Comparison of Bedside Index for Severity in Acute Pancreatitis and Emergency Department SpO2, Age and Systemic Inflammatory Response Syndrome Scores in Predicting Severe Acute Pancreatitis in Patients with Acute Pancreatitis in the Emergency Department.

BACKGROUND: As the mortality of severe acute pancreatitis (SAP) is significantly higher than those with mild or moderate severity, it is of clinical significance to identify patients most likely to develop SAP at the time of emergency department (ED) presentation. OBJECTIVES: The aim of this study was to compare the performance of the Bedside Index for Severity in Acute Pancreatitis (BISAP) and the Emergency Department SpO2, Age and SIRS (ED-SAS) scoring systems as early risk assessment tools for identifying patients at high-risk of developing SAP. METHODS: We retrospectively reviewed adult patients with AP presented to ED between January 2019-September 2022. We calculated the scores of each patient with the parameters of the initial data. The primary outcome was SAP. The secondary outcomes were 30-day mortality, intensive care admission, and identifying low-risk patients without complications. RESULTS: Of 415 patients, 34 (8.2%) developed SAP and 15 (3.6%) died. With regard to predicting SAP, BISAP and ED-SAS scores had similar discriminative ability with area under the curves (AUCs) of 0.84 (95% confidence interval [CI]:0.80-0.88) and 0.83 (95% CI:0.79-0.86), respectively (p = 0.642). At a cut-off score of ≥2 for SAP, sensitivity/specificity values were 73.5%/82.4% for BISAP, 76.5%/83.2% for ED-SAS. BISAP and ED-SAS scores of ≥3, yielded sensitivity/specificity values of 50%/95.8% and 35.3%/95.5%, respectively. BISAP and ED-SAS were also similar in predicting mortality (AUCs of 0.92 vs. 0.90, respectively) and intensive care unit admission (AUCs 0.91 vs. 0.91). CONCLUSION: The BISAP and ED-SAS scores performed similarly in predicting SAP, mortality, and intensive care unit admission. As an easily calculated tool early in the ED, ED-SAS may be helpful in disposition decisions for emergency physicians.

Prognostic Value of Jugular Venous Diameters and Compliance in Patients with Exacerbation of Chronic Obstructive Pulmonary Disease.

Background: Chronic obstructive pulmonary disease (COPD) exacerbations constitute a significant proportion of patients presenting to the emergency department (ED). It has been suggested that measurement of jugular venous diameter and compliance may have prognostic value in patients with heart failure. We hypothesized that these measurements may also be valuable in patients with advanced COPD. Methods: This study was a single-center, prospective, and cross-sectional study conducted in a university hospital between November 2020 and November 2021. In the study, internal jugular vein (IJV) diameters (inspiration, forced expiration, and rest) and jugular venous compliance were measured with ultrasound in patients who presented to the ED with COPD exacerbation. One month later, data about mortality, intensive care unit (ICU) admission, and any hospitalization were obtained and evaluated together with a range of laboratory parameters. Results: Data from a total of 93 patients were analyzed. Of these, 17 (18.2%) died, 19 (20.4%) were admitted to the ICU, and 36 (38.7%) were hospitalized at the end of the 1-month period. Consequently, a total of 44 patients (47.3%) were in the good outcome group and 49 patients (52.7%) were in the poor outcome group. In terms of mortality, inspiratory IJV diameter was 5.6 ± 2.9 mm in the survived group (n = 76) and 7.6 ± 3.9 mm in the deceased group (n = 17) (P = 0.031). There was no difference between the venous compliance values and other diameter measurements of the patients. In the analysis performed with the subgroup with high N-terminal prohormone brain natriuretic peptide values, it was shown that both resting and inspiration diameter measurements were higher in the group with poor outcomes. Conclusion: There was no difference between the jugular vein compliance values in terms of mortality in patients admitted to the ED with COPD exacerbation. However, these measurements may have prognostic value in patients with COPD exacerbations complicated by heart failure.

Impact of COVID-19 pneumonia on interstitial lung disease: semi-quantitative evaluation with computed tomography.

OBJECTIVES: To evaluate the CT scores and fibrotic pattern changes in interstitial lung disease (ILD) patients, with and without previous COVID-19 pneumonia. METHODS: Patients with ILD (idiopathic pulmonary fibrosis (IPF) and connective tissue disease-associated ILD (CTD-ILD)) were retrospectively enrolled in the study which consisted of patients who had COVID-19 pneumonia while the control group had not. All patients had two CT scans, initial and follow-up, which were evaluated semi-quantitatively for severity, extent, and total CT scores, fibrosis patterns, and traction bronchiectasis. RESULTS: A total of 102 patients (pneumonia group n = 48; control group n = 54) were enrolled in the study. For both groups, baseline characteristics were similar and CT scores were increased. While there was a 4.5 ± 4.6 point change in the total CT score of the COVID-19 group, there was a 1.2 ± 2.7 point change in the control group (p < 0.001). In the IPF subgroup, the change in total CT score was 7.0 points (95% CI: 4.1 to 9.9) in the COVID-19 group and 2.1 points (95% CI: 0.8 to 3.4) in the control group. Seven patients (14.6%) in the COVID-19 group progressed to a higher fibrosis pattern, but none in the control group. CONCLUSIONS: Semi-quantitative chest CT scores in ILD patients demonstrated a significant increase after having COVID-19 pneumonia compared to ILD patients who had not had COVID-19 pneumonia. The increase in CT scores was more prominent in the IPF subgroup. There was also a worsening in the fibrosis pattern in the COVID-19 group. KEY POINTS: • The impact of COVID-19 pneumonia on existing interstitial lung diseases and fibrosis is unclear. • COVID-19 pneumonia may worsen existing interstitial lung involvement with direct lung damage and indirect inflammatory effect. • COVID-19 pneumonia may affect existing lung fibrosis by triggering inflammatory pathways.

Clinical characteristics of neutrophilic, eosinophilic and mixed-type exacerbation phenotypes of COPD.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) comprises a significant number of emergency department (ED) presentations, and hematological phenotypes may have prognostic significance. The aim of this study was to investigate the effect of hematological phenotypes on serious outcomes in COPD exacerbations. METHODS: A prospective cohort study was carried out in patients with COPD exacerbation presenting to the ED. The patients were classified into three groups, including neutrophilic, eosinophilic, and mixed-type (including neutrophilic and eosinophilic features) COPD exacerbation. Outcome measures were defined as mortality, hospitalization, and need for intensive care unit (ICU) care within three months, and these outcomes were compared among groups. RESULTS: A total of 173 COPD patients were assessed for eligibility, and 147 of them were included in the final analysis. The study population consisted of 90 patients with neutrophilic exacerbation (61.2%), 26 patients with eosinophilic exacerbation (17.7%), and 31 patients with mixed-type exacerbation (21.1%). The neutrophilic exacerbation group was older, was more often tachycardic and desaturated, and had more sputum production compared with the eosinophilic exacerbation group. Mortality was seen in 35 patients in the neutrophilic exacerbation group (38.9%), whereas 5 patients in the eosinophilic group (19.2%) and 6 patients in the mixed-type group (19.4%) died (p = .044). No difference was observed among groups in terms of hospital and ICU admission. CONCLUSION: COPD exacerbations with neutrophilic phenotypes presented to the ED with more serious clinical findings compared with eosinophilic exacerbations. This may also have a possible effect on mortality.

Intravenous metoclopramide in the treatment of acute migraines: A randomized, placebo-controlled trial.

OBJECTIVES: The present study aimed to evaluate the efficacy and safety of intravenous metoclopramide for acute migraine treatment. MATERIALS AND METHODS: A double-blind, randomized, parallel-group, placebo-controlled trial was carried out in an academic emergency department. After the patients were assessed for eligibility via the International Headache Society criteria for migraines, they were randomized into 10 mg intravenous metoclopramide and normal saline groups. The headache intensity was evaluated using an 11-point numeric rating scale (NRS) score. The primary outcome measure was determined as the median between-group change in the score at the 30th minute. The secondary outcome measures were rescue medication needs, adverse events, and emergency department (ED) revisits after discharge. RESULTS: A total of 148 patients were randomized into two equal groups with similar baseline characteristics, including the baseline NRS scores (8 points). The median reduction in the NRS scores at the 30th minute was 4 [interquartile range (IQR): 2-6)] in the metoclopramide group and 3 (IQR: 1-4) in the normal saline group [median difference: -1.0, 95% confidence interval (CI): -2.1 to 0.1]. No serious adverse events were observed, and the rescue medication needs were similar in both groups. CONCLUSION: No difference was found between intravenous metoclopramide and placebo regarding efficacy and safety in patients with acute migraines.

Central nervous system toxicity due to mefenamic acid.

Mefenamic acid is a fenamate nonsteroidal anti-inflammatory (NSAI) drug, which is used for several years for pain management. However, it has been rarely reported that, mefenamic acid can induce central nervous system toxicity both in toxic doses and therapeutic usage. We report a case of a 27-year-old female who presented to the emergency department (ED) with altered mental status and vomiting. On admission to the ED, she was lethargic and disoriented. Her vital signs were normal and her physical examination was completely normal except dysarthric speech. The etiology of altered mental status was investigated with electrolyte levels, cranial computed tomography, cranial magnetic resonance imaging and EEG, however the results were normal. Her blood gas analysis revealed a deep metabolic acidosis with a pH of 7.14. Neither etiologic agent nor drug use history was provided at the presentation; she had only osteogenesis imperfecta since several years and she had been using various NSAI drugs. However, her relatives later stated that, she took mefenamic acid for her pains since two weeks. After her admission to intensive care unit, her neurologic state was improved gradually after plasmapheresis and she was discharged healthy. Although mefenamic acid has been considered as one of the safe NSAI drugs, its effects due to central nervous system toxicity should be cautiously handled.

The value of lactate clearance in admission decisions of patients with acute exacerbation of COPD.

BACKGROUND: Lactate and lactate clearance are being used as biomarkers in several critical conditions. The aim of this study was to examine the value of sixth hour lactate clearance in patients who were hospitalized with chronic obstructive pulmonary disease (COPD) exacerbations. METHODS: This single-center, cross-sectional study was conducted in a tertiary emergency department (ED) on patients who presented with acute exacerbation of COPD. Discharge or admission decisions were specified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria and the clinician's decision. In the study, lactate clearance was defined as the percent decrease in lactate from the time of presentation to the ED to the sixth hour. RESULTS: A total of 495 patients were evaluated and 397 patients were excluded. Among included patients, 53 (54.1%) were admitted to the hospital and 45 (45.9%) were discharged. The median lactate clearance was found to be -11.8% (95% CI: -50.0 to 34.5) in the admitted group and 14.7% (95% CI: -11.3 to 42.3) in the discharged group. Between the two groups, the median difference of lactate clearance was found to be 26.5% (95% CI: 0.6 to 52.4). Multivariate logistic regression analysis revealed that the delta lactate value can determine the hospitalization need of patients (OR: 0.91, 95% CI: 0.85 to 0.97). CONCLUSION: Lactate clearance can be evaluated as a useful marker in patients with COPD exacerbations. This study suggests that lactate monitoring in the ED has clinical benefits in addition to GOLD guidelines when deciding whether to discharge or hospitalize a patient.

Intranasal Lidocaine in Acute Treatment of Migraine: A Randomized Controlled Trial.

STUDY OBJECTIVE: The study aims to evaluate the efficacy and safety of intranasal lidocaine administration for migraine treatment. METHODS: This single-center, double-blind, randomized, controlled trial was conducted in a tertiary care emergency department. Included patients met the migraine criteria of the International Headache Society. Patients were randomized to intranasal lidocaine or saline solution; all participants received 10 mg of intravenous metoclopramide. Patient pain intensity was assessed with an 11-point numeric rating scale score. The primary outcome measure was the change in pain scores at 15 minutes; secondary outcomes were changes in pain intensity after pain onset and need for rescue medication. RESULTS: Patients (n=162) were randomized into 2 groups with similar baseline migraine characteristics and numeric rating scale scores. The median reduction in numeric rating scale score at 15 minutes was 3 (interquartile range [IQR] 2 to 5) for the lidocaine group and 2 (IQR 1 to 4) for the saline solution group (median difference=1.0; 95% confidence interval 0.1 to 2.1). The reduction in pain score at 30 minutes was 4 (IQR 3 to 7) for the lidocaine group and 5 (IQR 2 to 7) for the saline solution group (median difference=1.0; 95% confidence interval 0.1 to 2.1). Need for rescue medication did not differ between the groups, and local irritation was the most common adverse event in the lidocaine group. CONCLUSION: Although intranasal lidocaine was found no more efficacious than normal saline solution in our study, future studies should focus on patients who present earlier after headache onset.

Comparison of loop and primary incision & drainage techniques in adult patients with cutaneous abscess: A preliminary, randomized clinical trial.

OBJECTIVES: The aim of this study is to compare efficacy of loop drainage and standard incision & drainage (I&D) in adult patients with cutaneous abscess in the emergency department. METHODS: This study is an interventional, parallel group, randomized clinical trial. Adult patients with cutaneous abscess were randomized into loop drainage and standard I&D groups. The primary outcome was defined as change in diameter of abscess and cellulitis 7days after procedure. Secondary outcome measures were pain intensity at the end of the procedure and procedure duration. Also patient satisfaction, need for antibiotics and repetitive drainage were recorded. RESULTS: A total of 46 patients were included in the study (23 in each group). Both groups had similar baseline characteristics. Median abscess diameters were 3.2 (1.9-4.0) cm and 3.0 (2.4-4.8) cm in loop drainage and I&D groups respectively. In the loop drainage group there was a -0.6cm (95% CI: -1.7-0.5) difference in abscess diameter compared to the I&D group. There was also a reduction in cellulitis diameter (-1.3cm, 95% CI: -3.4-0.8). No statistically significant difference was found between groups in patient satisfaction, use of antibiotics or need for repetitive drainage. CONCLUSION: This preliminary study revealed that, loop drainage technique is similar to standard I&D technique in abscess resolution and complications. (Clinical Trials Registration ID: NCT02286479).

Distributive Shock in the Emergency Department: Sepsis, Anaphylaxis, or Capillary Leak Syndrome?

BACKGROUND: Distributive shock is a hyperdynamic process resulting from excessive vasodilatation. Impaired blood flow causes inadequate tissue perfusion, which can lead to end-organ damage. Although the most common etiology is septic shock, anaphylactic and other etiologies should be considered. CASE REPORT: We report the case of a 30-year-old female who presented to the emergency department with nonspecific symptoms and hypotension after a viral upper respiratory infection. Her physical examination revealed mild edema and rebound tenderness in the right upper and bilateral lower quadrants. She also presented with hypotension concomitant with hypoperfusion symptoms, which were manifested by the loss of consciousness in the hour after her presentation. Neither etiologic agent nor drug use history was provided at the presentation; these may have caused anaphylaxis; however, she later reported that she took a propolis extract 1 day earlier. The hypotensive state was refractory to large amount of crystalloid infusion and a series of examinations were performed to determine the shock etiology. Computed tomography images showed pneumonic infiltrates in the lower zone of the right lung, an enlarged liver, a thickened gallbladder wall, and an extensive amount of free fluid in the perihepatic and retroperitoneal areas. All radiologic changes were thought to be due to a secondary condition that triggers them, none were considered as septic focus. Capillary leak syndrome was considered in differential diagnosis and 3 days after her presentation, her hypotension improved and she was discharged in a healthy state. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Capillary leak syndrome is a variant of distributive shock. After assessing other etiologies for this condition, emergency physicians should focus on a triggering event that may have caused hypoalbuminemia and a fluid shift.

The association between weather conditions and stroke admissions in Turkey.

Although several factors such as cigarette smoking, blood pressure, diabetes, obesity, hypercholesterolemia, physical inactivity and dietary factors have been well documented to increase the risk for stroke, there are conflicting data about the role of meteorological variables in the etiology of stroke. We conducted a retrospective study to investigate the association between weather patterns, including daily temperature, humidity, wind speed, and air pressure, and stroke admissions to the Emergency Department of Atatürk Training and Research Hospital in Ankara, Turkey, between January 2009 and April 2010. Generalized additive models with logistic link function were used to investigate the relationship between predictors and days with and without stroke admission at lags 0-4. A total of 373 stroke patients were admitted to the emergency department (ED) between January 2009 and April 2010. Of patients, 297 had ischemic stroke (IS), 34 hemorrhagic stroke (HS), and 42 subarachnoidal hemorrhage (SAH). Although we did not find any association between overall admissions due to stroke and meteorological parameters, univariable analysis indicated that there were significantly more SAH cases on days with lower daily mean temperatures of 8.79 ± 8.75 °C as compared to relatively mild days with higher temperatures (mean temperature = 11.89 ± 7.94 °C, p = 0.021). The multivariable analysis demonstrated that admissions due to SAH increased on days with lower daily mean temperatures for the same day (lag 0; odds ratio (OR) [95% confidence interval (95% CI)] = 0.93 [0.89-0.98], p = 0.004) and lag 1 (OR [95% CI] =0.76 [0.67-0.86], p = 0.001). Furthermore, the wind speed at both lag 1 (OR [95% CI] = 1.63 [1.27-2.09], p = 0.001) and lag 3 (OR [95% CI] = 1.43 [1.12-1.81], p = 0.004) increased admissions due to HS, respectively. In conclusion, our study demonstrated that there was an association between ED admissions due to SAH and HS and weather conditions suggesting that meteorological variables may, at least in part, play as risk factors for intracranial hemorrhages.

Comparison of the therapeutic efficacy of intravenous dimenhydrinate and intravenous piracetam in patients with vertigo: a randomised clinical trial.

BACKGROUND: The present study aimed to compare the therapeutic efficacy of dimenhydrinate and piracetam in patients with vertigo. METHODS: A blinded, parallel group, superiority, randomised clinical trial was carried out on patients who presented to the emergency department (ED) with vertigo. Healthy adult patients presenting to the ED with undifferentiated vertigo were included in the study. The efficacy of intravenous dimenhydrinate (100 mg) and intravenous piracetam (2000 mg) for reducing the intensity of vertigo was compared in two randomised treatment groups using a 10-point numeric rating scale (NRS). The determination of NRS scores was performed at presentation and at the 30th minute of presentation, after the study drug was implemented, both in immobile and ambulatory positions. The primary outcome variable was reduction in vertigo intensity documented on the NRS at the 30th minute after medication administration, analysed by intention to treat. RESULTS: A total of 94 patients were included in the randomisation (n=47 in both groups). The baseline NRS scores were 7.55±2.00 in the dimenhydrinate group and 8.19±1.79 in the piracetam group. The changes from baseline for dimenhydrinate and piracetam were 2.92±3.11 and 3.75±3.40 (difference -0.83 (95% CI -2.23 to 0.57)) in the immobile position and were 2.04±3.07 and 2.72±2.91 (difference -0.68 (95% CI -2.03 to 0.67)) in the ambulatory position. Rescue medication need was similar in both treatment groups (p=0.330), and only one adverse reaction was reported. CONCLUSIONS: We found no evidence of a difference between dimenhydrinate and piracetam in relieving the symptoms of vertigo. TRIAL REGISTRATION NUMBER: Clinical Trials Registration ID: NCT01890538.

The accuracy of mainstream end-tidal carbon dioxide levels to predict the severity of chronic obstructive pulmonary disease exacerbations presented to the ED.

INTRODUCTION: The end-tidal carbon dioxide (ETCO2) measurement was considered as an essential tool for the assessment of several conditions in emergency medicine. However, the diagnostic role of capnography in dyspneic patients still remains unclear. We aimed to analyze the alteration of the ETCO2 levels in chronic obstructive pulmonary disease (COPD) exacerbations and its role in the decision-making process. METHODS: All the individuals who were presented to the emergency department (ED) after COPD exacerbations were prospectively enrolled in the study. The patients were excluded if they refused to give informed consent, intubated after initial assessment, and had uncertain COPD diagnosis. The ETCO2 measurement using a mainstream capnometer was undertaken in the pretreatment and post-treatment period of COPD exacerbations. RESULTS: A total of 102 patients were enrolled in the study. Pre-ETCO2 and post-ETCO2 levels were positively correlated with arterial partial carbon dioxide pressure levels (r=0.756, P<.001 and r=0.629, P<.001, respectively). The median pre-ETCO2 level was 32.0 (30.5-40.5) in discharged patients and 39.0 (31.0-53.5) in admitted patients. After the initial therapy in the ED was completed, the median post-ETCO2 level was found to be 32.0 (28.0-37.5) in discharged patients and 36.0 (32.0-52.0) in admitted patients. Although a statistically significant difference was observed in the pretreatment period (P=.043), no difference was observed in post-treatment period between ETCO2 levels (P=.107). CONCLUSION: End-tidal carbon dioxide levels were higher in admitted patients when compared with discharged patients on arrival to the ED. ETCO2 measurement has very little contributions while evaluating patients with COPD exacerbation in the ED.

Determining the diagnostic value of endogenous carbon monoxide in chronic obstructive pulmonary disease exacerbations.

OBJECTIVE: To determine whether endogenous carbon monoxide levels in exacerbations of Chronic Obstructive Pulmonary Disease patients were higher compared to healthy individuals and to investigate alteration of carbon monoxide levels across the three different severity stages of Global Initiative for Chronic Obstructive Lung Disease criteria related to Chronic Obstructive Pulmonary Disease exacerbations. METHODS: The prospective study was conducted from January to March 2011 at two medical institutions in Ankara, Turkey, and comprised patients of acute Chronic Obstructive Pulmonary Disease exacerbations. The severity of the exacerbations was based on the Global Initiative for Chronic Obstructive Lung Disease criteria. Patients with active tobacco smoking, suspicious carbon monoxide poisoning and uncertain diagnosis were excluded. healthy control subjects who did not have any comorbid diseases and smoking habitus were also enrolled to compare the differences between carboxyhaemoglobin levels A two-tailed Mann-Whitney U test with Bonferroni correction was done following a Kruskal-Wallis test for statistical purposes. RESULTS: There were 90 patients and 81 controls in the study. Carboxyhaemoglobin levels were higher in the patients than the controls (p < 0.001). As for the three severity stages, Group 1 had a median carboxyhaemoglobin of 1.6 (0.95- 2.00). The corresponding levels in Group 2 (1.8 [1.38-2.20]) and Group 3 (1.9 [1.5-3.0]) were higher than the controls (p < 0.001 and p < 0.005 respectively). No statistically significant difference between Group 1 and the controls (1.30 [1.10-1.55]) was observed (p < 0.434). CONCLUSION: Carboxyhaemoglobin levels were significantly higher in exacerbations compared with the normal population. Also, in more serious exacerbations, carboxyhaemoglobin levels were significantly increased compared with healthy individuals and mild exacerbations.

Effects of fast-track in a university emergency department through the National Emergency Department Overcrowding Study.

OBJECTIVE: To determine the impact of a fast track area on emergency department crowding and its efficacy for non-urgent patients. METHODS: The prospective cross-sectional study was conducted in an adult emergency department of a university-affiliated hospital in Turkey from September 17 to 30, 2010. Non-urgent patients were defined as those with Canadian Triage Acuity Scale category 4/5. The fast track area was open in the emergency department for one whole week, followed by another week in which fast track area was closed. Demographic information of patients, their complaints on admission, waiting times, length of stay and revisits were recorded. Overcrowding evaluation was performed via the National Emergency Department Overcrowding Study scale. In both weeks, the results of the patients were compared and the effects of fast track on the results were analysed. Continuous variables were compared via student's t test or Mann Whitney U test. Demographic features of the groups were evaluated by chi-square test. RESULTS: A total of 249 patients were seen during the fast track week, and 239 during the non-fast track week at the emergency department. Satisfaction level was higher in the fast track group than the non-fast track group (p < 0.001). The waiting times shortened from 20 minutes to 10 minutes and length of stay shortened from 80 minutes to 42 minutes during the fast track week. Morbidity and mortality rates remained unchanged. CONCLUSION: Owing to fast track, overcrowding in the emergency department was lessened. It also improved effectiveness and quality measures.