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.

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.

The relationship between abnormal intracranial findings in brain computed tomography and antiplatelet or anticoagulant use in patients with nontraumatic headache: a prospective cohort study.

OBJECTIVE: This study aimed to investigate the relationship between abnormal intracranial findings on brain computed tomography and antiplatelet or anticoagulant use in patients with nontraumatic headache in the emergency department (ED). METHODS: This was a single-center prospective observational study of patients admitted to the tertiary ED with complaints of nontraumatic headache between May 1, 2016 and September 1, 2016. Anticoagulant or antiplatelet drug use by the patient was recorded. Brain computed tomography (CT) results were categorized into two groups, abnormal results (CT positive) and no pathologic results (CT negative), and compared. The CT positive group included any pathological signs in the brain and the negative group was considered a normal read. A logistic regression analysis was used for evaluating the association of antiplatelets and anticoagulants with abnormal CT findings. RESULTS: Of the 837 patients with nontraumatic headaches, 157 (18.8%) patients who underwent brain CT scanning were included. The mean age of the patients was 44.4±16.7 years. Eighty-eight (56.1%) of the patients were women. Of the 29 (18.4%) patients using antiplatelets or anticoagulants, 16 (55.2%) were in the CT positive group. There was a statistically significant difference between both groups in terms of drug use compared to the CT negative group (P<0.001). Factors affecting CT restuls were examined in logistic regression analysis and a statistically significant difference was found in the detection of positive results in antiplatelet or anticoagulant drug users (adjusted odds ratio, 2.478; 95% confidence interval, 1.006-6.102; P=0.048). CONCLUSION: The use of antiplatelets or anticoagulants in patients admitted to the ED with nontraumatic headache is associated with an increased risk of abnormal intracranial results in brain CT.

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.

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.

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".

Pseudoaneurysm of the anterior tibial artery detected by emergency medicine physician performing bedside ultrasound.

We present the case of an anterior tibial artery pseudoaneurysm secondary to lacerating trauma caused by a straight-edge trimming blade. A 56-year-old man presented to emergency department (ED) with 1-month history of left calf pain. Thirty days before presentation, the patient lacerated his left lateral pretibial area with a cutting blade--similar to a machete--while cutting grass. He was seen at the state hospital, and primary suture was performed. Ten days later, the suture was removed. A week later, the patient revisited his physician, complaining of swelling and tenderness in the left calf. Hematoma formation of the calf was suspected and aspirated by syringe. Three days later, the patient presented to the ED with a repeat of his symptoms. On physical examination, the calf was swollen and tender. The vascular examination revealed a palpable dorsalis pedis and diminished posterior tibialis pulse. Localized swelling was present, and circumference of the affected calf was increased. No pulsatile mass was palpated. Ultrasound (US) performed at the bedside revealed a pulsating anechoic lesion surrounded by a hypoechoic lesion suggestive of thrombus formation. Doppler US of the patient showed 4.5x2.5-cm partially thrombosed pseudoaneurysm of the anterior tibial artery. In this case, the pseudoaneurysm was believed to be compressing the posterior tibial artery, resulting in a diminished pulse on examination. Emergency US use may enhance emergency physician performance by the shortening of the length of stay in the ED, reduce the number of unnecessary tests to be ordered, and hasten critical therapeutic interventions.

Inhalational and dermal injury due to explosion of calcium hypochlorite.

Calcium hypochlorite is a yellow-white powder widely used as a disinfectant in swimming pools. It releases chlorine gas when added to water and can cause respiratory effects. Dermal and eye injury can occur because of the caustic nature of chlorine. We report a case of chlorine toxicity and burns on a man's face due to the explosion of calcium hypochlorite while he was mixing it into the water.

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.

Detection and treatment of traumatic separation of the distal humeral epiphysis in a neonate: a case report.

Traumatic separation of the distal humeral epiphysis during delivery is an uncommon injury in neonates and usually mimics elbow dislocation. Emergency medicine physicians and orthopedic surgeons must have a high index of suspicion for distal humeral epiphysis separation when evaluating elbow trauma in neonates. Magnetic resonance imaging (MRI) scan is an important diagnostic tool for this purpose. We report a case in which fracture-separation of the distal humeral epiphysis in a newborn was diagnosed with the help of ultrasonography and MRI scan, which provided a clear delineation of the injury.

Portal vein thrombosis related to Cassia angustifolia.

INTRODUCTION: Cassia angustifolia (Senna), used as a laxative, is a plant from the Fabaceae family. It includes hydroxyanthracene glycosides, also known as Senna Sennoside. These glycosides stimulate the peristalsis of the colon and alter colonic absorption and secretion resulting in fluid accumulation and expulsion. In the literature, there are reports illustrating the hepatotoxic effects of Cassia angustifolia but there is no report of portal vein thrombosis caused by Cassia Angustifolia. CASE REPORT: A 42-year-old woman was admitted to the emergency department with a five-day history of worsening epigastric pain, anorexia, episodic vomiting, and intermittent fever. She reported that she had boiled dried senna leaves she had bought from herbalists and drank approximately 200 mL daily for two years. Color Doppler screening found an echogen thrombus obliterating portal vein bifurcation and the right branch. The lumen was obstructed at this level and there was no blood flow through it. Treatment with thrombolytics was unsuccessful. DISCUSSION: Severe hepatotoxicity senna use is unusual. The cause of senna-related hepatotoxicity is unclear but could be explained by the exposure of the liver to unusual amounts of toxic metabolites of anthraquinone glycosides. CONCLUSION: Chronic use of Cassia angustifolia may rarely be associated with portal vein thrombosis.

Abamectin intoxication with coma and hypotension.

Abamectin is a potent antihelmintic, insecticide, and miticide used to control pests of humans, veterinary animals, and crops. The toxic effects of abamectin are usually seen after oral ingestions. These are altered mental status, respiratory failure, and hypotension. We report a case of acute abamectin intoxication who presented with altered mental status to the emergency department after oral ingestion.

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.