The comparison of heparinized insulin syringes and safety-engineered blood gas syringes used in arterial blood gas sampling in the ED setting (randomized controlled study).

INTRODUCTION: The arterial blood gas measurement process is a painful and invasive procedure, often uncomfortable for both the patient and the physician. Because the patient-related factors that determine the difficulty of the process cannot be controlled, the physician-related factors and blood gas measurement techniques are a modifiable area of improvement that ought to be considered. Many hospitals use insulin syringes or syringes washed with heparin for the purpose of blood gas measurement because they do not have blood gas-specific syringes. In this prospective cross-sectional study, we aimed to compare safety-engineered blood gas syringes and conventional heparinized syringes used during the arterial blood gas extraction process in terms of ease of operation, the physician-patient satisfaction, laboratory appropriateness, and complications. METHODS: Our study included patients whose arterial blood gas needed to be measured in the emergency department and who agreed to participate in the study. Patients were randomly divided into 2 groups. The arterial blood gas of the patients from the first group was measured by using conventional heparinized syringes, whereas safety-engineered blood gas syringes were used to measure the arterial blood gas of the patients from the second group. The groups were compared in terms of demographic data, the number of attempts, the physician and patient satisfaction, early and late-term complications, and laboratory appropriateness of the taken sample. RESULTS: A total of 550 patients were included in our study in a 2-month study period. There were no significant differences between patients in terms of sex, age, weight, height, body mass index, and wrist circumference. In addition, the number of attempts (P=.489), patients' pain level during the procedure (P=.145), and the degree of difficulty of the procedure according to the patient (P=.109) and physician (P=.554) were not significantly different between the groups. After arterial blood gas extraction procedure, 115 patients (20.9%) developed complications. In the conventional heparinized syringe group, the complication rate (n=69; 25.1%) was significantly higher compared with the group that used safety-engineered blood gas syringes (n=46; 16%; P=.0211). Localized pain, which is one of the most common early complications, was more frequent in the conventional heparinized syringe group (19.3%). Complications in women (P=.003) and local pain (P=.01) developed lesser in the second group that used safety-engineered blood gas syringes, and the patient-physician satisfaction was higher in that group, as well. In the evaluation 48 hours after the procedure, the ratios of infection and local hematoma were higher in the conventional heparinized syringe group (P=.0213 and P < .0001). CONCLUSION: In this study, we did not find any significant differences between the conventional heparinized syringes and safety-engineered blood gas syringes in terms of ease of operation, physician and patient satisfaction, and appropriateness of the taken sample. However, patients whose arterial blood gas was extracted by using safety-engineered blood gas syringes felt less pain and experienced fewer infections and hematomas at their puncture site.

Novel biochemical marker for differential diagnosis of seizure: ischemia-modified albumin.

INTRODUCTION: Differential diagnosis of seizure is critical in patients presented to emergency department (ED) with altered mental status or loss of consciousness. Although electroencephalogram is important for the diagnosis of seizures, its use in EDs is limited. The level of ischemia-modified albumin (IMA) increases in conditions of ischemic distress such as acute coronary syndrome, pulmonary embolism, and mesenteric ischemia. No studies exist in literature regarding the increase of IMA levels parallel to increased seizure activity in adults. The aim of the study was to investigate the diagnostic value of IMA in adult patients presented to ED with seizures. METHODS: Forty patients presented to ED with seizure, and 40 control patients of similar age and sex as the study group were enrolled in this study. Initial and fourth-hour levels of IMA and albumin were measured. Groups were compared in terms of sociodemographic data and details regarding their seizures as well as initial and fourth-hour levels of IMA. RESULTS: Mean levels of IMA were 61.5 IU/mL and 18.5 IU/mL (P < .001) initially and 56.7 IU/mL and 15.4 IU/mL (P < .001) at the fourth hour; levels were higher in the study group compared with control group. Ischemia-modified albumin/albumin ratios in study and control groups were 1555.3 IU/g and 462.4 IU/g (P < .001) initially and 1431.4 IU/g and 383.6 IU/g (P < .001) at the fourth hour, respectively. CONCLUSION: Blood IMA level and IMA/albumin ratio significantly increase in adult patients who experienced seizures. Ischemia-modified albumin may be considered as a useful biomarker in the differential diagnosis of seizure.

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.

Clinical efficacy of dexamethasone for acute exudative pharyngitis.

The objective of this study was to investigate whether treatment with single-dose dexamethasone can provide relief of symptoms in acute exudative pharyngitis. A prospective, randomized, double-blinded, placebo-controlled clinical trial was undertaken over a 3-month period in a university-based Emergency Department. The study included all consecutive patients between 18 and 65 years of age presenting with acute exudative pharyngitis, sore throat, odynophagia, or a combination, and with more than two Centor criteria. Each patient was empirically treated with azithromycin and paracetamol for 3 days. The effects of placebo and a fixed single dose (8 mg) of intramuscular injection of dexamethasone were compared. The patients were asked to report the exact time to onset of pain relief and time to complete relief of pain. After completion of the treatment, telephone follow-up regarding the relief of pain was conducted. A total of 103 patients were enrolled. Thirty patients with a history of recent antibiotic use, pregnancy, those who were elderly (>65 years of age) and patients who failed to give informed consent were excluded. Forty-two patients were assigned to the placebo group and 31 were assigned to the intramuscular dexamethasone group (8-mg single dose). Time to perceived onset of pain relief was 8.06+/-4.86 h in steroid-treated patients, as opposed to 19.90+/-9.39 h in the control group (p=0.000). The interval required to become pain-free was 28.97+/-12.00 h in the dexamethasone group, vs. 53.74+/-16.23 h in the placebo group (p=0.000). No significant difference was observed in vital signs between the regimens. No side effects and no new complaints attributable to the dexamethasone and azithromycin were observed. Sore throat and odynophagia in patients with acute exudative pharyngitis may respond better to treatment with an 8-mg single dose of intramuscular dexamethasone accompanied by an antibiotic regimen than to antibiotics alone.

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.

Angiographic extent of coronary artery stenosis in patients with high and intermediate likelihood of unstable angina according to likelihood classification of American Heart Association.

OBJECTIVE: In accordance with the AHA/ACC clinical practice guideline, the likelihood of acute ischemia caused by coronary artery disease (CAD) is to be determined as high, intermediate, or low for all patients presenting with chest discomfort. This study was conducted to estimate extent of significant CAD in patients with high and intermediate likelihood of unstable angina (UA) according to "AHA likelihood classification". METHODS: Overall, 133 consecutive patients presented with symptoms or signs suggestive of UA, which was classified as of high or intermediate likelihood in Emergency Department (ED), and undergoing coronary angiography (CAG) within one week were enrolled into the study. The characteristics of the patients in either subgroup were compared in terms of the findings of the CAG. RESULTS: In patients with high likelihood of UA (n=89), CAG revealed that 62 had significant CAD, 7-moderate CAD, 20-mild CAD or normal coronary angiogram. In patients with intermediate likelihood of UA (n=19), CAG revealed that 2 patients had significant CAD, and 17-mild CAD or normal coronary angiogram. The rate of significant CAD was significantly higher in patients with high likelihood (p<0.001, LR 23.97, 95% CI 4.21-90.43). The sensitivity and specificity of having at least one of high likelihood features for detecting significant CAD were found to be 96.8% and 38.6% respectively. CONCLUSION: We suggest that the likelihood classification is useful for the triage of the UA patients in the ED. When supported with further studies, utilization of this classification will yield a high diagnostic accuracy in predicting or ruling out severe CAD in patients presenting with chest pain.

The diagnostic value of QT dispersion for acute coronary syndrome in patients presenting with chest pain and nondiagnostic initial electrocardiograms.

BACKGROUND: Patients presenting with chest pain and nondiagnostic electrocardiograms (ECG) in the emergency department (ED) often pose a challenge to physicians. QT dispersion (QTD) is an electrocardiographic marker of myocardial ischemia due to nonhomogenous ventricular repolarization. We hypothesized that QTD could accurately identify patients with acute coronary syndrome (ACS) who presented with chest pain and nondiagnostic initial ECGs. METHODS: All patients admitted to the ED with chest pain and nondiagnostic initial ECGs were included in the study prospectively. QTD and QTc dispersion (QTcD) were measured at the initial ECGs and compared for ACS patients vs. non-ACS patients. A receiver operating characteristic curve was drawn to evaluate the diagnostic value of QTD and QTcD for ACS. RESULTS: Of the 137 patients with an initially nondiagnostic ECG, 51 were finally diagnosed with ACS (37%). Mean QTD and QTcD of patients with ACS were significantly greater than those of patients without ACS (39.61 +/- 12.9 vs. 32.56 +/- 15.1, p=0.004; 46.12 +/- 16.3 vs. 38.10 +/- 18.2, p=0.009, respectively). The area under the curve was 0.624, p=0.015 for QTD, and 0.603 and p=0.049 for QTcD. When various cut-off points were evaluated, potentially useful values were determined between 30 and 50 ms for QTD (sensitivity 86% and 10%, specificity 35% and 97%, respectively). These values were 40.5 and 49.5 ms for QTcD (sensitivity was 96% and 32%, specificity was 12% and 77%, respectively). CONCLUSION: For patients with chest pain and nondiagnostic initial ECG, ACS risk is high if QTD and QTcD values are greater than 40 ms. Therefore, QTD and QTcD can help identify patients with acute coronary syndrome who present with chest pain and a nondiagnostic initial ECG. However, poor operator characteristics of QT dispersion could limit its value as a diagnostic test in the clinical setting.

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.

The comparison of the efficiency of traditional lectures to video-supported lectures within the training of the Emergency Medicine residents.

OBJECTIVES: Recent developments in computer and video technology, multimedia resources enter quickest way possible into medical education and have started to gain popularity. The aim of this study is to evaluate the impact of video-supported lectures on leaning, with comparison to traditional lectures. METHODS: According to lecture techniques, two separate groups; one is the traditional lectures group (TLG) and the other is video-supported lectures group (VSLG), are formed. While the TLG is offered a traditional lecture the VSLG is offered a video-supported lecture with imbedded videos which are related to the topics in the traditional lecture. Both study groups take pretest and posttest with MCQs (multiple choice questions) and OSCEs (objective structured clinical examination). RESULTS: The study includes 30 volunteer residents in Dokuz Eylul University School of Medicine Department of Emergency Medicine. No difference is observed between TGL and VSLG in pretest and posttest scores (p = 0.949, p = 0.580). And additionally, comparing the scores of both groups, we cannot observe any difference between the pretest OSCE scores of each group (p = 0.300), however posttest OSCE scores shows a dramatic odd in-between (p = 0.010). When pretest MCQs and posttest MCQs mean scores are compared, both tests (TLG, VSLG) has not any significant difference (p=0.949, p = 0.580). Nevertheless, after comparing OSCEs pretest and posttest mean scores, we can see significant difference in mean scores of both (TLG, VSLG), (p = 0.011, p = 0.001). CONCLUSIONS: Taken into consideration, the findings of this study shows possibility of improving educational techniques to acquire clinical skills by using local resources and low-cost technology.

Emergency department visits caused by adverse drug reactions: results of aTurkish university hospital.

BACKGROUND/AIM: We aimed to evaluate adverse drug reaction (ADR)-related emergency department (ED) visits in the ED of the Dokuz Eylül University Hospital prospectively. MATERIALS AND METHODS: Patients who were admitted to the ED during 1-week periods of four different seasons between July 2010 and April 2011 were enrolled. Demographics of patients, previous ADR history, clinical progress, and outcomes were recorded. Causality assessment was done according to World Health Organization Uppsala Monitoring Centre categories. ADRs were categorized as certain, probable, or possible. RESULTS: Patients who were on medications (26.5%, n = 1838) were evaluated for ADR-related ED admissions. ADRs accounted for 5.9% of cases (n = 108). The most frequently affected systems were the gastrointestinal (35.2%, n = 38), dermatological (23.1%, n = 25), and hematological (10.2%, n = 11) systems (7.4%, n = 8). The most common causes of ADRs were antiinfectives (31.6%, n = 33). Amoxicillin, Coumadin, and paracetamol were the most common medications that caused ADRs. CONCLUSION: Nearly 6% of the admissions were ADR-related. ADRs should always be considered when patients who are on medication are admitted to the ED. Multicenter epidemiologic studies are required to know the real rates of ADR cases in EDs in Turkey.

Acute myocardial infarction after hydrochloric acid ingestion.

We report a case of acute ST segment elevated myocardial infarction associated with hydrochloric acid ingestion. Severe systemic acidosis developed shortly after massive hydrochloric ingestion; it was complicated by the presence of acute myocardial infarction. A new complication of acid ingestion is presented and a possible mechanism is discussed.

To be vaccinated or not? A survey of Turkish emergency physicians regarding smallpox.

We investigated Turkish emergency physicians' opinions about the threat of smallpox, smallpox vaccination, and the treatment of patients with suspected smallpox, and sought to identify factors that affect willingness to receive smallpox vaccination. Anonymous surveys were sent by mail to university-affiliated Emergency Departments in Turkey. Ten of the 21 university-based Emergency Medicine programs participated in the study, and 125 physicians (48% of all emergency physicians in Turkey) completed the survey. The probability of a bioterror attack using smallpox within Turkish borders was viewed as none or minimal by 43.2% of participants. Only 22.4% of the participants stated that they would agree to be vaccinated. The only factor that affected the rate of participants' willingness to receive smallpox vaccination was the occurrence of a smallpox case within Turkish borders. Decisions about the treatment of patients with suspected smallpox are strongly influenced by whether or not the physician has been vaccinated against smallpox. At the time of the survey, even during the weeks leading up to and during the war in Iraq, Turkish emergency physicians' perceived risk of a bioterror attack using the smallpox virus was low. A significant number of Turkish emergency physicians were unwilling to participate in a hypothetical vaccination program. This study shows that the occurrence of a smallpox case within Turkish borders would significantly increase the willingness of emergency physicians to receive the smallpox vaccine. Decisions about treatment of patients with suspected smallpox are strongly influenced by whether or not the physician has been vaccinated against smallpox.

Luxatio erecta: clinical presentation and management in the emergency department.

Luxatio erecta (inferior glenohumeral dislocation) is an uncommon type of shoulder dislocation. Early recognition and reduction is important to prevent neurovascular sequelae. We report two cases of luxatio erecta in order to describe the clinical presentation and reduction technique in the Emergency Department.

Injury and illness among athletes during a multi-day elite cycling road race.

OBJECTIVES: Although road bicycle races have been held for more than a century, injury and illness patterns during multi-day bicycle events have not been widely studied. The aim of this study was to determine the incidence of injury and illness among riders and describe the medical care interventions provided to participants of cycling road races. METHODS: A prospective observational study was conducted on the Presidential Cycling Tour of Turkey, which was held between April 26 and May 3, 2015. The race lasted 8 days and covered 1258 km of road. There were 166 elite cycling athletes representing 21 teams from various countries. Data collected pertaining to incidents involving injury or illness included the following: type of injury; anatomical location of injury; details of the medical encounter; location of the intervention; treatment provided; medication administered and disposition of the rider. An injury was defined as a physical complaint or observable damage to the body produced by the transfer of energy of the rider. An illness was defined as a physical complaint or presentation not related to injury. RESULTS: The overall incidence (injury and illness) was 5.83 per 1000 cycling hours. (Injury incidence was 2.82 vs illness incidence of 3.01 per 1000 hours cycling). A total of 31 incidents occurred. Of these, 15 were injuries, while 16 were complaints of a non-traumatic nature. A total of 43 interventions were made in the 15 cases of injury. The most commonly injured body regions were limbs; the majority of injuries involved the skin and soft tissue. The most common medical intervention was wound care (64% of all interventions). Two riders had to withdraw from the race, and one was hospitalized due to a traumatic pneumothorax. None of the non-traumatic cases resulted in withdrawal from the race. CONCLUSIONS: A broad spectrum of illness and injury occurs during elite multi-day road races, ranging from simple skin injuries to serious injuries requiring hospital admission. Most injuries and illnesses are minor; however, medical teams must be prepared to treat life-threatening trauma.

[Emergency physicians and "burn out" syndrome]. / Acil servis hekimleri ve "tükenme" sendromu.

Emergency physicians are continuously under stress because of overcrowded departments, severity of cases, and their work schedules. In addition to this work stress, unregular social and family life are the main components of ongoing burn out process in these professionals. Burn out is the end point of the process which is complicated by the loss of professional enthusiasm and satisfaction, and negative behavioral approach to the patients. This review includes detailed statements on specific headlines, such as residency period, shift system, sleep management, risk of physical and psychological diseases, and stress management for emergency physicians.

Evaluation of physical findings in acute wrist trauma in the emergency department.

OBJECTIVE: The aim of the study was to evaluate the value of physical findings to predict fracture in patients with acute wrist trauma. METHODS: This prospective clinical study was conducted over a period of four months from December 1998. The patients who were older than 18 years and presenting with acute wrist trauma within 24 hours of the time of injury were included in the study. Magnetic resonance imaging (MRI) was done for the patients who had inconsistency between clinical and radiographic diagnosis. RESULTS: Fifty-five patients were included in the study. Four fractures were diagnosed on the MRI of eight patients who have contradiction between clinical diagnosis and X-ray studies. The positive predictive values of edema, localized tenderness, pain on active and passive motion, pain with grip and pain in supination were found as 95.2%, 67.3%, 77.3%, 91,7%, 89.3%, and 96%, respectively. Physical findings having high sensitivity were found as localized tenderness (94.3%), pain on the active and passive motion (97.1%, 94.3%, respectively). Pain on the active and passive motion were determined as physical findings with highest negative predictive values (%90.9, %89.5, respectively). CONCLUSION: Edema, pain on grip and supination, and especially pain on passive and active motion and localized tenderness can be valuable to predict or rule out fracture in acute wrist trauma cases who have no deformity.

A New Model in Reducing Emergency Department Crowding: The Electronic Blockage System.

OBJECTIVES: Emergency department (ED) crowding is a growing problem across the world. Hospitals need to identify the situation using emergency department crowding scoring systems and to produce appropriate solutions. METHODS: A new program (Electronic Blockage System, EBS) was written supplementary to the Hospital Information System. It was planned that the number of empty beds in the hospital should primarily be used for patients awaiting admission to a hospital bed at the ED. In the presence of patients awaiting admission at the ED, non-urgent admissions to other departments were blocked. ED overcrowded was measured in the period before initiation of EBS, the early post-EBS period and the late post-EBS period, of one-week's duration each, using NEDOCS scoring. RESULTS: NEDOCS values were significantly lower in the early post-EBS period compared to the other periods (p≤0.0001). Although outpatient numbers applying to the ED and existing patient numbers at time of measurement remained unchanged in all three periods, the number of patients awaiting admission in the early post-EBS period was significantly lower than in the pre-EBS and late post-EBS periods (p=0.0001, p=0.001). CONCLUSIONS: EBS is a form of triage system aimed at preventing crowding and ensuring the priority admission of emergency patients over that of polyclinic patients. In hospitals with an insufficient number of total beds it can be used to reduce ED crowding and accelerate admissions to hospital from the ED.