Traumatic laceration of the portal vein.

Despite its relatively protected position, the liver is the most frequently injured solid intra-abdominal organ. 1 Most liver injuries can be managed conservatively, but about 5% to 10% require urgent laparotomy, usually when the mechanism of injury involves a vehicle accident and hemodynamic instability persists, in spite of 40 mL/kg of blood transfusion. 2 , 3 In particular, grades IV and V liver injuries may pose a challenge to the surgeon trying to control hemorrhage, the leading cause of mortality. 4 Traumatic injuries to the portal vein are rare but devastating. The mortality rate for portal vein injury ranges from 50% to 70%. A recent study of portal triad injuries has highighted the higher mortality rates associated with combination injuries involving multiple portal triad components, especially those that include portal vein injury. 5 This case study describes a unique case of relatively minor trauma in a child resulting in portal triad injury, sudden demise, and surgical repair.

Inter-rater reliability and validity of the Ministry of Health of Turkey's mandatory emergency triage instrument.

OBJECTIVES: In 2009, the Ministry of Health in Turkey mandated a three-level emergency triage scale coded with the colours red, yellow and green in descending order of acuity. This study was conducted to assess the reliability and validity of this mandatory emergency triage instrument in Turkey. METHODS: This prospective study was conducted in the ED of an academic hospital with 40,000 presentations per year. The reliability assessment was between triage of a real life patient by an emergency medical technician vs the consensus of the investigators based on retrospective medical record review. The inter-rater agreement method with quadratic weighted kappa analysis was used. The instrument's validity was measured by ED length of stay, admission rates, in-hospital mortality, ED resource utilisation and lifesaving intervention. RESULTS: A total of 618 patients were assigned to either red (n = 126), yellow (n = 352), or green (n = 140) by acuity level at triage. In this study, the triage scale demonstrated 'substantial' reliability with a quadratic weighted kappa value of 0.725 (95% CI 0.68-0.77). It also suggested validity regarding all the measured surrogate markers, as they were strongly associated with acuity level (P < 0.001 for each). Spearman's rank correlation coefficient between triage acuity and total number of used resources was 0.482 (95% CI 0.42-0.54). CONCLUSIONS: This study demonstrates substantial reliability of Turkey's Ministry of Health's mandatory three-level triage instrument. Significant association was also observed between the triage levels and the validity parameters measured in the study.

Rabies Suspected Animal Contact Cases in a City with Animal Husbandry and the Appropriateness of Prophylactic Procedures.

OBJECTIVES: This study aims to evaluate the features of rabies suspected animal contact cases in the emergency department and the appropriateness of administering post-exposure prophylaxis procedures according to World Health Organization (WHO) instructions. METHODS: Rabies suspected animal contact cases that applied to the emergency department between August 2012 and December 2013 were included in the study. Patients' data were obtained retrospectively from patient files, records of hospital automation system, and the "Rabies Suspected Animal Contact Cases Examination Form". The post-exposure prophylaxis recommended by the WHO were compared to the prophylactic applications administered by the emergency department. RESULTS: A total of 515 cases were included in the study. According to WHO classification, cases involving category 3 injuries (n=378, 73.4%) were more common than the others (p>0.0001). Compared to post-exposure prophylaxis recommendations by the WHO, 44.7% of all cases (n=230) were administered inappropriate prophylaxis. Thirty-seven percent of cases received less rabies Ig than recommended, despite category 3 contact. Six percent of cases with category 2 contact were given unnecessary rabies Ig and all cases with category 1 contact (1.5% of all cases) were given unnecessary rabies vaccine. CONCLUSIONS: We observed that in 44.7% of cases, post-exposure prophylaxis was applied inappropriately according to WHO instructions. Not only were there unnecessary vaccine and Ig applications, there were also missing prophylaxis procedures. Updating the current "Rabies Prevention and Control Directive" plus educating and controlling healthcare personnel on a regular schedule may help prevent inadequacies in prophylactic application.

Comparison of short-term infusion regimens of N-acetylcysteine plus intravenous fluids, sodium bicarbonate plus intravenous fluids, and intravenous fluids alone for prevention of contrast-induced nephropathy in the emergency department.

BACKGROUND: There is no evidence regarding the several short-term prophylaxis protocols for contrast-induced nephropathy (CIN) that may be most feasibly convenient in emergency settings. OBJECTIVES: The purpose of this study was to compare the efficacies of short-term CIN prophylaxis protocols of normal saline, N-acetylcysteine (NAC) plus saline, and sodium bicarbonate plus saline in emergency department (ED) patients at moderate or high risk of CIN after receiving intravenous (IV) contrast agent. METHODS: This single-center, randomized, nonblinded clinical trial was conducted in the ED with adult patients requiring contrast-enhanced computed tomography (CT). Patients with moderate to high risk of CIN according to the Mehran risk score, who consented to participate, were eligible. Patients with continuous renal replacement therapy or who reported contrast allergy were excluded. Enrolled patients were randomly assigned to receive 150 mg/kg NAC in 1000 mL of 0.9% sodium chloride (NaCl), 150 mEq of sodium bicarbonate in 1000 mL of 0.9% NaCl, or 1000 mL of IV saline infusion, all given at 350 mL/hr for 3 hours. All of the patients were administered less than 100 mL of nonionic, low-osmolality contrast agent. The primary outcome of CIN was defined as a 25% increase or a greater than 0.5 mg/dL increase in the serum creatinine level 48 to 72 hours later compared with the baseline measurement. RESULTS: A total of 107 patients were randomized to NAC (n = 36), sodium bicarbonate (n = 36), and saline prophylaxis (n = 35). The mean age of the patients was 71 years (95% confidence interval [CI] = 65 to 77 years), and 58 (54.2%) were male. The groups were similar regarding baseline characteristics and nephropathy risks. Of the 16 (14.9%) patients who eventually developed CIN, seven (19.4%) were in the NAC plus saline group, four (11.1%) were in the sodium bicarbonate plus saline group, and five (14.2%) were in the saline group. There were no significant differences between the groups in terms of the prevention of CIN (p = 0.60). CONCLUSIONS: None of the short-term protocols with normal saline, NAC, or sodium bicarbonate was superior in ED patients requiring contrast-enhanced CT who had a moderate or high risk of CIN.

Asymptomatic Chronic Epidural Hematoma in a Child As a Result of Extracranial Decompression.

BACKGROUND: Epidural hematoma (EDH) in children is a diagnostic challenge due to its nonspecific clinical presentation. Asymptomatic chronic epidural hematoma is a very rare entity. Reports of spontaneous decompression into the subgaleal spaces are limited with acute epidural hematomas in the literature. OBJECTIVE: We report a child presenting with chronic epidural hematoma at 15 days after a head trauma. She remained asymptomatic, owing to spontaneous decompression via a skull fracture. We intend to remind emergency physicians to be alert about epidural hematomas in asymptomatic children in the presence of a history of, even minor and distant, trauma. CASE PRESENTATION: An 8-year-old girl presented to the Emergency Department with a swelling in the right parietal region. She had fallen at the playground and struck her head on the ground 15 days prior. Computed tomography showed a mixed-density subacute-chronic parietal epidural hematoma with a linear fracture overlying it. There was no evidence of midline shift or ipsilateral ventricular compression. CONCLUSION: An initially minimal but expanding EDH in a child can remain asymptomatic even in the later phases, owing to the spontaneous decompression through a skull fracture.