[Impact of the practice of "Extended Focused Assessment with Sonography for Trauma" (e-FAST) on clinical decision in the emergency department]. / Acil serviste "Genisletilmis Acil Travma Ultrasonografisi" uygulamalarinin klinik karar üzerine etkisi.

BACKGROUND: We aimed to show the sensitivity of Extended Focused Assessment with Sonography for Trauma (e-FAST) for detection of pneumothorax, hemothorax and intraabdominal injury. We also investigated the relationship between e-FAST and need for invasive treatment. METHODS: This study included patients who experienced multiple trauma. The emergency physician, who had no clinical information about the patient, performed e-FAST. Findings on a supine chest X-ray and invasive interventions were recorded. The results of abdomen and thorax computed tomography (CT) were reviewed (the size of the pneumothorax was scored). RESULTS: Compared with CT, the sensitivities of e-FAST for intraabdominal injury and hemothorax were 54.5% and 71%, respectively. The patients with hemothorax and intraabdominal injuries were not identified with e-FAST, didn't need for invasive intervention. Pneumothorax diagnosis was established in 27 patients with e-FAST (sensitivity 81.8%) from among 33 (30.8%) pneumothorax patients. According to the grading on CT, pneumothoraces less than 1 cm in width and not exceeding the midcoronal line in length were not identified. e-FAST was positive for all patients performed with tube thoracostomy. CONCLUSION: e-FAST can be used with high sensitivity for determination of pneumothorax requiring invasive procedure. It has low sensitivity in the diagnosis of intraabdominal injury and hemothorax; however, e-FAST can predict the need for invasive procedures.

De novo cerebral arteriovenous malformation: Pink Floyd's song "Brick in the Wall" as a warning sign.

BACKGROUND: Arteriovenous malformations are shunts between an artery and the venous system that lie within a nidus without an intervening capillary bed. These lesions are thought to be congenital, but recent reports have challenged this assumption. CASE REPORT: A 50-year-old man presented to the emergency department with a generalized tonic-clonic seizure. Before the onset of his seizure, he experienced a vivid auditory hallucination of his favorite song by the band Pink Floyd, "A Brick in the Wall." He had been diagnosed with epilepsy 25 years previously. On presentation, his neurological examination was normal, but a computed tomography scan of the brain revealed a large arteriovenous malformation (AVM) occupying the left temporal lobe. Upon more detailed questioning, he recalled that a brain angiogram had been performed 25 years before and was reported to be normal. Neurosurgery was not performed in view of the size of the malformation. The patient is being followed-up as an outpatient. CONCLUSION: AVMs may arise de novo and then spontaneously become symptomatic. Cerebral de novo AVM should be considered in the differential diagnosis in patients with complex auditory musical hallucinations or any new neuropsychiatric symptoms.

Evaluation of the effectiveness of the Australian Mental Health Triage Scale in the emergency department: The case of Turkey.

PURPOSE: To examine the effectiveness of the Australian Mental Health Triage Scale(AMHTS) in Turkey. DESIGN AND METHODS: The study is a methodological and semiexperimental study. It was carried out with 30 emergency service nurses and 378 psychiatric patients at a university hospital. The validity and reliability of the AMHTS were examined. FINDINGS: The reliability of the AMHTS is good level (Cohen's κ = 0.631, p < 0.05). It is valid for making the patients' waiting time in triage more efficient(p < 0.05), and increases the nurses' ability to determine the treatment acuity. PRACTICE IMPLICATIONS: It is an important tool that affects the quality of emergency psychiatric care for nurses working in the emergency departments of general hospitals.

Investigation of acute effects of topical Alpinia officinarum (galangal) treatment in experimental contact type burns and comparison with topical silver sulfadiazine treatment.

BACKGROUND: It was aimed to determine whether Alpinia officinarum (AO) (galangal), which has been regarded to be effective on wound healing, is healing on experimental contact type burns and compare its effects with silver sulfadiazine (SSD). METHODS: Thirty-five rats were divided into five groups of seven rats each group. Superficial second degree burns were formed by contacting a 1×1 cm copper tip which was kept at 100°C constant temperature to the three shaved areas on the back of rats without applying any pressure for 10 s. All groups were irrigated with a 100 cc saline solution for 2 min. Any procedure or treatment was not applied to Group I (Control). Group II (Burn Control) was only irrigated, Group III (SSD) was applied topical SSD 4 times, with 6-h intervals (at h 0, 6, 12 and 18), Group IV (Galangal) was applied topical AO 4 times, and Group V (Gel) was applied placebo topical material, used for the preparation of topical AO, 4 times. Wound healing findings were evaluated histopathologically. RESULTS: In the galangal group, it was found that collagen discoloration didn't penetrate into deep dermis compared to other groups; epidermis, hair follicles, and sebaceous glands remained protected compared to the burn control group, and there was a thicker layer of epidermis. It was found that the galangal group was the closest group to the control group histologically. In the galangal group, it was determined that the number of vessels and total hair follicles were significantly higher in the 8th h and 4th h respectively (p<0.05), while epidermal thickness and number of degenerated hair follicles were significantly higher in all hours compared to other three groups (p<0.05). It was determined that galangal group had the lowest scores in the evaluation of edema, polymorphonuclear leukocytes infiltration, collagen discoloration, injury of vessels, hair follicles and sebaceous glands in comparisons between groups and within groups' own processes. CONCLUSION: Administrating AO containing gel 4 times a day within the first 24 h is effective in the experimental contact type second degree burn model. It is significantly superior to SSD treatment, especially in the first 8 h of administration.

The healing effects of Hyperium perforatum (St. John's Wort) on experimental alkaline corrosive eosephageal and stomach burns.

BACKGROUND: The most frequent etiologic cause is alkaline substances. We investigated the protective effects of the plant St. John 's Wort (Hypericum perforatum). METHODS: We included 42 Wistar albino rats weighing between 200-300 grams and divided into six groups as Group 1: Control, Group 2: Burn+Saline (BS), Group 3: Burn+St. John's Wort (BSJW), Group 4: Burn+Plasebo (BP), Group 5: St. John's Wort (SJW), Group 6: Placebo (P). After 15 days of treatment, esophagus, stomach and liver tissue samples were derived by dissection for histopathologic and biochemical markers. The cytotoxic effects of formulation on fibroblasts is evaluated in vitro on human dermoblast fibroblast line (HDFa, Gibco Invitrogen cell culture, C-013-5C). RESULTS: The weight of the rats increased in Group 1, 3, 4, 6, decreased in Group 2 and did not change in Group 5. In the BSJW group, submucosal collagen accumulation, muscularis mucosa damage, tunica muscularis damage and collagen accumulation in esophagus were similar to the control group but lesser than BS and placebo group. In the stomach, mucosal damage, gastric gland dilatation, submucosal polymorphonuclear infiltration were similar to the control group and lesser than the BS group. The lethal concentration of SJW was 2.58 gr/mL. CONCLUSION: SJW substrate is effective in protecting the esophagus and stomach in mild to moderate alcali corrosive burns in the subacute period. We should keep in mind the protective effects of STW substrate in alkaline corrosive burns of the gastrointestinal system.

A rare diagnosis in emergency department: spontaneous spinal epidural hematoma.

We report a case of a 32-year-old man who presented to the emergency department (ED) with a sudden onset of paraplegia due to spontaneous spinal epidural hematoma. Although the patient had a poor neurological condition on presentation, he was successfully operated and discharged without any neurological sequel. Spontaneous spinal epidural hematoma is a rarely seen clinical entity, especially in the ED. Magnetic resonance imaging is the best choice for early diagnosis, and urgent surgical decompression is essential to prevent serious neurological deficits.

Determination of advanced life support knowledge level of residents in a Turkish university hospital.

The aim of the study was to determine the advanced cardiac life support (ACLS) knowledge level of residents and related factors in the departments of Anesthesiology, Emergency Medicine, Internal Medicine, and Cardiology in a university hospital. For this cross-sectional study, a total of 20 multiple-choice questions were prepared concerning several different topics, including: fatal dysrhythmias, oxygenation, ventilation and airway control, asystole, and pulseless electrical activity. Questions were given to residents before their periodic training meetings and collected in 30 min. There were 101 of 120 residents from four clinical departments (participation rate 84%) tested. Average point total and standard deviations of all residents were 66.3 +/- 17 out of 100 points. On a departmental basis, statistically significant differences were found in the knowledge level of residents (Emergency Medicine: 86.2 +/- 8.2, Cardiology: 66.7 +/- 12.9, Anesthesiology: 59.3 +/- 16.2, Internal Medicine: 56.1 +/- 13.5, F: 28.6, p < 0.0001). The factors that affect ACLS knowledge level of residents were "postgraduate ACLS training," "awareness of guidelines," and "resuscitation frequency." Postgraduate training and the frequency of ACLS practice seem to increase the ACLS knowledge level of residents. The present study emphasizes the necessity for a standardized systematic postgraduate ACLS training program for the residents of related medical disciplines. Further studies with larger groups are needed to investigate theoretical knowledge, resuscitation skill competency, and related factors.

Effective treatment of hereditary angioedema with fresh frozen plasma in an emergency department.

Hereditary angioedema (HAE) is a rarely seen disorder of C1 inhibitor (C1-INH) deficiency usually manifested by non-pruritic swelling of the skin. Acute exacerbations are not sensitive to conventional medications, and C1-esterase inhibitor concentrates are recommended as the first-line therapy. However, fresh frozen plasma is the main treatment alternative in many centers due to the lack of C1-esterase inhibitor concentrates. In this report, we present 3 patients with acute exacerbations of hereditary angioedema who were effectively and safely treated with fresh frozen plasma.

Treatment of Amlodipine Intoxication with Intravenous Lipid Emulsion Therapy: A Case Report and Review of the Literature.

We report the case of a 25-year-old female presenting to the emergency department after committing suicide by ingesting 100 mg amlodipine. The patient was initially treated with intravenous fluids, calcium gluconate, catecholamines and glucagone without effect. The clinical condition of the patient improved quickly and dramatically on the 20th minute of intravenous lipid emulsion (ILE) therapy. Different treatment methods have been developed for calcium channel blocker intoxication over the last years. Among these, lipid emulsion therapy has risen over the last decade as a salvation in cases which do not respond to other treatments. However, given the paucity of data, there are conflicting recommendations about the indications, dose and timing of ILE in the literature. In the light of this case report, we review the literature and discuss whether ILE therapy can find itself a place among first-line therapy recommendations.

Acute myocardial infarction associated with amitriptyline overdose.

Tricyclic antidepressant overdose is known to cause cardiopulmonary and central nervous system complications. As with other cardiovascular complications, amitriptyline toxicity may cause acute myocardial infarction. This paper reports the case of a young female with acute myocardial infarction as a novel consequence of tricyclic antidepressant overdose.

Views of emergency physicians working in university and state hospitals in Turkey regarding the use of analgesics in patients with acute abdominal pain.

BACKGROUND: Use of narcotic analgesics in patients with acute abdominal pain does not cause delayed misdiagnosis, increases patient comfort and does not suppresses physical examination. The purpose of this study was to determine attitudes anddaily practices of emergency medicine (EM) specialists, residents and faculty members in Turkey on the use of analgesics in patients with acute abdominal pain and factors affecting their decisions on the use of analgesics. METHODS: A cross-sectional study was performed between November 15, 2013 and January 25, 2014 by conducting a questionnaire to EM physicians working in University Hospitals, Education and Research Hospitals of the Ministry of Health, State Hospitals, and Private Hospitals in Turkey. RESULTS: A total of 803 questionnaires (participation rate: 47%) were completed. 59.3% (n=470) of the participants were research assistants. 49.5% of the participants reported that analgesic drugs "suppressed'' physical examination findings. They stated that 90% of the patients "always'' and "often'' requested analgesics and that 34.6% of surgery consultant physicians "rarely" recommended the use of analgesics, while 28.7% "never" recommended, and that there was no common policy established together with surgical departments (79.1%). According to the comparison between the EM specialists and residents, residents in the group stating that they would "never'' use analgesics were higher than specialists in number (p=0.002); residents reported that they administered analgesics "upon surgical intervention decision", while specialists reported that they administered analgesics "after patient's examination and treatment plan" (p=0.021); residents reported that analgesics "suppressed'' physical examination findings, while specialists reported that analgesics "clarified'' physical examination findings (p<0.0001); residents reported that they did not administer analgesics "before examination by surgeon'', while specialists reported otherwise (p=0.0001). Senior residents (>24 months) reported that they administered analgesics "often'' compared to junior residents (p=0.034) and that junior residents believed that the use of analgesics would "suppress physical examination findings'' at a higher percentage (p=0.002). CONCLUSION: The rates of use of analgesics in patients with acute abdominal pain by EM physicians are very low. The rates of use of analgesics by EM residents are much lower compared to EM specialists, and they highly believe that analgesic drugs suppress physical examination findings. Residents tend to administer analgesic drugs at a later stage. As seniority of residents increases, the rate of analgesics use and the opinion that analgesic drugs have no effect on physical examination findings increases.

The effect of the use of ultrasound in the success of peripheral venous catheterisation.

The aim of this study was to investigate the effect of ultrasound-guided peripheral venous catheterisation in patients where difficulty was experienced in peripheral venous catheterisation. The study was conducted in the emergency department at a university hospital in Izmir Turkey. After obtaining institutional review board approval and written informed consent, 60 patients with a history or suspicion of difficult cannulation were enrolled with 30 patients in traditional and 30 in ultrasound group. In the ultrasound group, peripheral intravenous catheterisation was performed using a portable ultrasound device with 13.5 MHz ultrasound probe and 20 gauge intravenous catheter. The success rate of peripheral venous catheterisation was 30% in the control group and 70% in the treatment group. The success rate was significantly higher among the treatment group. The mean intensity of felt pain was 6.00 ± 1.98 in the control group and 4.77 ± 1.74 in the treatment group. The mean intensity of felt pain was significantly lower in the treatment group. The state of chronic disease affected the success rate in patients in the treatment group.

Investigation of acute effects of Hypericum perforatum (St. John's Wort-Kantaron) treatment in experimental thermal burns and comparison with silver sulfadiazine treatment.

BACKGROUND: Hypericum perforatum (HP) (St. John's Wort-Kantaron) has been used widely for the treatment of burn injuries for many years in traditional Turkish medicine. The aim of study was to investigate HP treatment in experimental thermal burns and compare it with silver sulfadiazine (SS) treatment. METHODS: Thirty-five rats were randomly assigned to one of the five groups, 7 rats in each. A second-degree thermal burn was created on the dorsal sites of rats by exposing an area of 4×4 cm to 100 °C boiled water for 10 seconds. All groups were provided with irrigation for three (3) minutes with 50 cc saline solution (SS). Group 1 (Control Group) was not administered any treatment. Group 2 (Burn Control Group) was administered only irrigation, Group 3 (topical silver sulfadiazine [SS]) was administered SS twice a day, Group 4 (the Topical HP Group) was administered HP four times a day (every six hours), Group 5 (treatment with agent -gel-) was administered other topical material used for the preparation of HP four times a day (every six hours). Wound site healing on the skin was histopathologically evaluated. RESULTS: It was found that collagen discoloration of the HP treatment group was localized in the lower part of the epidermal layer and did not go up to the depth of dermis compared to the other groups, and epidermis, hair follicles and sebaceous glands remained protected compared to the groups administered burn, gel and SS in every hour of the experiment and it was the group closest to the control group structurally. It was determined that the epidermal thickness and the number of vessels of the HP Group were significantly higher compared to the other groups (p<0.05), which was the group closest to the control group in terms of these parameters and these numbers did not show any difference within hours (p>0.05). The number of degenerated hair follicles in the HP Group was significantly less than the other groups (p <0.05), and it was determined that the total number of hair follicles significantly increased in the twenty-fourth (p<0.05) and this number did not differ by the control group (p>0.05). CONCLUSION: Administration of HP four times a day within the first 24 hours is clearly effective in wound healing in the experimental thermal second degree burn modality and is significantly superior to SS treatment.

Comparison of Conventional Radiography and Digital Computerized Radiography in Patients Presenting to Emergency Department.

OBJECTIVES: To compare the differences between conventional radiography and digital computerized radiography (CR) in patients presenting to the emergency department. METHODS: The study enrolled consecutive patients presenting to the emergency department who needed chest radiography. Quality score of the radiogram was assessed with visual analogue score (VAS-100 mm), measured in terms of millimeters and recorded at the end of study. Examination time, interpretation time, total time, and cost of radiograms were calculated. RESULTS: There were significant differences between conventional radiography and digital CR groups in terms of location unit (Care Unit, Trauma, Resuscitation), hour of presentation, diagnosis group, examination time, interpretation time, and examination quality. Examination times for conventional radiography and digital CR were 45.2 and 34.2 minutes, respectively. Interpretation times for conventional radiography and digital CR were 25.2 and 39.7 minutes, respectively. Mean radiography quality scores for conventional radiography and digital CR were 69.1 mm and 82.0 mm. Digital CR had a 1.05 TL cheaper cost per radiogram compared to conventional radiography. CONCLUSIONS: Since interpretation of digital radiograms is performed via terminals inside the emergency department, the patient has to be left in order to interpret the digital radiograms, which prolongs interpretation times. We think that interpretation of digital radiograms with the help of a mobile device would eliminate these difficulties. Although the initial cost of setup of digital CR and PACS service is high at the emergency department, we think that Digital CR is more cost-effective than conventional radiography for emergency departments in the long-term.

The effects of oral antibiotics on infection prophylaxis in traumatic wounds.

BACKGROUND: The objective of this study is to examine the effectiveness of oral antibiotics in the prevention of infection development in traumatic wounds. METHODS: Forty Wistar albino rats were divided into five groups of eight animals. After the crushed wound model was made on the back of the rats, wounds were closed with a simple suture and Staphylococcus aureus ATCC 29213 strain was used to create infection. All rats apart from the controls were given oral gavage with antibiotics, including cephalexin, amoxicillin-clavulanate, clarithromycin (CAM), or levofloxacin for 5 days. Wounds were evaluated qualitatively and quantitatively on 5th day approximately 18 h after the last treatment. RESULTS: In the quantitative evaluation, no infection was observed in the treatment groups with amoxicillin-clavulanate, CAM, cephalexin, or levofloxacin. There was no significant difference on the numbers of bacteria found in the wounds among the groups. In terms of quantitative inflammation findings, no hyperemia or pus was detected in the groups that were given medication. Furthermore, no statistically significant difference was found among the groups in terms of induration. CONCLUSION: Oral prophylactic antibiotics have been found to be effective in the prevention of wound infection in the traumatic crushed wound model infected with S. aureus in rats.

Acute coronary syndrome mimicked by acute cholecystitis.

Various aetiologies have been reported that cause severe trauma segment and T-wave abnormalities that are not related to acute coronary syndromes. However, the reports of transient ECG abnormalities associated with acute cholecystitis are limited in the literature. We describe a 42-year-old man presented with abdominal pain and hypertensive episode that developed dynamic ECG changes mimicking acute coronary syndrome and was diagnosed acute cholecystitis eventually. Emergency physicians should keep in mind dynamic T-wave changes mimicking acute myocardial ischaemia in patients with acute cholecystitis.

Can D-dimer testing help emergency department physicians to detect acute aortic dissections?

OBJECTIVE: To determine the diagnostic accuracy of D-dimer testing for detection of acute aortic dissection. METHODS: This study is a retrospective chart review of patients who had been evaluated with suspicion of acute aortic dissection. All patients' D-dimer levels were determined prior to their further work up in the emergency department. The study was conducted in a tertiary care center between February 2006-August 2008. The D-dimer assay used was the immunoturbidimetric assay, with a normal range up to 0.246 µg/ml. Statistical analysis was accomplished using Chi-square test, Student's t-test and a receiver-operating characteristics (ROC) curve analysis. RESULTS: Ninety-nine patients were included in the study, 30 patients were diagnosed as having acute aortic dissection and 69 patients were evaluated in non-acute aortic dissection group. In comparison of the two groups, positive D-dimer results were found to be significantly higher in acute aortic dissection group than in non-acute aortic dissection group (p=0.001). Sensitivity of the D-dimer test in detection of acute aortic dissection was found as 96.6% and the negative predictive value of the test was 97.3%. Specificity and positive predictive value of the D-dimer test were 52.2% and 46.8%, respectively. The area under the ROC curve yielded an acceptable certainty for excluding acute aortic dissection on base of negative results (AUC: 0.764; CI 95%: 0.674-0.855; p=0.001). CONCLUSION: D-dimer testing is helpful for emergency physicians in detection of patients with suspected acute aortic dissection in the emergency department.

Current status of emergency residency training programs in Turkey: after 14 years of experience.

OBJECTIVE: Emergency residency training programs, which have been developing in Turkey over the last 14 years, have been improving emergency health services by training each year a significant number of emergency medicine specialists. Sufficient data about these emergency residency training programs is not currently available. The purpose of this study is to determine (i) the structure of emergency residency training programs and (ii) trainer and resident views concerning these programs. METHODS: The data in this cross-sectional study was gathered by means of questionnaires. Three different forms of questionnaires were used for residents, trainers, and heads of departments. RESULTS: This study covers 20 emergency medicine departments and 261 physicians. It was determined that written rotational objectives have been indicated in 17 of the emergency medicine departments and log books are used in 16 departments. Although 60% of resident views on 'practical skills', 23% on 'the contribution of rotations to the training', and 44% on 'the level of residency training programs' were rated as 'sufficient', trainers indicated 'sufficiency' on these subjects as 78, 37, and 77%, respectively. Regarding theoretical and practical skills, residents and trainers, respectively rated as 'sufficient' following subjects: cardiovascular 74, 91%; neurology 68, 86%; resuscitation 83, 98%; trauma 76, 87%; orthopedics 56, 75%; pediatrics 16, 27%; and toxicology 63, 82%. CONCLUSION: Most of the departments have developed the basic components for resident education. Residents and trainers frequently had different views on their own level of knowledge, practical skills, and the content of their training.

Can elevated troponin I levels predict complicated clinical course and inhospital mortality in patients with acute pulmonary embolism?

OBJECTIVE: The purpose of this study was to evaluate the value of elevated cardiac troponin I (cTnI) for prediction of complicated clinical course and in-hospital mortality in patients with confirmed acute pulmonary embolism (PE). METHODS AND RESULTS: This study was a retrospective chart review of patients diagnosed as having PE, in whom cTnI testing was obtained at emergency department (ED) presentation between January 2002 and April 2006. Clinical characteristics; echocardiographic right ventricular dysfunction; inhospital mortality; and adverse clinical events including need for inotropic support, mechanical ventilation, and thrombolysis were compared in patients with elevated cTnI levels vs patients with normal cTnI levels. One hundred sixteen patients with PE were identified, and 77 of them (66%) were included in the study. Thirty-three patients (42%) had elevated cTnI levels. Elevated cTnI levels were associated with inhospital mortality (P = .02), complicated clinical course (P < .001), and right ventricular dysfunction (P < .001). In patients with elevated cTnI levels, inhospital mortality (odds ratio [OR], 3.31; 95% confidence interval [CI], 1.82-9.29), hypotension (OR, 7.37; 95% CI, 2.31-23.28), thrombolysis (OR, 5.71; 95% CI, 1.63-19.92), need for mechanical ventilation (OR, 5.00; 95% CI, 1.42-17.57), and need for inotropic support (OR, 3.02; 95% CI, 1.03-8.85) were more prevalent. The patients with elevated cTnI levels had more serious vital parameters (systolic blood pressure, pulse, and oxygen saturation) at ED presentation. CONCLUSION: Our results indicate that elevated cTnI levels are associated with higher risk for inhospital mortality and complicated clinical course. Troponin I may play an important role for the risk assessment of patients with PE. The idea that an elevation in cTnI levels is a valuable parameter for the risk stratification of patients with PE needs to be examined in larger prospective studies.