The efficacy of transcutaneous cardiac pacing in ED.

INTRODUCTION: Transcutaneous cardiac pacing (TCP) is a rapid, time-saving, and noninvasive ventricular stimulation that is tolerated by conscious patients despite the painful intervention for treatment of symptomatic bradycardias. The goal of this study was to determine the efficacy of TCP in unstable bradycardia patients in emergency department (ED). METHODS: This single-central, observational clinical study was conducted on patients older than 18 years who presented with acute unstable bradycardia to the tertiary care university ED. Primary outcome measure was to determine the efficacy of TCP in unstable bradycardia patients in the emergency settings. Efficacy of TCP was to determine changes of clinically significant vital signs and electrocardiography. RESULTS: Of 349 patients who visited the ED presenting with bradycardia, 89 patients who met the criteria were included in the study. There was a statistically significant difference between before and after the first administration TCP in mean systolic (71.2 [64.8-77.6] and 105.3 [97.6-112.9 mm Hg]) and diastolic blood pressure (42.9 [38.8-47.0] and 61.0 [56.4-65.5] mm Hg) and median heart rate (40 [39-42] and 74 [71-78] beats/min, P< .0001). CONCLUSION: Transcutaneous cardiac pacing is a clinically effective treatment modality in patients with atropine-resistant unstable bradycardia.

The impact of goal-directed transvaginal ultrasonography on clinical decision-making for emergency physicians.

The aim of study was to determine the impact of "goal-directed transvaginal ultrasonography" (TVUSG) on real-time clinical decision making of attending emergency physicians evaluating their level of certainty for preliminary diagnosis, admission, surgery, treatment, additional laboratory, and discharge in patients presenting with acute pelvic pain to the emergency department (ED). This prospective cross-sectional clinical study was conducted on sexually active female patients older than 18 years who presented with acute pelvic pain in the ED. The level of certainty of clinical decision making as mentioned above was measured by a visual analogue scale from 0 to 100 mm with 100 mm being most certain before and after TVUSG. Statistical analysis was performed on 88 patients. The mean age was 31.7 ±8.3 years with a median of 30 years. Among clinical decisions, there was a significant difference between pre-TVUSG and post-TVUSG certainty of the decision to perform preliminary diagnoses derived from patient's history and physical examination but not in the other outcomes (treatment, admission, surgery, and discharge). (P = .05). Of the patients included in the study, 11 (12.5%) were admitted to hospital, and 2 (2.3%) of them were operated on. The remaining 75 (85.2%) patients were discharged from the ED; of the patients that had been discharged, 18 (20.5%) patients later consulted another physician, and no further pathology could be discovered. In conclusion, US performed by attending emergency physicians may affect the certainty of their decisions in patients presenting with acute pelvic pain. This effect statistically significantly on the decision to determine preliminary diagnosis.

Nail bed injury detected by ultrasonography.

A 46-year-old man presented to the emergency department after being injured with a press machine from his left hand 30 minutes before admission. Subungual hematoma was diagnosed in his index finger, although the nail plate was intact. Emergency physicians could identify nail bed injury with bedside ultrasonography examination. This noninvasive, inexpensive, and repeatable diagnostic modality could preserve patients from a complex, invasive nail removal procedure.

Fire-eater's pneumonia: two case reports of accidentally aspirated paraffin oil.

BACKGROUND: Fire-eater's pneumonia is a chemical pneumonitis that can develop after accidental aspiration of liquid hydrocarbon-based fuel during a flame-blowing or a fire-eating performance. Typical findings of the patient are similar with any infectious pneumonia: chest pain, shortness of breath, cough, fever, and hemoptysis can be seen. CASE REPORTS: We report two cases of acute paraffin oil-induced pneumonia due to accidental aspiration during fire-eating performance. CONCLUSION: The symptoms and course of respiratory manifestations and the treatment strategies of fire-eater's pneumonia are reviewed.

Traditional Kehr's sign: Left shoulder pain related to splenic abscess.

Kehr’s sign was originally described by the German surgeon Hans Kehr (1862-1916). It is a classical example of referred pain: irritation of the diaphragm is signaled by the phrenic nerve as pain in the area above the clavicle. We present a case of a 21-year-old woman admitted to the emergency department with the chief complaint of left shoulder pain related to splenic abscess.

ETCO2: a predictive tool for excluding metabolic disturbances in nonintubated patients.

OBJECTIVES: The purpose of this study is to examine the relation between end-tidal carbon dioxide (ETCO2) measurement and bicarbonate (HCO3) level reflecting the patient's metabolic status. METHOD: This prospective cross-sectional study has been carried out during a 3-month period in a tertiary care university hospital's emergency department (ED). During the study period, every spontaneously ventilating ED patient requiring arterial blood gas analysis for any medical indication, regardless of presenting symptoms, had a simultaneous ETCO2 measurement using a Medlab Cap 10 side stream capnograph. The demographics and clinical outcomes of the patients were recorded. RESULTS: Of 399 eligible patients, 240 with possible metabolic disturbance were enrolled into the study. There was a statistically significant correlation between the value of ETCO2 and HCO3 levels (r = 0.506). The mean ET(CO)2 level was statistically significantly lower in patients who died (26.5 ± 7.2, 95% confidence interval [CI], 24.2-28.6, vs 30 ± 7.5, 95% CI, 29-31; P = .007) and who had low bicarbonate levels (25.7 ± 6.7, 95% CI, 24.3-27.1, vs 31.6 ± 7.1, 95% CI, 30.4-32.8; P = .000). The value of ET(CO)2 measurement to detect low bicarbonate level was found to be significant. The area under the receiver operating characteristic curve was 0.734, the (+) likelihood ratio for ETCO2 less than or equal to 25 was 2.7, and the (-) likelihood ratio for ETCO2 greater than or equal to 36 was 0.05. CONCLUSION: ETCO2 values correlate moderately with HCO3 levels and thus might predict mortality and metabolic acidosis. Therefore, side stream capnograph can be used as a noninvasive diagnostic tool for ruling out suspected severe metabolic disturbance in the ED.

The value of procalcitonin, a novel inflammatory marker, in the diagnosis of myocardial infarction and evaluation of acute coronary syndrome patients.

BACKGROUND: Procalcitonin is a calcitonin precursor that is used as an inflammatory biomarker in the plasma of patients with sepsis. OBJECTIVE: The aim of this study was to determine the diagnostic accuracy of emergency department (ED) point-of-care blood procalcitonin testing in identifying myocardial infarction (MI) in patients with chest pain of presumed ischemic origin. METHODS: Patients over 18 years of age who presented to the ED with MI-typical chest pain of presumed ischemic origin were included in the study. An initial point-of-care blood sample was drawn from each study patient for testing procalcitonin, troponin T, myoglobin, and creatine kinase-MB levels. A second sample was taken 4h after admission for a procalcitonin test. Finally, a 6-h post-admission blood sample was taken to measure troponin T, myoglobin, and creatine kinase-MB levels in each study patient who had an initial negative cardiac marker test. RESULTS: A total of 1008 patients with chest pain were admitted to the ED during the study period, and a total of 141 patients met study criteria and were entered into the study. ED point-of-care blood procalcitonin testing to identify myocardial infarction in patients with chest pain of presumed ischemic origin had a sensitivity of 38.3% (95% confidence interval [CI] 28.8-47.3%) and a specificity of 77.8% (95% CI 70.0-84.4%), a positive likelihood ratio (LR+) of 1.725 and a negative likelihood ratio (LR-) of 0.792. The 4th hour diagnostic values (sensitivity, specificity, LR+ and LR-) of procalcitonin semi-quantitative (PCT-Q) testing were 90% (95% CI 80.9-95.7%), 59.3% (95% CI 52.5-63.5%), 2.2, and 0.16, respectively. CONCLUSION: ED point-of-care testing for procalcitonin had poor diagnostic accuracy for predicting myocardial infarction.

Pseudoephedrine-induced paroxysmal supraventricular tachycardia: a case report.

Palpitation is a common chief complaint among emergency department patients, and is often associated with a tachydysrhythmia. Tachydysrhythmia is classified as supraventricular tachycardia or ventricular tachycardia. Reentry in a normal or accessory pathway is one of the most frequently seen mechanisms explaining the tachydysrhythmia. In the present case, we report an unusual cause of atrioventricular paroxysmal supraventricular tachycardia due to pseudoephedrine intake.

Sonographic diagnosis of epiglottal enlargement.

The case is presented of epiglottal and pre-epiglottal oedema secondary to infection of the pharyngolaryngeal area. The purpose of this report was to assess the utility of ultrasonography to image epiglottal and pre-epiglottal oedema. Bedside emergency department ultrasonography could be a valuable tool to detect pathological enlargement of the epiglottis. Ultrasonography may be used in unstable patients for diagnosing epiglottitis because it is cheap, rapid, non-invasive and does not aggravate the patient's symptoms.

Intravenous paracetamol or morphine for the treatment of renal colic: a randomized, placebo-controlled trial.

STUDY OBJECTIVE: This randomized, placebo-controlled trial evaluates the analgesic efficacy and safety of intravenous single-dose paracetamol and morphine for the treatment of renal colic. METHODS: We conducted a randomized, double-blind, placebo-controlled clinical trial comparing single intravenous doses of paracetamol (1 g), morphine (0.1 mg/kg), and placebo (normal saline solution) for patients presenting to the emergency department (ED) with suspected renal colic. Subjects with inadequate pain relief at 30 minutes received rescue fentanyl (0.75 microg/kg). We compared changes in pain intensity 30 minutes after treatment among the 3 arms, as well as the need for rescue medication and the presence of adverse effects. RESULTS: Six hundred forty-five consecutive patients were screened for study and 165 were entered. Eight subjects were subsequently excluded from analysis because of protocol violations and 11 were excluded because of uncertain diagnoses, leaving 146 subjects available for analysis. The mean reduction in visual analogue scale pain intensity scores at 30 minutes was 43 mm for paracetamol (95% confidence interval [CI] 35 to 51 mm), 40 mm for morphine (95% CI 29 to 52 mm), and 27 mm for placebo (95% CI 19 to 34 mm). Statistically significant mean differences in pain intensity reductions compared with those for placebo were observed for paracetamol (16; 95% CI 5 to 27; P=.005) and morphine (14; 95% CI 0.4 to 27; P=.05); however, no difference was found between paracetamol and morphine (2; 95% CI -13 to 16; P=.74). Rescue analgesics at 30 minutes were required by 21 subjects (45%) receiving paracetamol, 24 subjects (49%) receiving morphine, and 34 subjects (67%) receiving placebo (P=.08). At least 1 adverse effect was experienced by 11 (24%) receiving paracetamol, 16 (33%) receiving morphine, and 8 (16%) in the placebo group (P=.14). There were no serious adverse events. CONCLUSION: Intravenous paracetamol is an efficacious and safe treatment for ED patients with renal colic.

Determination of difficult intubation in the ED.

OBJECTIVE: The aim of this study is to determine the predictors of difficult intubation in the emergency setting. METHODS: This prospective observational clinical study was conducted in the emergency department (ED) of a University Hospital with an annually census of 50 000 visits from May 2005 to May 2007. All patients requiring intubation in the ED were included into the study. During the study period, same airway management protocol was used all intubations. The study form included patient's demographic and variables according to intubation such as the Cormack-Lehane grade, modified LEMON score, Glasgow Coma Scale score, success rate, and associated complications. RESULTS: A total of 366 patients were included in the study. The mean age of the study patients was 46.8 +/- 22.8, and 68.6% (n = 251) of them were male. A total of 86 (23.5%) patients were classified in the difficult intubation group and 280 (76.5%) patients in easy intubation group. Logistic regression analysis performed by the variables found to be significant in the univariate analysis revealed thyroid-to-hyoid distance less than 2 fingers (odds ratio, 3.34; 95% confidence interval, 1.35-8.27; P = .009) as an independent factor complicating the intubation. Cormack and Lehane classification was strongly related to difficult intubation. Intubation was more difficult from grade 1 to 4 (11% vs 25.2% vs 34% vs 81.8%, respectively; P = .000). CONCLUSIONS: The thyroid-to-hyoid distance less than 2 fingers is the only independent variable in predicting difficult intubation. Mallampati classification is not a useful tool in classifying the difficult intubation in the ED that the "LEMON" acrostic can be modified to "LEON".

Water park injuries.

BACKGROUND: The purpose of this study was to identify water park injuries, particularly injuries related to waterslides. METHODS: This prospective observational study was carried out between May 2005 and September 2006 in a university hospital emergency clinic, which has 50,000 annual visits. The study form, including patient demographics, types and mechanisms of injuries and the final diagnoses, was completed for all patients. A total of 73 patients were enrolled into the study. The mean age of the patients was 23.92+/-15.05 and 48 patients (65.8%) were male. RESULTS: The mechanisms of injury were as follows: 23 patients (31.5%) were injured on waterslides, 16 (21.9%) were injured in pools and 34 (46.6%) were injured by slipping and falling on the wet surfaces. After the emergency department evaluations, 15 patients (20.5%) were diagnosed to have spinal trauma, 16 (21.9%) head trauma, 15 (20.5%) maxillofacial trauma, and 30 (41%) other injuries. CONCLUSION: In water park injuries, while children have especially head and maxillofacial trauma, extremity and spinal injuries are more frequent in the adult group. Unless sufficient and required safety precautions are maintained during water park activities, fatal injuries may occur.

Prothrombin complex concentrates utility for warfarin-associated hemorrhage.

INTRODUCTION: Prothrombin Complex Concentrate (PCC) for reversal of warfarin is the main therapeutic option in cases of life-threatening bleeding. Aim of the study was to investigate for using 4-factor PCC brought to the therapeutic levels of International Normalized Ratio (INR) values in cases of life-threatening bleeding in Emergency Department. METHODS: This retrospective cohort study was performed in a tertiary care university emergency department. Patients with active bleeding who were taking warfarin with INR levels of ≥1.5, and had received 4-factor prothrombin complex concentrate for treatment were included in to study. RESULTS: A total of 75 patients were included in the study. The median age of the study participants was 68 (minimum 23 to maximum 87) years and 45.3% (n = 34) of them were male. INR levels was normalized all patients who were received 4-factor PCC. Red blood cell (RBC) was transfused in 16 patients (21%) because of the low hemoglobin levels. Mean unite of the RBC packet was 2,75. The lengths of hospital stay of receiving 4-factor PCC rate were determined 4.9 ± 8.7 days. No thrombotic complications or adverse drug reactions were observed after 4-factor PCC administration in any of the patients. CONCLUSIONS: In our study 4-factor PCC was found to be effective and safe in rapidly reversing the effects of warfarin.

Randomized controlled trial of morphine in elderly patients with acute abdominal pain.

BACKGROUND: The objective of this study was to determine the clinically important change in diagnostic accuracy and physical examination in the morphine vs. placebo group. METHODS: Subjects were randomized in a 1:1 ratio to receive a single dose intravenous morphine or placebo in a blinded fashion. Primary outcome measure was to determine if there was a clinically important change in diagnostic accuracy and physical examination in the morphine vs. placebo group. RESULTS: 80 subjects (39 were assigned to morphine and 41 to placebo) were included in the final analysis. Clinically important diagnostic accuracy rate was found to be 80% in the morphine group (31/39) and 78% in the placebo group (32/41), with a difference rate of 2% (95% CI -7% to 13%, p=0.9802. There was a statistically significant change in abdominal rigidity finding (15%) in morphine group in all of the abdominal physical examinations findings; however there was no change in placebo group (0%). The difference between two groups was also statistically significant (95% CI 2.3% to 30.5%, p= 0.031). CONCLUSION: Administration of opioid analgesia is safe and does not seem to impair clinical diagnostic accuracy in elderly patients with acute undifferentiated abdominal pain. Nevermore, opioids may change the physical examination findings such as abdominal rigidity.

An unusual syncope cause in the ED: favism.

Favism is an acute hemolytic syndrome occurring in glucose-6-phosphate dehydrogenase (G6PD)-deficient individuals after the consumption of fava beans. The highest incidence is in boys aged 2-6 years. We report a 56-year-old man presented to the emergency department (ED) with recurrent syncope attacks due to favism. In our knowledge, this is the first report of favism-caused syncope in an adult patient without a G6PD deficiency diagnosis in the past and diagnosed in ED.

Pseudoaneurysm of the superficial femoral artery detected by emergency medicine bedside ultrasound.

BACKGROUND: Femoral artery pseudoaneurysm following by cardiac catheterization is a serious groin complication requiring careful assessment and prompt intervention. AIMS: Risk of femoral artery pseudoaneurysm is estimated at 0.6 to 17 following diagnostic and interventional procedures. METHODS: The clinical usage of bedside ultrasonography as part of the physical examination by attending emergency physicians has increased significantly over recent years. RESULTS: Bedside Emergency Department ultrasonography provides the clinician with critical information noninvasively, rapidly determining various anatomical structures. CONCLUSIONS: We presented the case of a femoral artery pseudoaneurysm detected by the bedside emergency department ultrasonography secondary to angiographic catheterization.