Comparison of self versus expert-assisted feedback for cricothyroidotomy training: a randomized trial.

BACKGROUND: The self-video feedback method may have the potential to provide a low-cost alternative to physician-driven simulation-based training. This study aimed to assess the utility of two video feedback methods by comparing the improvement in performing cricothyroidotomy procedure following self video feedback (trainees review their performance by themselves) and expert-assisted video feedback (trainees review their performance while an emergency physician provides additional feedback). METHODS: This study was pretest-posttest and two-group designed research performed at a university simulation center with 89 final-year medical students and used a cricothyroidotomy simulation model. After seeing an educational presentation and a best practice video, trainees were randomized into two groups; self video feedback group (SVFG) and expert-assisted video feedback group (EVFG). They performed the cricothyroidotomy before and after the feedback. The procedures were also recorded and scored by two emergency physicians. RESULTS: There was a statistically significant improvement between pre-feedback and post-feedback assessments in terms of scores received and time needed for the procedures in both SVFG and EVFG groups (p < 0.05). Additionally, the post-feedback assessment scores were higher and time needed for the procedure was lower in the EVFG when compared with SVFG (p < 0.05 for both). CONCLUSIONS: Results demonstrated significant improvement in cricothyroidotomy performance with both types of video feedback method. Even though the improvement was better in the EVFG compared to the SVFG, the self video feedback may have value especially in situations where expert-assisted feedback is not possible.

Developing Cricothyroidotomy Skills Using a Biomaterial-Covered Model.

INTRODUCTION: Cricothyroidotomy is an advanced and life-saving technique, but it is also a rare and a difficult procedure. The purpose of the present study was to produce a low-cost simulation model with realistic anatomic features to investigate its effectiveness in developing cricothyroidotomy skills. METHODS: This study was performed at a university simulation center with 57 second-year student paramedics and a cricothyroidotomy simulation model. Total scores were assessed using a checklist. This consisted of 13 steps and was scored as misapplication/omission=0, correct performance and timing with hesitation=1, and correct performance and timing without hesitation=2. One of these steps, local anesthesia of the area if time is available, was not performed owing to time limitations. The highest possible score was 24. Data are presented as mean±SD with range, as appropriate. Normal distribution was evaluated using the Kolmogorov-Smirnov test, Student t test, and Mann-Whitney U test, and correlation analysis was used for statistical analysis. RESULTS: Students completed the cricothyroidotomy procedure steps in 116±46 (55-238) s. At performance assessment, the score achieved was 12±5 (2-24). The highest total score of 24 was achieved by 3 students (5%). Total scores exhibited negative and significant correlation with procedure time (r=-0.403, P=0.002). CONCLUSIONS: The model developed in this study is an inexpensive and effective method that can be used in cricothyroidotomy training for student paramedics. We think that repeating the cricothyroidotomy procedure on the model will increase success levels.

Unilateral Isolated Hypoglossal Nerve Palsy Caused by Gunshot Injury.

Cranial nerve palsies after gunshot injury are not uncommon. However, in the literature, only 1 patient with isolated hypoglossal nerve paralysis caused by gunshot has been published. The authors describe a 34-year-old man suffering from unilateral isolated hypoglossal nerve palsy caused by gunshot injury as a second reported patient. The bullet entered maxillary sinus, and caused condylar fracture, then ended up C1-2 interspace. The bullet was surgically removed by a posterior approach. It is important to pay attention to hypoglossal nerve injury when confronted with a gunshot wound. The authors recommend early and sufficient surgical decompression.

Isolated abducens nerve palsy due to pituitary apoplexy after mild head trauma.

Pituitary apoplexy is a relatively rare condition. Cranial nerve palsies may develop due to compression of the surrounding structures by the rapidly expanding tumor. While the most commonly affected nerve is the oculomotor nerve, abducens nerve palsy may also occur less commonly. A 68-year-old male patient was admitted to the emergency department with complaints of severe headache, nausea, vomiting, and diplopia after head trauma due to falling. His magnetic resonance imaging evaluation demonstrated a large pituitary adenoma and bleeding into the tumor, which was acutely expanding and leading to compression of the abducens nerve laterally. Isolated abducens palsy due to posttraumatic pituitary apoplexy is a rare clinical condition, and as the symptoms and signs are nonspecific, it can commonly remain clinically undiagnosed. In this article, our aim was to draw attention to a clinical condition in which unfavorable complications may develop if the diagnosis is overlooked.

Monitoring the response to treatment of acute heart failure patients by ultrasonographic inferior vena cava collapsibility index.

OBJECTIVE: Our aim was to determine if N-terminal pro-brain natriuretic peptide (NT-proBNP) or sonographic measurements of inferior vena caval (IVC) diameters and collapsibility index (IVC-CI) have a role in the monitoring of acute heart failure (AHF) therapy. METHODS: Inferior vena caval diameters of 50 healthy people (control group) were measured to determine the normal values of the IVC parameters. We then prospectively enrolled patients who were admitted to the emergency department (ED) with a primary diagnosis of AHF. At presentation, IVC diameters were measured during expiration and inspiration, and blood was drawn for NT-proBNP. We repeated the measurement of the IVC parameters and collected a second blood sample 12 hours after the therapy was administered. The data were analyzed in SPSS 15.0 (IBM, Armonk, NY) using the Student t test and Mann-Whitney U test. RESULTS: A total of 97 subjects were enrolled: 47 in the patient group and 50 in the control group. The mean IVC during expiration was 2.10 ± 0.37 cm before and 1.57 ± 0.24 cm after the therapy (P < .001). The mean IVC during inspiration was 1.63 ± 0.40 cm before and 0.90 ± 0.26 cm after the therapy (P < .001). The mean IVC-CI rose from 22.80% ± 10.97% to 43.09% ± 13.63% (P < .001). After the therapy, there was no difference between the IVC-CI of the patients and controls (P = .246). There was no significant change in the mean NT-proBNP levels after the therapy. CONCLUSION: Inferior vena caval collapsibility index may be helpful in monitoring AHF patients' responses to therapy in the ED.

The prognostic value of cystatin C compared with trauma scores in multiple blunt trauma: a prospective cohort study.

BACKGROUND: Many scoring systems have been developed to predict the prognosis of the traumatized patients in Emergency Departments, and the necessary calculations make complex scoring systems difficult to use as a part of the initial trauma patient assessment, and they also have limited accuracy. STUDY OBJECTIVE: This study compares the accuracy of cystatin C with trauma scoring systems in predicting the mortality of trauma patients. METHODS: Serum cystatin C levels were measured upon arrival in consecutive adult multiple blunt trauma patients during a 12-month period. Correlation analysis was used to assess the relationship between Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Scale (GCS) Score, and cystatin C. Trauma scores and cystatin C were used in Cox regression models to predict trauma patients' risk of death. RESULTS: During the study period, 153 patients were enrolled and 18 died. There were negative correlations between cystatin C levels and the GCS (r = -0.666, p < 0.001) as well as the RTS (r = -0.229, p = 0.004). A moderate correlation was found between the ISS and the cystatin C level (r = 0.492, p < 0.001). In Cox regression models, every increase in units of cystatin C levels and ISS (the cut-off levels were 0.93 mg/L and ≥ 16, respectively) results in a 4.22- and 1.068-fold increase in mortality, respectively. CONCLUSION: Cystatin C may represent an important severity-of-illness indicator, easily available to clinicians during the initial assessment of trauma victims on admission.

Paramedic-performed Focused Assessment with Sonography in Trauma (FAST) in the emergency department.

BACKGROUND: Our objective was to evaluate the accuracy of paramedic-performed Focused Assessment with Sonography in Trauma (PFAST) for detection of free fluid in patients admitted to the Emergency Department (ED) following trauma. METHODS: After four hours of didactic and four hours of hands-on training, four paramedics prospectively evaluated trauma patients. Our gold standard was the official radiologist reports of ultrasonography and computerized abdominal tomography (CAT). The sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of PFAST were calculated and analyzed using SPSS 15.0 with ?2 testing. RESULTS: One hundred and twenty-seven patients were evaluated by the paramedics. Fourteen patients had positive free fluid in the abdomen. Of these, 11 were corroborated by radiology reports and CAT (true positives), and three were found to be negative (false positives). In 113 cases, PFAST was negative for free fluid. Of these, 111 were determined not to have free fluid (true negatives), whereas free fluid was detected by CAT in 2 (false negatives). The sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio of PFAST were 84.62, 97.37, 32.15, 0.16, and 203.50, respectively. CONCLUSION: Our study shows that paramedics can perform FAST in hospital Eds with a high degree of accuracy.

Pneumomediastinum associated with pneumopericardium and epidural pneumatosis.

Spontaneous pneumomediastinum is a relatively rare benign condition. It may rarely be associated with one or combination of pneumothorax, epidural pneumatosis, pneumopericardium, or subcutaneous emphysema. We present a unique case with four of the radiological findings in a 9-year-old male child who presented to our emergency department with his parents with complaints of unproductive cough, dyspnea, and swelling on chest wall. Bilateral subcutaneous emphysema was palpated on anterior chest wall from sternum to midaxillary regions. His anteroposterior and lateral chest radiogram revealed subcutaneous emphysema and pneumomediastinum. His thorax computed tomography to rule out life-threatening conditions revealed bilateral subcutaneous, mediastinal, pericardial, and epidural emphysema without pneumothorax. He was transferred to pediatric intensive care unit for close monitorization and conservative treatment. He was followed-up by chest radiographs. He was relieved from symptoms and signs around the fifth day and he was discharged at the seventh day. Diagnosis of pneumomediastinum is often made based on physical findings and plain radiographs. It may not be as catastrophic as it is seen. Close cardiopulmonary monitorization is mandatory for complications and accompanying conditions. Most patients with uncomplicated spontaneous pneumomediastinum respond well to oxygen and conservative management without any specific treatment.

A Case of Ramsay Hunt Syndrome with Atypical Presentation.

Ramsay Hunt syndrome is a rare complication of herpes zoster which results from the reactivation of the latent varicella-zoster virus in the geniculate ganglion. Although facial nerve is the most common affected nerve in Ramsay Hunt syndrome, other cranial and cervical nerves can also be affected. We present an atypical case of Ramsay Hunt syndrome in a 42-year-old male, with cervical nerve involvement. As spontaneous recovery rate in Ramsay Hunt syndrome is low, early diagnosis and treatment plays a key role in full recovery of paralysis.

Comparison of existing syncope rules and newly proposed anatolian syncope rule to predict short-term serious outcomes after syncope in the Turkish population.

BACKGROUND: We wished to compare the San Francisco Syncope Rule (SFSR), Evaluation of Guidelines in Syncope Study (EGSYS) and the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk scores and to assess their efficacy in recognising patients with syncope at high risk for short-term adverse events (death, the need for major therapeutic procedures, and early readmission to the hospital). We also wanted to test those variables to designate a local risk score, the Anatolian Syncope Rule (ASR). METHODS: This prospective, cohort study was conducted at the emergency department of a tertiary care centre. Between December 1 2009 and December 31 2010, we prospectively collected data on patients of ages 18 and over who presented to the emergency department with syncope. RESULTS: We enrolled 231 patients to the study. A univariate analysis found 23 variables that predicted syncope with adverse events. Dyspnoea, orthostatic hypotension, precipitating cause of syncope, age over 58 years, congestive heart failure, and electrocardiogram abnormality (termed DO-PACE) were found to predict short-term serious outcomes by logistic regression analysis and these were used to compose the ASR. The sensitivity of ASR, OESIL, EGSYS and SFSR for mortality were 100% (0.66 to 1.00); 90% (0.54 to 0.99), 80% (0.44 to 0.97) and 100% (0.66 to 1.00), respectively. The specificity of ASR, OESIL, EGSYS and SFSR for mortality were 78% (0.72 to 0.83); 76% (0.70 to 0.82); 80% (0.74 to 0.85) and 70% (0.63 to 0.76). The sensitivity of ASR, OESIL, EGSYS and SFSR for any adverse event were 97% (0.85 to 1.00); 70% (0.52 to 0.82); 56% (0.40 to 0.72) and 87% (0.72 to 0.95). The specificity of ASR, OESIL, EGSYS and SFSR for any adverse event were 72% (0.64 to 0.78); 82% (0.76 to 0.87); 84% (0.78 to 0.89); 78% (0.71 to 0.83), respectively. CONCLUSION: The newly proposed ASR appears to be highly sensitive for identifying patients at risk for short-term serious outcomes, with scores at least as good as those provided by existing diagnostic rules, and it is easier to perform at the bedside within the Turkish population. If prospectively validated, it may offer a tool to aid physicians' decision-making.

Do we routinely need cranial computed tomography for mild head injuries in Turkey?

The objectives of this study were to determine the role of clinical parameters in detecting intracranial injury and to find out whether cranial computed tomography (CT) is routinely needed for mild head injury (MHI) in Turkey. This retrospective study was conducted by reviewing the records of patients with MHI who underwent cranial CT in our emergency department. We carried out multiple logistic regression analysis, and odds ratios with 95% confidence intervals were calculated by using SPSS 15.0. This study included 923 patients. Positive cranial CT findings were determined in 17 patients (1.8%) and six of them (0.6%) underwent surgery. Statistically significant correlations were found among headache, presence of clinical findings of skull fracture, focal neurological deficit and positive cranial CT findings. Although the incidence of the intracranial lesions, especially those requiring surgery, is low in MHI, the liberal use of CT scanning in MHI seems to be justified in countries such as Turkey.