Original/Research Article

Prevalence of Arcuate Foramen among Emergency Department Visitors; an Epidemiologic Study

Seyyed Mahdi Zia Ziabari, Payman Asadi, Malek Masoud Ansar, Alireza Razzaghi, Vahid Monsef Kasmaei

Iranian Journal of Emergency Medicine, Vol. 4 No. 2 (2017), 30 March 2017, Page 51-46

Introduction: Arcuate foramen anomaly is an anatomic variation in the first thoracic vertebrae that forms a space for passing of vertebral artery. Considering the role of this bony bridge in migraine development and its effect on prevalence of various types of pain in head, shoulder, and neck areas, as well as its importance in screw placement on the lateral mass of atlas, the present study evaluated the prevalence of this anomaly among those presented to the emergency department (ED) of Poursina Hospital, Rasht, Iran. Methods: The present study is a cross-sectional one, carried out on patients over 18 years of age that visited ED of Poursina Hospital, Rasht, Iran, in 2015 and underwent lateral neck radiography using census method. Data of the patients were gathered using their medical profile or by asking them on the phone, and recorded in a pre-designed checklist. Data were analyzed with the aid of SPSS version 24 and chi-square and independent t-test statistical tests. P-values less than 0.05 were considered as significant. Results: 1146 patients with the mean age of 37.95 ± 15.88 years were studied (69.2% male). Mean age was 36.05 ± 15.26 years among men and 14.21 ± 16.44 years among women (p < 0.001). The overall prevalence of arcuate foramen was calculated to be 9.6% [95% confidence interval 7.89 – 11.30; 110 patients (74.5% male)]. This anomaly had a prevalence of 10.34% in men and 7.93% in women (p > 0.05). Conclusion: Based on the results of the present study, the prevalence of arcuate foramen anomaly was estimated to be 9.6% in Guilan province using lateral neck radiography. Its prevalence rate was 10.34% in men and 7.93% in women. Considering this prevalence rate, presence of this anomaly should be considered as a possibility in patients with complaints of head, shoulder, and neck pain. 

Adverse Effects of Intratracheal Intubation by Emergency Medicine Residents; a Cross-Sectional Study

Iraj Golikhatir, Hamid Reza Hatamabadi, Ali Arhami Dolaatabadi, Zabihollah Taleshi

Iranian Journal of Emergency Medicine, Vol. 4 No. 2 (2017), 30 March 2017, Page 56-52

Introduction: Airway management of patients is among the responsibilities of an emergency medicine specialist. To decrease the adverse effects of intubation, sufficient knowledge of the drugs used and proper skill in intratracheal intubation is needed. Therefore, the present study was carried out aiming to evaluate the success rate and adverse effects of intratracheal intubation by emergency medicine residents. Methods: This cross-sectional study was done during 18 months in the emergency department (ED) of Imam Hossein Hospital, Tehran, Iran. All the residents who had spent at least 6 months of their education program in ED and had passed the 2-month specialized course in anesthesiology rotation were included in the study using census method. The researcher, who was a senior emergency medicine resident, would be present at the time of intubation and would gather the required data using a pre-designed checklist. Hypoxia, hypotension, aspiration, esophageal intubation, right main bronchus intubation, fracture of teeth, and tracheal rupture were considered as the studied adverse effects. In addition, more than 3 attempts for intratracheal intubation was considered unsuccessful intubation. Results: Finally, the findings of 100 patients with the mean age of 63.4 ± 16.8 years were analyzed (57% female). Attempts for intratracheal intubation were successful in all cases and 81 patients were intubated on first attempt, 15 on second attempt and 4 on third attempt. There was no unsuccessful intubation that needed more than 3 attempts among the residents. Success rate of intubation was 31 (83%) cases among first year residents, 52 (94%) cases in second year residents and 17 (100%) cases for third year residents. This difference among residents in various levels was statistically significant (p = 0.0014). Hypoxia, esophageal intubation, aspiration, hypotension, and right main bronchus intubation, were the most common adverse effects observed, respectively. No fracture of teeth or tracheal rupture case was observed. Rates of esophageal intubation (p = 0.002) and right main bronchus intubation (p = 0.023) were significantly different among residents of different levels. Number of attempts and adverse effects of intratracheal intubation were significantly related in this study as 75 (88%) cases of the observed adverse effects were seen in those who were intubated on the first attempt. Meanwhile, adverse effects were seen in only 6 (7%) cases that were intubated on the second or third attempt (p < 0.001). Conclusion: Attempts for intratracheal intubation was successful in all the patients but the difference in number of attempts was statistically significant between the residents of various levels. Hypoxia, esophageal intubation, aspiration, hypotension, and right main bronchus intubation, were the most common adverse effects observed, respectively. No fracture of teeth or tracheal rupture case was observed. 

Evaluating the Timing of Emergency Department Services in Hospitals of Arak City

Ali Jadidi, Soleiman Zand, Mahmood Khosravi, Mehdi Harorani, Akram Bayati, Taghi Amni, Rahele Mohmadi, Mahdi Safarabadi

Iranian Journal of Emergency Medicine, Vol. 4 No. 2 (2017), 30 March 2017, Page 62-57

Introduction: Emergency department (ED) is one of the most important wards in a hospital and its function can deeply affect the function of other wards and patient satisfaction. Therefore, the speed of providing services in ED is of great importance in order to decrease mortality and disabilities. Thus, the present study was done with the aim of evaluating timing of services in 2 teaching hospitals in Arak. Methods: In this cross-sectional study, researchers were present in the hospitals for 3 months in various working shifts and recorded the time of the patients’ presentation to triage unit. They also recorded the times of physician’s visit, sending samples to laboratory and receiving their results, radiography performance, and decision making in a checklist using a chronometer. Results: In the present study, 200 patients with the mean age of 45.8 ± 2.5 years participated (53.5% male). The findings of the study showed that mean time interval between triage and physician’s visit was 8.1 ± 4.3 minutes, time between visit and the first treatment measure was 8.7 ± 2.3 minutes, time between ordering a test and receiving results was 60.9 ± 17.5 minutes, time between ordering radiography and getting the results was 55.4 ± 18.1 minutes, time between ordering electrocardiography and getting the results was 5.4 ± 2.3 minutes and the patient’s length of stay in ED was 6.9 ± 3.3 hours. Conclusion: It seems that although the timing of providing the studied services is less than similar studies in some cases, it is still far from the international standards. 

Evaluating Knowledge and Performance of Emergency Medical Services Staff Regarding Pre-Hospital Triage

Hamidreza Aghababaeian, Soheila Sedaghat, Nourollah Taheri, Seyed Ahmad Mousavi, Morteza Habibi-Moghadam, Fatemeh Pourmotahari

Iranian Journal of Emergency Medicine, Vol. 4 No. 2 (2017), 30 March 2017, Page 67-63

Introduction: One of the important indices of preparedness for accidents and disasters is evaluation of knowledge and performance of emergency medical services (EMS) staff regarding principles of triage. Therefore, the present study was done with the aim of determining the knowledge and performance of EMS staff regarding START pre-hospital triage in 2016. Methods: This cross-sectional study was carried out on EMS staff in north of Khuzestan province. Individuals who met the inclusion criteria were included via census sampling. Data were gathered via a questionnaire consisting of 5 demographic data questions, 15 triage knowledge questions and 19 triage performance questions. The data were then statistically analyzed. Results: 117 individuals with the mean age of 33.21 ±6.08 years and mean job experience of 7.35 ± 4.32 years participated all of whom were male. Mean knowledge of the studied population regarding triage was average (mean score: 9.44) and their performance score revealed that their performance was also average (mean score: 9.58). Conclusion: Based on the findings of the current study, knowledge and performance of EMS staff in north of Khuzestan province was average regarding pre-hospital triage. 

Evaluating the Correlation between Intratracheal Intubation Difficulty Scoring Systems and Anthropometric Factors of Individuals’ Body; an Epidemiologic Study

Maryam Motamedi, Maleheh Soltani, Marzieh Amiri, Elham Memary, Alireza Baratloo

Iranian Journal of Emergency Medicine, Vol. 4 No. 2 (2017), 30 March 2017, Page 73-68

Introduction: The aim of this study was to evaluate the correlation between malampathy score, upper lip bite test and 3-3-2 maneuver with anthropometric factors of body in people. Methods: This cross-sectional study was carried out during 2014-2015 in Yazd, Iran. Samples were selected from the whole population using simple randomization and were included in the study after giving informed consent. Baseline and demographic data including age, sex, and anthropometric factors of their body such as weight, height, neck circumference, waist circumference, hip circumference, body mass index (BMI), and waist to hip ratio were gathered in a pre-designed checklist. Then malampathy score, upper lip bite score, and 3-3-2 maneuver were evaluated and recorded by the researcher. Results: 498 people with the mean age of 42.1 ± 16.1 were studied (51% female). In total, 168 (69%) of the studied men and 182 (72%) of the studied women had a BMI higher than 25. 74 (39%) of the men had a waist to hip ratio over 0.93 and 152 (60%) of the women had a waist to hip ratio over 0.81. Results of the upper lip bite test was a score of 3 in 10 (2%) people, result of malampathy test was a score of 3 or 4 in 152 (31%) participants and result of 3-3-2 maneuver showed an abnormal condition in 20 (4%), which indicate the probability of difficult intubation. With an increase in age, based on all 3 methods, the probability of difficult intratracheal intubation rises (p < 0.001). However, none of the 3 evaluation methods showed a significant correlation between difficult intratracheal intubation and sex (p > 0.05). There was a significant correlation between malampathy score and upper lip biting with all anthropometric factors of the body. 3-3-2 rule also significantly correlated with weight, height, waist circumference, hip circumference, and BMI, but not with neck circumference (p = 0.328) or waist to hip ratio (p = 0.121). Conclusion: It seems that with an increase in age, based on all 3 methods, the probability of difficult intratracheal intubation rises. However, none of the 3 methods of intratracheal intubation difficulty evaluation have a significant correlation with sex. In addition, according to the results of the current study, a significant correlation exists between upper lip biting and malampathy score with all anthropometric factors of the body assessed in this study. Yet, 3-3-2 maneuver does not have a significant correlation with neck circumference or waist to hip ratio. 

Letter to Editor

Necessary Care When Facing Patients with Suspected Rabies in Emergency Department

Mohammad Darvishi, Behnam Shokati, Ebrahim Karimi

Iranian Journal of Emergency Medicine, Vol. 4 No. 2 (2017), 30 March 2017, Page 45-44

Rabies is one of the most ancient and dangerous diseases that have been introduced in medical texts. This disease has been reported in more than 150 countries around the world except for the South Pole. According to a report by world health organization (WHO) in 2015 about 99% of rabies cases are due to being bitten by a rabid dog and more than 95% of mortalities in humans following rabies have occurred in Asia followed by Africa. Most cases of human deaths due to rabies occur in India. There is little data available regarding Central Asia and Middle East and more studies are needed. Considering the deadly nature of this disease and noting that only 7 individuals have survived this illness until now as well as Iran’s geographical location, the importance of paying more attention to this disease is recognized even more. In a case report by Dr. Sadeghi et al. that has been published in Iranian Journal of Emergency Medicine, the furious form of the disease, which is the common type of rabies, has been introduced. In the end, the patient sadly died despite receiving immunoglobulin, being vaccinated after being exposed, and taking necessary treatment measures. What should be noted regarding the mentioned patient in our opinion is evaluating and giving information regarding nursing and burial process of the victim. Theoretically, the disease can be transmitted form one human to another in case of saliva and other secretions of the patient coming into contact with mucosa or open wounds of another, yet a definite and proved case of this has not been reported yet. Considering this point, people who take care of patients with suspected rabies should be vaccinated against the disease. Therefore, educating and training a special medical group for taking care of these patients like influenza and viral hemorrhagic fevers and etc seems necessary. Additionally, exposed individuals should use mask, gloves, gown and glasses throughout the time of exposure. Moreover, considering the deadly nature of the disease, all the individuals exposed to the mucosa, saliva, or other mouth secretions of the rabies patient should receive a complete set of vaccine after exposure if they have not been vaccinated before; especially if they have an open wound or cracks in their hand and foot. The corpse of the patient dying from rabies should not be buried conventionally. The corpse should be disinfected and then wrapped in a thick impenetrable piece of nylon after spraying disinfectant powder and then sanitarily buried as a package. Therefore, if a patient dies of rabies, in addition to taking the aforementioned measures, it is suggested to inform the authorities of cemeteries regarding the burial of these victims. 

Brief Report

Nowadays, the academic world is faced with various challenges involving fraudulent activities related to publishing. The most important of these concerns the fast growth in predatory journals, a phenomenon that has more victims than others. In response, we have offered papers and proceedings that discuss the issue of predatory journals in trying to increase the awareness of researchers. The unproven hypothesis is that by increasing awareness among junior researchers the numbers of victims will decrease. This hypothesis, however, has never been tested. In this short piece, we try to prove or reject this conjecture. 

Case Report

Lidocaine induced seizure during rapid sequence intubation, a case report

Majid Hajimaghsoudi, Faeze Zeinali, Mehrdad Mansory, Javad Seyedhosseini

Iranian Journal of Emergency Medicine, Vol. 4 No. 2 (2017), 30 March 2017, Page 82-79

The best choice for Patients who need intubation in the emergency ward is rapid sequence intubation in order to reduce laryngoscopic adverse effect and to have better condition for intubation. Lidocaine is one of the drugs used in premedication before induction and paralysis to attenuate laryngoscopic sympathetic reflex. We present a patient that had an episode of seizure immediately after administering lidocaine intravenously during rapid sequence intubation, not reported before.


Acute Metabolic Complications of Diabetes in Emergency Department

Anita Sabzghabaei, Sahar Mirbaha, Majid Shojaee

Iranian Journal of Emergency Medicine, Vol. 4 No. 2 (2017), 30 March 2017, Page 90-83

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are 2 acute metabolic crisis of uncontrolled diabetes mellitus. DKA usually occurs in patients with type 1 diabetes and HHS is seen mostly in those with type 2. In DKA, hyperglycemia, metabolic acidosis, and dehydration are the most prominent clinical symptoms and HHS is identified by hyperglycemia, severe dehydration without acidosis, and alterations in level of consciousness from sleepiness to confusion, seizure and coma. Treatment for both conditions is based on correction of dehydration and hyperglycemia, and establishing homeostasis of electrolytes. In the present review, we decided to present a comprehensive picture of the pathology and clinical manifestations, diagnosis and treatment of these 2 important conditions.