Topical Ketoprofen Versus Placebo in Children Presenting With Ankle Sprain to the Emergency Department: A Randomized Controlled Study.

OBJECTIVE: Despite the favorable data concerning topical agents use in outpatient clinics, they are not commonly in emergency departments (EDs). The present study aimed to compare the effect of 2.5% topical ketoprofen (gel form) to placebo in children presenting with ankle sprain to the ED. STUDY DESIGN: Children between 7 and 18 years old presenting with ankle sprain composed the study population. Study patients were randomized into 2 study arms: 2.5% ketoprofen gel and placebo administered in a 5-cm area locally. Pain improvements at 15 and 30 minutes were measured by visual analog scale. RESULTS: Median pain reductions at 15 minutes for ketoprofen and placebo groups were 27.5 (16-39) and 5 (4-10), respectively. Median changes in pain intensity at 30 minutes for ketoprofen and placebo gel groups were 48 (43-52) and 9 (6-16), respectively. When compared 2 arms for the pain improvement at 15 and 30 minutes, the differences between 2 study drugs were 20 (13-28) and 35 (29-41), respectively. There were 7 (12.7%) rescue drug needs in the placebo group and 1 (1.7%) in the ketoprofen group (difference, 10.9%; 95% confidence interval, -6% to 7%; P = 0.83). There were no adverse effects in either group. CONCLUSIONS: Ketoprofen gel is superior to placebo in ceasing pain in children presenting with ankle sprain to the ED with a high safety profile.

Longitudinal Clival Fracture in a Child: Case Report and Review of the Literature.

Clival fracture is a rare and serious injury, which mostly results in the death of the victim before reaching the hospital. The entity is hardly diagnosed in the early phase because of high mortality rates and deficiencies in completion of radiological imaging. The incidence of diagnoses increased year by year after the usage of computed tomography gained widespread availability. In this article, we aimed to present radiological and clinical characteristics of a 5-year-old patient brought to the emergency department after a motor vehicle accident. The most current recommendations with regard to the management of clival fracture of a pediatric patient are also discussed.

Ketoprofen gel improves low back pain in addition to IV dexketoprofen: a randomized placebo-controlled trial.

OBJECTIVE: Oligoanalgesia is common in emergency departments (EDs), and pain management is of concern for ED physicians. The aim of this study was to reveal the effect of ketoprofen gel in patients presenting with mechanical low back pain to the ED. METHOD: All the study patients received intravenous dexketoprofen additional to study drugs. After dexketoprofen, 2 g of 2.5% ketoprofen gel or placebo was administered to the site with pain and tenderness. Pain relief at 15 and 30 minutes was measured by visual analog scale scores. Rescue drug need and adverse effects were also recorded. RESULTS: A total of 140 patients were enrolled into the study. The mean age of the study patients was 35±12, and 56% (n=79) of them were male. The mean pain reduction at 30 minutes was 52±18 for ketoprofen gel and 37±17 for placebo, and ketoprofen gel was better than placebo at 30 minutes (mean difference, 16 mm; 95% confidence interval, 10-21). Ten patients (14%) in the placebo group and 2 patients (3%) in the ketoprofen gel group needed rescue drug (P=.35). CONCLUSION: Ketoprofen gel improves pain in patients presenting with mechanical low back pain to ED at 30 minutes in addition to intravenous dexketoprofen when compared to placebo.

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.

Adropin levels and target organ damage secondary to high blood pressure in the ED.

BACKGROUND: High blood pressure is still a challenge for emergency physicians to discern the patients that require further analysis to establish the existence of acute hypertensive target organ damage (TOD). The present study aimed to reveal that adropin levels are useful for detecting TOD in patients presenting with high blood pressure. METHODS: Patients presenting with a blood pressure of more than 180/110 mm Hg were enrolled into the study. After a resting period of 15 minutes, patients' blood pressures were measured thrice at 5-minute intervals while the patients were sitting on a chair, and the average of these measurements was accepted as the baseline value. Blood samples were obtained for either adropin levels or possible TOD during the emergency department admission. RESULTS: A total of 119 patients were included in the study. The mean systolic and diastolic blood pressures of study patients were 204.8±23.2 and 108.3 ± 10.3, respectively, and 42% (n = 50) of the patients had TOD. Although the adropin levels were similar between the patients with or without TOD (TOD group = 195 pg/mL, interquartile range [IQR]: 178-201; no-TOD group = 196 pg/mL, IQR: 176-204 [P = .982]), it is significantly higher in normotensive patients (normotensive group = 289 pg/mL, IQR: 193-403) compared with the hypertensive ones (P < .001). CONCLUSIONS: Despite the significantly higher levels of adropin in normotensive patients compared with hypertensive ones, adropin could not be used as a decision tool for detecting TOD in patients presenting with high blood pressure to the emergency department.

The Validity of YouTube Videos on Pediatric BLS and CPR.

BACKGROUND: There are few data regarding the validity of cardiopulmonary resuscitation (CPR) and basic life support (BLS) videos on YouTube in the medical literature, and those that do are only analyzing adult CPR videos. The present study aimed to determine the reliability and accuracy of pediatric CPR and BLS videos as to whether they are consistent with the 2010 CPR guidelines. MATERIALS AND METHODS: YouTube was scanned in January 2015 using the key words "Pediatric CPR Pediatric BLS" without any filters. The raw data collected in the study included sources that uploaded the videos, the record time, the number of viewers in the study period, and inclusion of human or mannequins. Furthermore, the contents of the videos were evaluated as to whether they are consistent with the 2010 resuscitation guidelines. All videos were seen by two independent researchers (emergency physicians) and scored between 0 and 8. RESULTS: In total, 1,200 videos were evaluated regarding the exclusion criteria, which yielded 232 eligible ones. Most of the videos were found to be uploaded by individuals with unspecified credentials (34.1%). Of the videos, 15.5% have content inconsistent with the 2010 guidelines. The median score of all the videos are not high enough (5 [interquartile range (IQR), 4-7]), and only one-third of the videos have optimal quality with scores of 7 or 8. The downloaded number of videos compatible with guidelines was significantly higher relative to the videos not compatible with the guidelines (15,389 [IQR, 881-31515] versus 477 [IQR, 108-3,797); p = 0.0001). The videos downloaded more than 10,000 times had a higher score than the others (median scores of 7 and 5, respectively; p = 0.0001). CONCLUSIONS: Moderate numbers of YouTube videos purporting to be about pediatric life support have optimal quality, and few of them are perfect. Furthermore, YouTube videos uploaded by news programs with an insufficient quality have the highest download rates.

Ketamine may be related to minor troponin elevations in children undergoing minor procedures in the ED.

OBJECTIVE: Ketamine is a dissociative anesthetic agent that has an increased frequency of usage in the last years particularly in emergency departments. In the present study, we aimed to determine whether ketamine is related to myocardial injury in children undergoing minor procedures. METHOD: Children younger than 18 years undergoing procedural sedation secondary to minor trauma composed the study population. Patients were administered ketamine with a dose of 1.5 mg/kg via intravenous route. QT interval was measured by Bazett's formula, and QT dispersion was determined by taking the average of 3 different QT intervals. High-sensitive troponin levels were measured before and 3 hours after the ketamine administration. RESULTS: A total of 30 patients were included into the study. Study subjects had a median age of 2 years (interquartile range, 1-4 years). There were 2 patients among the study patients who had troponin elevations 3 hours after the ketamine administrations. High-sensitive troponin levels of these 2 at the time of preketamine, 3, 5, and 24 hours after the ketamine administration were as follows: 5, 29, 15, and 5 ng/L and 3, 44, 41, and 4 ng/L, respectively. There was no difference before and after the ketamine administration for the corrected QT intervals and QT dispersions. CONCLUSION: Ketamine may be related to minor troponin elevations in children undergoing procedural sedation without a permanent cardiac dysfunction.

Pulmonary thromboembolism due to paliperidone: report of 2 cases.

Venous thromboembolism (VTE) is serious medical condition, which might be caused by psychotropic medications. Previously, antipsychotic-induced VTE due to olanzapine, risperidone, clozapine, and amisulpiride was reported. In this report, we present 2 cases of paliperidone-induced VTE.

Intravenous paracetamol versus dexketoprofen versus morphine in acute mechanical low back pain in the emergency department: a randomised double-blind controlled trial.

STUDY OBJECTIVE: The objective of this study was to determine the analgesic efficacy and safety of intravenous, single-dose paracetamol versus dexketoprofen versus morphine in patients presenting with mechanical low back pain (LBP) to the emergency department (ED). METHODS: This randomised double-blind study compared the efficacy of intravenous 1 gm paracetamol, 50 mg dexketoprofen and 0.1 mg/kg morphine in patients with acute mechanical LBP. Visual analogue scale (VAS) was used for pain measurement at baseline, after 15 and after 30 min. RESULTS: A total of 874 patients were eligible for the study, and 137 of them were included in the final analysis: 46 patients from the paracetamol group, 46 patients in the dexketoprofen group and 45 patients in the morphine group. The mean age of study subjects was 31.5 ± 9.5 years, and 60.6% (n=83) of them were men. The median reduction in VAS score at the 30th minute for the paracetamol group was 65 mm (95% CI 58 to 72), 67 mm (95% CI 60 to 73) for the morphine group and 58 mm (95% CI 50 to 64) for the dexketoprophen group. Although morphine was not superior to paracetamol at 30 min (difference: 3.8 ± 4.9 (95% CI -6 to 14), the difference between morphine and dexketoprofen in reducing pain was 11.2 ± 4.7 (95% CI 2 to 21). At least one adverse effect occurred in 8.7% (n=4) of the cases in the paracetamol group, 15.5% (n=7) of the morphine group, and 8.7% (n=4) of the dexketoprophen group (p=0.482). CONCLUSIONS: Intravenous paracetamol, dexketoprofen and morphine are not superior to each other for the treatment of mechanical LBP in ED.

Intravenous paracetamol versus dexketoprofen in acute migraine attack in the emergency department: a randomised clinical trial.

OBJECTIVE: Migraine is a common form of headache that is a major burden for patients who often seek emergency care. The goal of this study was to compare the effectiveness of intravenous non-steroidal anti-inflammatory medication (dexketoprofen) with paracetamol (acetaminophen) in the treatment of an acute migraine attack. MATERIALS AND METHODS: This prospective, randomised, double blind, controlled study was conducted in a tertiary care emergency unit. Study patients were randomised into two groups to receive either 50 mg of dexketoprofen trometamol or 1000 mg of paracetamol intravenously by rapid infusion in 150 mL of normal saline. Pain reduction was measured at baseline, and after 15 and 30 min, using a Visual Analogue Scale (VAS)) as the primary outcome. VAS is a measurement tool ranging from 0 (no pain) to 100 mm (worst pain). RESULTS: 200 patients were included in the final analysis. Mean (SD) age of the study subjects was 30.1 ± 11 years and 81% (n=162) were women. Median reduction in VAS score at 30 min was 56 (IQR 30-78.5) for the paracetamol group and 55 (IQR 34-75) for the dexketoprofen group, with a difference of 1 mm (95% CI -7 to 10) between the two groups. CONCLUSIONS: Intravenous paracetamol and dexketoprofen appear to produce equivalent pain relief for migraine in the emergency department. CLINICALTRIALS.GOV NO: NCT01730326.

Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blind controlled trial.

OBJECTIVE: To determine the analgesic efficacy and safety of intravenous single-dose paracetamol versus morphine in patients presenting to the emergency department with renal colic. METHODS: A randomised double-blind study was performed to compare the efficacy of intravenous paracetamol (1 g) and 0.1 mg/kg morphine in patients with renal colic. The efficacy of the study drugs was measured by a visual analogue scale and a verbal rating scale at baseline and after 15 and 30 min. The adverse effects and need for rescue medication (1 µg/kg intravenous fentanyl) were also recorded at the end of the study. RESULTS: 133 patients were eligible for enrolment in the study, with 73 patients included in the final analysis (38 in the paracetamol group and 35 in the morphine group). The mean±SD age of the subjects was 30.2±8.6 years and 51 (70%) were men. The mean reduction in scores at 30 min after study drug administration was 63.7 mm (95% CI 57 to 71) for paracetamol and 56.6 mm (95% CI 48 to 65) for morphine. The difference between pain reduction scores for the two groups at 30 min was 7.1 mm (95% CI -18 to 4), demonstrating no statistical or clinical significance. Two adverse events (5.3%) were recorded in the paracetamol group and five (14.3%) in the morphine group (difference 9%, 95% CI -7% to 26%). CONCLUSION: Intravenous paracetamol is effective in treating patients presenting with renal colic to the emergency department. CLINICAL TRIALS REGISTRATION NO: ClinicalTrials.gov ID number NCT01318187.

Work-related injuries in textile industry workers in Turkey.

BACKGROUND: This study was conducted as a survey including work-related injuries (WRI) of workers in the textile and clothing industry admitted to the emergency department (ED). METHODS: This prospective study included patients with WRI reportedly occurring in the textile and clothing industry over a two-year period. The study sample comprised only the casualties occurring at the workplace and while working de facto. RESULTS: A total of 374 patients were eligible for the study. More than three-fourths of the study sample were females (76.2%, n=285). A significant proportion of the patients were between 14 and 24 years of age (44.7%, n=167). Approximately two-thirds reported that this was their first admission to a hospital related to WRI (65.8%, n=246). WRIs occurred most frequently between 07:00-09:00 (27.3%) and 23:00-01:00 (17.9%). "Carelessness" and "rushing" were the most commonly reported causes of WRIs from the patients perspective (40.6% and 21.4%, respectively). Three-fourths of the patients reported that they were using protective equipment (74.3%, n=278). With respect to injury types, laceration/puncture/ amputation/avulsion injuries accounted for 55.6% (n=208) of the sample. Trauma to the upper extremities was the main type of injury in 75.1% (n=281) of the cases. CONCLUSION: Broad population-based studies are needed to define the situation as a whole in WRIs in the textile and clothing industry in the country. Strict measures should be undertaken and revised accordingly to prevent WRIs in these growing sectors.

Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial.

STUDY OBJECTIVE: We assess whether midazolam reduces recovery agitation after ketamine administration in adult emergency department (ED) patients and also compared the incidence of adverse events (recovery agitation, respiratory, and nausea/vomiting) by the intravenous (IV) versus intramuscular (IM) route. METHODS: This prospective, double-blind, placebo-controlled, 2×2 factorial trial randomized consecutive ED patients aged 18 to 50 years to 4 groups: receiving either 0.03 mg/kg IV midazolam or placebo, and with ketamine administered either 1.5 mg/kg IV or 4 mg/kg IM. Adverse events and sedation characteristics were recorded. RESULTS: Of the 182 subjects, recovery agitation was less common in the midazolam cohorts (8% versus 25%; difference 17%; 95% confidence interval [CI] 6% to 28%; number needed to treat 6). When IV versus IM routes were compared, the incidences of adverse events were similar (recovery agitation 13% versus 17%, difference 4%, 95% CI -8% to 16%; respiratory events 0% versus 0%, difference 0%, 95% CI -2% to 2%; nausea/vomiting 28% versus 34%, difference 6%, 95% CI -8% to 20%). CONCLUSION: Coadministered midazolam significantly reduces the incidence of recovery agitation after ketamine procedural sedation and analgesia in ED adults (number needed to treat 6). Adverse events occur at similar frequency by the IV or IM routes.

Therapeutic plasma exchange in amitriptyline intoxication: case report and review of the literature.

Severe amitriptyline poisoning results in cardiac and neurological toxicity and continues to be a leading cause of significant morbidity and mortality both in children and adults. We present a case of severe amitriptyline poisoning successfully treated with plasma exchange. Due to high plasma protein binding property of amitriptyline, plasma exchange therapy should be considered in cases of severe amitriptyline intoxication as a life saving therapeutic modality.

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.

[Characteristics of injuries due to traffic accidents in the pediatric age group]. / Pediyatrik yas grubunda trafik kazasi sonucu olusan yaralanmalar ve özellikleri.

BACKGROUND: In this study, the pediatric age group exposed to road traffic accidents was investigated, and patients with risk factors were studied to obtain relevant data. METHODS: Trauma patients under the age of 15 who were admitted to the emergency department of this university over five years were analyzed retrospectively. Age, gender, accident time and type, personal injury area, type of injury, and clinical outcome were examined. RESULTS: When the cases were analyzed with respect to the causes that led to the accidents, in-vehicle accidents formed the largest group (n=479, 59%). More than a quarter of all applications (34%) took place in summer months. Most of the applications were between 17:00 and 17:59 (n=94, 11.6%), followed by between 18:00 and 18:59 (n=88, 10.8%). The most commonly affected body parts were the head and neck region (n=226, 27.8%) and extremities (lower extremity: n=144, 17.7%; upper extremity: n=99, 12.2%). The most frequently seen injuries were contusions, abrasions, hematomas, and crush (n=443, 54.6%). The majority of patients who died were pedestrians who were hit by a motor vehicle (n=19, 59.4%). CONCLUSION: In this study, it was observed that in the pediatric age group, traffic accidents involving a pedestrian and vehicle collision have greater fatality.

[Evaluation of medicolegal reports written by physicians in the emergency unit with regard to deficiencies and mistakes]. / Acil servis hekimleri tarafindan düzenlenen adli raporlarin eksiklik ve yanlisliklar yönünden degerlendirilmesi.

BACKGROUND: Doctors working in emergency services often fulfill the task of preparing judicial reports. For a number of reasons, these reports have undesirable mistakes that become problematic in subsequent judicial processes. This study aimed to evaluate the judicial reports that were prepared over a certain period at a university hospital with regard to any mistakes or deficiencies. METHODS: The distribution of the judicial reports prepared between 01 June 2005 and 30 June 2009 in the emergency service of a University Research and Training Hospital was determined with respect to the types of cases, and their contents were studied for mistakes, deficiencies and legibility. Out of 3499 visits to the emergency service during the specified period, 3219 judicial reports that were accessible were considered in the evaluation. RESULTS: It was determined that the most frequent types of cases were traffic accidents and injuries by sharp and penetrating instruments. Furthermore, many mistakes were made frequently regarding the presence of life-threatening conditions, and personal identification information and times of the event and examination were often incomplete. CONCLUSION: The fact that the doctors largely failed to prepare precise reports and tended to write unsatisfactory reports even for cases with adequate information and findings was attributed to their insufficient training in this area. At the same time, mistakes in life-threatening situations and in treatment by using simple medical interventions stem from lack of training and sensibility. Pre- and post-graduate forensic medicine education must be considered highly important, and periodic on-the-job training must be organized, creating a better awareness among doctors regarding their legal responsibilities.

[Domestic accidents involving women and first aid knowledge]. / Kadinlarin basina gelen ev kazalari ve ilk yardim bilgi düzeyleri.

BACKGROUND: Domestic accidents (DA) are preventable and untoward events occurring in a house, pool or garage. Those events constitute a major issue in the context of public health. The objective of this study was to highlight the characteristics of female involvement in DA and their level of knowledge regarding first aid. METHODS: Adult female relatives of patients presenting at the university-based emergency department within the six-month study period comprised the study sample. They were asked to answer a 23-item self-reported questionnaire, and the responses were analyzed. RESULTS: A total of 1017 women (mean age: 29.2±11.1 years) were enrolled in the study. Hand lacerations (n=924, 90.8%), sprain and contusions (n=904, 88.8%) and burns (n=803, 78.9%) were the most commonly reported types of DA. The children were reported to suffer mostly from hits, sprains and contusions (n=478, 91.7%), followed by falls and slipping (n=452, 86.7%). The telephone number of emergency medical services was recalled most frequently (n=871, 85.6%), while that of the poison control center was known least commonly (n=48, 4.7%). The group with the highest level of education had a significantly higher mean number of correct answers than that of the group with the lowest level of education (p=0.001). The knowledge level of the women who worked was significantly lower than that of the unemployed women (p=0.02). CONCLUSION: Extensive training of women on DA should be undertaken and the mass media should be utilized to achieve this goal.

Hospital cost analysis of management of patients with renal colic in the emergency department.

Acute severe colicky pain in the flank region is termed as renal colic (RC), which is commonly diagnosed and treated in the emergency department (ED). The present study is designed to investigate the hospital costs of patients with RC admitted to the ED and factors affecting the figures. Retrospective analysis includes all patients diagnosed with RC following physical examination and X-ray, ultrasound, computed tomography together with laboratory investigations in the university-based ED between February 2007 and February 2009. The study included 574 patients eligible for the predefined criteria. Mean total hospital cost in patients admitted to the ED due to RC was calculated to be 55.77 Euro. The greatest contribution to the total cost was made by radiological investigations in the ED (40.5%) followed by treatment costs (19.7%). Size and location of the stone and stay times in the ED were the independent variables affecting the costs. The costs were higher as the stones were bigger and as they were more distal in the ureter. Renal stones were associated with the lowest hospital costs. Radiological investigations are the greatest contributors in the ED costs in patients with RC. Effective measures need to be undertaken to reduce resultant costs. Preventive measures as well as diagnostic and therapeutic procedures should be standardized in the ED in accordance with technological advances and also cost-effectiveness when appropriate.