Treatment in carbon monoxide poisoning patients with headache: a prospective, multicenter, double-blind, controlled clinical trial.

BACKGROUND: There is a lack of specificity of the analgesic agents used to treat headache and underlying acute carbon monoxide poisoning. OBJECTIVE: To compare effectiveness of "oxygen alone" vs "metoclopramide plus oxygen" vs "metamizole plus oxygen" therapy in treating carbon monoxide-induced headache. DESIGN: A prospective, multicenter, double-blind, controlled trial. SETTING: Three emergency departments in Turkey. POPULATION: Adult carbon monoxide poisoning patients with headache. METHODS: A total of 117 carbon monoxide-intoxicated patients with headache were randomized into 3 groups and assessed at baseline, 30 minutes, 90 minutes, and 4 hours. MAIN OUTCOME MEASURE: The primary outcome was patient-reported improvement rates for headache. Secondary end points included nausea, need for rescue medication during treatment, and reduction in carboxyhemoglobin levels. RESULTS: During observation, there was no statistical difference between drug type and visual analog scale score change at 30 minutes, 90 minutes, or 4 hours, for either headache or nausea. No rescue medication was needed during the study period. The reduction in carboxyhemoglobin levels did not differ among the 3 groups. CONCLUSION: The use of "oxygen alone" is as efficacious as "oxygen plus metoclopramide" or "oxygen plus metamizole sodium" in the treatment of carbon monoxide-induced headache.

Spotted lipid sign floating on the blood to differentiate obscured open fractures from simple wound lacerations.

Open fractures are not so obvious sometimes, and in the case of multiorgan injuries, they may be misdiagnosed in emergency department. Here, we report a 48-year old man with motor vehicle crash injury. There were ominous facial, vertebral, thoracic, and abdominal injuries as well as distal femoral shaft fracture and multiple skin lacerations in different parts of the body in the initial examination. On the tertiary examination, we incidentally caught an important finding showing an open fracture: oily (greasy) bleeding from the wound (Video 1, Fig. 1 and 2). We think that the characteristic of the blood, namely, the spotted lipid sign floating on the blood, is a unique and pathognomonic finding differentiating between simple wound lacerations and obscured open fractures.

Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury.

This is the first case report of an adult who had spontaneous reduction of ileoileal intussusception occurred after punching to the abdomen. A 40-year-old man was brought to our emergency department by ground ambulance due to pounding and punching a few hours ago. Physical examination showed multiple dermabrasions on his face, abdomen, and lower extremities. All other examinations were unremarkable except that of mild abdominal pain. Laboratory results gave no clues. On abdominal x-ray, paucity of intestinal gas, pseudomass and surrounding gas appearances were visible. No nausea or vomiting occurred during observation. His abdominal pain resolved gradually. On the 24th hour after admission, control computed tomography showed that the findings of intussusception disappeared. He was discharged after 1 day of observation. Outpatient follow-up did not show any abnormality. We suggest that, in patients with mild to moderate trauma, even if the patient has mild abdominal pain, physicians should rule out invagination. Computed tomography is the suggested imaging modality. These patients should be kept in close follow-up. If symptoms resolve and intussusception findings disappear in computed tomography, no further treatment is required.

Dual-source computed tomography may define cardiac contusion in patients with blunt chest trauma in ED.

We report a 20-year-old woman with blunt chest trauma because of a motor vehicle injury who has traumatic asphyxia and hypotension. The diagnosis of blunt cardiac injury was put by using dual-energy computed tomography in the emergency department because other laboratory and imaging modalities were useless. After hospitalization in intensive care unit, she was treated with supportive and antiedema therapy. The patient was extubated on the fifth day and discharged on the ninth day without any sequel. Coexistence of traumatic asphyxia with blunt cardiac injury is rare. Several imaging techniques such as transthoracic and transesophageal echocardiography, contrast-enhanced multislice thorax computed tomography or initial electrocardiogram, and troponin I levels are used to detect the myocardial damage, but diagnostic capability is low. Dual-energy computed tomography is a promising new technology with the ability of defining blunt cardiac injuries and may have an indication in the emergency setting in patients with hemodynamic instability to rule in traumatic cardiac complications especially when electrocardiogram and transthoracic echocardiography are useless in the emergency department.

A novel insertion mutation identified in exon 10 of the MEFV gene associated with Familial Mediterranean Fever.

BACKGROUND: Familial Mediterranean Fever (FMF), characterized by recurrent fever and inflammation of serous membranes, is an autosomal recessive disease caused by mutations in the Mediterranean fever (MEFV) gene. Around 296 mutations have been reported to date. METHODS: Two two-generation Turkish families with a total of four members diagnosed with FMF clinically were screened with DNA sequencing performed on exon 2 and exon 10 of the MEFV genes. Then, complete exome sequencing analysis of MEFV gene was done for four patients in whom novel mutation was detected. RESULTS: A novel single base Guanine (G) insertion mutation in the coding region of MEFV gene, named c.2330dupG (p.Gln778Serfs*4 or Q778SfsX4) resulting in a mutated Pyrin/Marenostrin protein was identified. CONCLUSIONS: This is the first report of a new mutation in exon 10 of the MEFV gene in two Turkish families. This novel pattern of insertion mutation may provide important information for further studies on FMF pathogenesis.

Sensitivity and specificity of red cell distribution width in diagnosing acute mesenteric ischemia in patients with abdominal pain.

BACKGROUND: We investigated the utility of the red cell distribution width (RDW) in diagnosing acute mesenteric ischemia (AMI) in patients with abdominal pain. METHODS: The patients were divided into two groups in this retrospective case-control study: patients with AMI and patients with abdominal pain who did not require urgent surgery. Venous blood was collected from the patients upon admission to the emergency department, and abdominal computed tomography angiography was performed. The RDW and hematological and biochemical parameters of the groups were compared. The primary outcome was AMI among the patients with abdominal pain. The secondary outcome was mortality, complaint period, and size of ischemia/necrosis among the AMI patients. RESULTS: The RDW, white blood cell lactate dehydrogenase, and blood urea nitrogen of the patients with AMI were significantly different from those of the control group. When the average RDW (15.04 %) of the patients with AMI was used as a cut-off value, the sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood (-LR) were 40.8 %, 81.2 %, 2.17, and 0.73, respectively. When patients with AMI and anemia were included in the group, the sensitivity and specificity values did not change. There was no relation between the RDW and mortality, size of the ischemia/necrosis, and complaint period. Furthermore, there was no significant difference in the average RDW between the patients with ischemia/necrosis in the small intestine only and those with ischemia/necrosis in the colon. CONCLUSION: The RDW on admission is of marginal help to diagnose AMI among patients with abdominal pain.

Intracranial hemorrhage with electrocardiographic abnormalities and troponin elevation.

Electrocardiographic (ECG) abnormalities and cardiac troponin I elevation are seen in addition to the classic clinical symptoms and signs of subarachnoid hemorrhage (SAH). We aimed to show that, in patients with ST elevation, troponin elevation, and altered consciousness, the reason may be SAH. A 36-year-old man presented to emergency service with ECG abnormalities, high level of cardiac troponin I, and neurologic symptoms. In the patient's initial ECG, there were sinus arrhythmia, bradycardia, T-wave inversions inferiorly, and concave ST elevations in V1 to V4. Three hours later, his ECG showed increased ST-segment elevations with normal heart rate. The patient's troponin I value was 10 mg/L. Ejection fraction was 60%, and there were no wall motion abnormalities on echocardiography. Computed tomographic scan of the brain demonstrated SAH with falx sign and midline cerebellar hematoma (3 × 4 cm in size) in the occipital region. The patient died on the 10th day of follow-up because of severe metabolic acidosis, multiorgan failure, and bradycardia. Cardiac evaluation is recommended in patients with intracranial hemorrhage in many studies. In our opinion, if there are neurologic symptoms or signs in patients diagnosed as acute myocardial infarction with ECG changes and troponin elevation, requesting threshold of brain computed tomography should be low before the thrombolytic therapy.

Complete atrioventricular block due to overdose of pregabalin.

Pregabalin, a synthetic derivate of the inhibitory neurotransmitter γ-aminobutyric acid, shows antiepileptic, analgesic, anticonvulsant, anxiolytic, and sleep-modulating activities. The major advantage of pregabalin is its relative reliability, easy use, high tolerance, and lack of negative interaction with other drugs. A 65-year-old woman with medical histories of diabetes mellitus, lumbar spondylosis, diabetic nephropathy, chronic renal failure, and anemia of chronic disease was admitted with the complaint of dizziness and syncope. She had been taking pregabalin 300 mg daily for 8 months. Electrocardiogram revealed complete atrioventricular (AV) block and right bundle-brunch block with a heart rate of 39 per minute. Her creatinine was 1.8 mg/dL, and creatinine clearance was 50 mL/min. Pregabalin treatment was discontinued. Four days later, the complete AV block resolved spontaneously to Mobitz type II block and to sinus rhythm with right bundle-brunch block on the seventh day. To our knowledge, this is the first case of complete AV block associated with pregabalin. We believe that AV block occurred as a result of pregabalin's effect on L-type Ca++ channels in the heart. Pregabalin's different effects on electrocardiogram and on the heart in different individuals may have an association with the patterns of distribution of the L-type calcium channels in myocardium.

Two questions for Kounis syndrome: can we use magnetic resonance imaging in the diagnosis and does ST elevation correlates with troponin levels?

Kounis syndrome (KS) is an acute coronary vasospasm after exposure to an allergen due to mast cell degranulation and existing mediators. Various drugs, conditions, and environmental exposures can cause KS. We presented 2 cases, 1 of whom had taken an antiflu drug (containing paracetamol, pseudoephedrine, and dextromethorphan). His electrocardiogram (ECG) showed inferior ST elevations (2 mm) with normal cardiac biomarkers. His cardiac magnetic resonance imaging showed hypokinesis and myocardial hibernation on apical septum and on the left ventricle. The second patient took a pill of naproxen sodium. The ECG showed 1-mm ST elevation in leads DII, V5, and V6. His troponin was markedly elevated. These cases showed that there seems to be no correlation with ECG and troponin levels in KS. In addition, for patients in whom KS type 1 is expected without troponin elevation, noninvasive cardiac magnetic resonance imaging study seems to be appropriate for the diagnosis of KS.

A fatal folk remedy: rope wrapping to the back.

BACKGROUND: Despite the developments in medicine in recent years, people in many regions of the world still tend to use alternative, or non-medical, folkloric treatment methods for many different health problems. One of these methods is "rope wrapping to the back," which is considered to be therapeutic for patients with lumbar disc hernias or low back pain. This method is practiced by local individuals without medical training. CASE REPORT: Over the course of 3 years, 14 patients, 8 women and 6 men, presented to Atatürk University and Erzurum state hospitals in eastern Turkey after undergoing the folk treatment known as "rope wrapping to the back" for low back pain. One of the patients, who had symptoms of systemic infection, later died. Of the other patients, 4 had local infections, 6 had unresolved complaints, and 3 had other complaints. Nine of the patients were treated in the emergency department and 4 required surgery. Two case reports are provided as examples. CONCLUSION: Improvements are needed to increase the accessibility of health care, improve physician-patient communication, and provide information to people, so as to prevent the use of folk remedies, which can have serious complications, sometimes resulting in death.

Acute abdomen associated with organophosphate poisoning.

BACKGROUND: Pesticides are extensively used in developed and developing countries. OBJECTIVES: The present study was designed to evaluate the clinical course of patients with carbamate or organophosphate poisoning presenting to a University-based emergency department (ED). METHODS: All consecutive patients admitted to our ED due to intoxication with carbamate or organophosphate compounds over a 2-year period were enrolled prospectively. RESULTS: A total of 49 consecutive patients (26 females) were diagnosed with carbamate or organophosphate poisoning in the 24-month study period. The mean age of the patients was 32±13.1 years (range 16-70 years). Signs and symptoms most frequently noted in patients with organophosphate or carbamate poisoning were perspiration, vomiting, and bronchorrhea. Abdominal pain was reported by 65.3% of the patients. Abdominal ultrasonography was performed in 22 patients who complained of abdominal pain as a leading symptom. Among these, 63.6% were found to have abdominal free fluid. Pancreatitis and peritonitis developed in one case. Atropine treatment was administered for approximately 24-36h, with a mean total dose of 13.75±6.75mg. Pralidoxime was administered to 70.9% of patients with organophosphate poisoning, but was not used in patients intoxicated with carbamates. Endotracheal intubation and mechanical ventilatory support were required in 14.2% of the patients. Mean duration of mechanical ventilation was 3.7±2.2 days. The overall mortality rate was 10.2%. CONCLUSION: Patients with a diagnosis of organophosphate poisoning should be screened for acute abdomen. The findings in our study suggest that these patients should undergo routine abdominal ultrasonography, especially in cases with abdominal pain along with other abdominal complaints.

Myocarditis due to oral flurbiprofen use.

We report a 23-year-old man presenting with chest pain. He denoted skin eruptions on his hands, lips, mouth, and penis 24 to 36 hours after he had taken flurbiprofen 10 days ago. Detailed examination showed an ulcerated, pitching lesion with a dimension of approximately 2x2 cm on his penis; however, other explained skin lesions were ameliorated. ST elevations were present in the electrocardiogram. Cardiac biomarkers gradually rose. The scintigraphy showed myocardial hypoperfusion in the inferoseptal wall. This phenomenon is a rare case of myocarditis due to hypersensitivity reaction. In the case of nonspecific angina pectoris accompanied by electrocardiogram changes, drug-induced myocarditis must hold a place in differential diagnoses.

Plasmapheresis is useful in phenprobamate overdose.

Although previous scientific articles claim that morbidity and mortality are low in pure skeletal muscle relaxant ingestion, this is the 10th leading cause of death recently; however, this represents only a 2.1% ratio in adult toxic exposures in the United States. We report the case of a patient with phenprobamate overdose whose neurologic and psychiatric symptoms were the dominant findings. We were unable to perform hemoperfusion because of insufficient equipment. Thus, the patient was taken to for hemodialysis for 3 hours. However, the clinical response was inadequate. Furthermore, plasmapheresis was applied using 12 U of fresh frozen plasma for the consecutive 2 days. This caused resolution of neurologic and psychiatric symptoms. The patient was released with no residual complication on the fifth day of admission. We conclude that in phenprobamate intoxication, if hemoperfusion is impossible, plasmapheresis seems to be the best modality.

Computed tomography pulmonary angiography in the diagnosis of acute pulmonary embolism in the emergency department.

This study was undertaken to evaluate the use of computed tomography pulmonary angiography (CTPA) in patients with pulmonary embolism (PE) who were followed in the emergency department (ED). The files and computer records of 850 patients older than 16 years of age who were seen in the Hacettepe University Hospital ED between April 10, 2001, and December 1, 2005, and who required CTPA for PE prediagnosis and/or another diagnosis, were studied retrospectively. PE was identified by CTPA in 9.4% of 416 women and in 5.8% of 434 men. A significant difference (P<.05) was noted in the women and men in whom PE was detected. The mean age of the patients was 58.13+/-17.88 y (range, 16-100 y). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for clinical susceptibility to PE among patients who underwent CTPA were assessed at 95.3%, 48.2%, 13%, and 99.2%, respectively. CTPA was done for different reasons: aortic aneurysm dissection (n=1), cough distinctive diagnosis (n=1), dyspnea distinctive diagnosis (n=6), chest pain distinctive diagnosis (n=3), PE prediagnosis (n=51), and other reasons (n=2). Also, sensitivity, specificity, PPV, and NPV were found to be 95.4%, 16.2%, 14.4%, and 96%, respectively, for D-dimer. CTPA, which is accessible on a 24-h basis in the ED, is a valuable tool for the diagnosis of PE.

Does contrast media volume affect long-term survival in patients with chronic kidney disease?

INTRODUCTION: The aim of this study was to investigate the relationships between survival and related features in patients with chronic kidney disease undergoing cardiac catheterization and coronary angiography. MATERIAL AND METHODS: Three hundred and seven consecutive patients with an estimated glomerular filtration rate (e-GFR) less than 60 ml/min/1.73 m2 undergoing coronary angiography were enrolled in the study. The study population was pursued with a median follow-up duration of 41.5 months. RESULTS: In the Cox proportional hazards regression model, age (HR = 1.047, 95% CI: 1.011-1.084, p = 0.01), contrast media volume (HR = 1.004, 95% CI: 1.001-1.007, p = 0.008), angiotensin II receptor blocker (ARB) use (HR = 0.485, 95% CI: 0.261-0.901, p = 0.02), and e-GFR (HR = 0.978, 95% CI: 0.940-1.016, p = 0.04) were found to be independent predictors of long-term all-cause mortality. The survival analysis showed that the long-term all-cause mortality rate was higher in patients using contrast media volume greater than 140 ml compared to patients given less than or equal to 140 ml during the coronary angiography (3.6% vs. 11.6% log-rank, p = 0.001). CONCLUSIONS: In patients with chronic kidney disease undergoing cardiac catheterization, age, contrast media volume, e-GFR and low ARB use were found to be independent predictors of long-term all-cause mortality. Contrast media volume used > 140 ml was independently associated with long-term all-cause mortality compared to less than or equal to 140 ml during cardiac catheterization.

Is this a simple drug eruption to be discharged?

'Erythema Multiforme associated with Phenytoin And Cranial radiation Therapy' (EMPACT) is a very rare clinic situation and classified in EM-like drug reactions. It can be easily misdiagnosed as acute urticaria or drug eruption in ED. Initial symptoms may resemble a simple skin problem, but diagnosing and early hospitalization of the patients can be lifesaving. Here, we present a man with renal cell cancer and brain metastases who admitted to ED due to fever and generalized rash. His skin lesions beginning from his head and spreading through the torso appeared four days after the end of radiotherapy (11 days after the initial dose of both radiation and oral phenytoin). Inspection showed erythematous lesions on the scalp, neck, torso and arms. These lesions had desquomative character on the scalp. Erythematous maculopapular lesions with the tendency of fusion were also visible on the chest, abdomen, back, on the flexor areas of the arm, forearm and femoral region. Laboratory studies showed normal complete blood counts, high creatinine kinase, creatinine kinase-MB, gamma-glutamyl transpeptidase, aspartate aminotransferase, lactate dehydrogenase, albumin and total protein. After discontinuation of phenytoin and giving H1, H2 receptor blockers and steroid intravenously, he was discharged two weeks later with full recovery.