract, 49 articles were selected for full-text review, and finally, five studies were included in the quantitative analysis.
A total of seven studies involving 277 AKI and 2592 non-AKI patients were included in the meta-analysis. The pooled SMD for AST was 1.46 (95% CI: 0.79–2.13, I² = 88.02%) in adults and 0.80 (95% CI: 0.23–1.37, I² = 65.49%) in children. Similarly, the SMD for LDH was 2.16 (95% CI: 0.20–4.11, I² = 97.37%) in adults and 1.18 (95% CI: 0.70–1.67, I² = 32.94%) in children.
Conclusion: Current evidence suggests a significant association between elevated levels of AST and LDH and the incidence of AKI following traumatic rhabdomyolysis, with moderate and low levels of evidence, respectively. However, due to the limited number of studies, it was not possible to assess their effectiveness as a screening test.

Abstract Objective: Blunt liver trauma in pediatric patients presents a significant clinical challenge,
especially in high-grade injuries complicated by multiple life-threatening conditions. While nonoperative management (NOM) is the standard of care for hemodynamically stable patients, severe
complications require an individualized, multidisciplinary approach.
Case Presentation: We present a 15-year-old boy with a grade V blunt liver injury following a
car accident. Initially stabilized with non-operative management, he later developed three rare
complications: abdominal compartment syndrome, acute kidney injury, and bile leakage. The
first two complications were treated with emergency decompressive laparotomy and continuous
renal replacement therapy. At the same time, bile leakage from a disrupted right posterior hepatic
duct was managed with percutaneous drainage and adjunctive glucagon therapy. With vigilant
monitoring and tailored interventions, he showed marked recovery within 2 months, and follow-up
imaging confirmed substantial improvement.
Conclusion: This case highlights the delicate balance of managing severe pediatric trauma, blending
established protocols with innovative approaches. The occurrence of three rare complications
in a single patient underscores the exceptional nature of this case. Successful management of
abdominal compartment syndrome, acute kidney injury, and bile leakage demonstrates the
importance of early diagnosis, multidisciplinary teamwork, and adaptability in complex trauma
care. It exemplifies how integrating evidence-based practices with novel strategies can transform
life-threatening conditions into successful recoveries

Abstract Objective: Cerebral fat embolism (CFE) is a rare but potentially life-threatening complication of
long-bone fractures. It poses a significant diagnostic challenge due to its heterogeneous clinical
presentation and frequently normal findings on early investigations. This report describes an atypical
case of delayed-onset cerebral fat embolism characterized by neurological deterioration despite
unremarkable initial pulmonary and neurodiagnostic findings and the absence of an intracardiac
shunt, which is commonly implicated in the passage of fat emboli into the arterial circulation. A
focused review of the literature is also provided to emphasize key diagnostic considerations and
clinical implications.
Case Presentation: A 20-year-old male presented following a road traffic accident with a right
subtrochanteric femur fracture. The patient was neurologically intact and hemodynamically
stable at admission. Forty-eight hours later, he developed acute respiratory distress followed
by progressive neurological deterioration, culminating in coma and the need for mechanical
ventilation. Initial investigations, including computed tomography of the brain (CT), computed
tomography pulmonary angiography (CTPA), electroencephalography (EEG), routine laboratory
tests, and transthoracic echocardiography (TTE), were unremarkable, with no evidence of a rightto-left intracardiac shunt. Persistent unexplained neurological impairment prompted magnetic
resonance imaging of the brain (MRI) on day five, which demonstrated multiple bilateral punctate
diffusion-restricted lesions in the subcortical and deep white matter, forming the characteristic
starfield pattern consistent with cerebral fat embolism. The patient was managed with supportive
critical care, systemic corticosteroids, and rehabilitation, resulting in gradual neurological recovery
and a favorable functional outcome.
Conclusion: This case highlights the diagnostic challenge posed by CFE. It emphasizes the
importance of maintaining a high index of suspicion in trauma patients who develop unexplained
neurological symptoms, particularly when initial imaging is inconclusive. Prompt MRI evaluation
and timely life-supportive management are essential for better outcomes