The effect of serum calcium level on the success of diltiazem treatment: A retrospective cohort study.

INTRODUCTION: Diltiazem is an antiarrhythmic drug widely used in the treatment of atrial fibrillation (AFib) with rapid ventricular response (RVR). It reveals its effect by blocking L-type calcium channels. Thus, it inhibits the extracellular calcium influx into the cytosol. The relationship between serum calcium level and the efficacy of intravenous (IV) diltiazem used in the treatment of AFib with RVR has not been investigated in vivo. The aim of this study is to investigate the mentioned relationship. METHODS: This study was planned as a single-center retrospective study. The data of 349 patients who presented to the emergency department with AFib with RVR and treated with diltiazem were retrospectively analyzed. A patient was considered to have responded to diltiazem treatment if the existing heart rhythm returned to sinus rhythm, or the heart rate decreased below 100 beats/min, or the heart rate decreased >20% provided that it was below 120 beats/min. The ionized calcium levels were recorded. The relationship between serum calcium level and the success of diltiazem treatment was examined. RESULTS: Fifty five percent of the patients were female. The median age was 75 years. The rate of response to diltiazem treatment was 67.3%. The median of ionized calcium levels in the group which responded to diltiazem treatment (n = 235) was 1.14 mmol/L (IQR: 0.12), and the group which did not respond to diltiazem treatment (n = 114) was 1.11 mmol/L (IQR: 0.12) (p = 0.322). The patients were divided into three groups as low, normal, and high calcium levels according to the calcium reference levels determined by the hospital laboratory. The rate of response to diltiazem treatment was 61.4% in patients with low ionized calcium levels, 76.1% in patients with normal ionized calcium levels, and 40.0% in patients with high ionized calcium levels. The rate of response to diltiazem treatment was higher in patients with normal ionized calcium levels compared to patients with low or high ionized calcium levels (p = 0.004, p = 0.003). CONCLUSION: The success rate of diltiazem used in the treatment of AFib with RVR was highest in physiological calcium levels. The current study may provide the clinician with awareness about the consideration of serum ionized calcium levels when choosing drugs in patients with AFib with RVR.

Targeted Temperature Management Experience of an Academic Emergency Department: A 5-Year Retrospective Study.

Targeted temperature management (TTM) for postcardiac arrest syndrome patients is a cornerstone therapy to reduce mortality and neurological morbidity. The care of critical patients is provided in the emergency department (ED) when intensive care units (ICUs) are unavailable. This study aimed to determine the characteristics and mortality outcomes of postcardiac arrest patients who underwent TTM in an academic ED. Postcardiac arrest patients who underwent TTM between January 1, 2014, to November 1, 2018, at a tertiary care academic ED in Turkey were examined retrospectively. The mean age of 24 patients in whom TTM was initiated in the ED was 60.7 ± 19.2 years. Five (20.8%) of the patients who underwent TTM were discharged. Four (80%) of the discharged patients were in out-of-hospital cardiac arrest (OHCA). All patients with a total cardiopulmonary resuscitation duration of >25 minutes died. Mortality was significantly higher in patients without light reflexes (p = 0.006). Two patients who underwent TTM in the ED became organ donors after neurological determination of death. If the ICU cannot meet the needs, early initiation of TTM in the ED may contribute to good neurological outcomes. In this study, 80% of the patients who have positive neurological outcomes are OHCA. Lack of light reflex may be an evidence of poor neurological outcomes in postcardiac arrest patients. Emergency physicians should be encouraged to apply TTM.

The determinants of neurological phenotypes during acute hypertensive crises - a preliminary study.

Background and Purpose: Acute blood pressure elevations lead to wide spectrum of neurologic manifestations, ranging from no overt neurologic symptoms to catastrophic events like ICH. Little is known regarding the determinants of this clinical variability. We determined clinical and imaging features of hypertensive crisis patients with normal neurological examination, ICH and posterior reversible encephalopathy syndrome (PRES).Methods: Cranial MRI was performed in patients with hypertensive urgency or emergency but normal neurological examination. Their clinical characteristics, and imaging features regarding cerebral small vessel disease were compared to ICH and PRES patients.Results: Hypertensive ICH patients (n = 58) were older, less likely to have hyperlipidemia, less commonly used calcium channel blockers, and had higher burden of chronic cSVD features in comparison to hypertensive crisis patients with normal neurological findings (n = 51). Multivariate analyses revealed cSVD burden score (p = 0.003) to be related with ICH, while higher admission blood pressure levels (p < 0.001), hyperlipidemia (p = 0.006) and calcium channel blocker usage (p = 0.005) were more common in patients with normal neurological examination. The PRES (n = 9) group was comprised of younger patients with recent history of hypertension and low burden of cSVD.Conclusions: Hypertensive surge is associated with ICH when cSVD burden is high, probably caused by microvascular dysfunction secondary to long-standing hypertension, while the episode causes no structural damage if this burden is less. Although our observations are exploratory, short term but severe hypertension manifests with PRES possibly due to the absence of adaptive changes.

The combined use of end-tidal carbon dioxide and alveolar dead space fraction values in the diagnosis of pulmonary embolism.

BACKGROUND: Several studies have reported that computed tomography pulmonary angiography is the best method for diagnosing pulmonary embolism (PE). This study, however, aimed to predict or exclude PE using the end-tidal carbon dioxide (ETCO2) value and alveolar dead space fraction (AVDSf) together. METHODS AND MATERIALS: One-hundred patients were included in the present study. Patients with suspected PE were evaluated using clinical prediction rules proposed by the Wells and the Modified Geneva scoring systems. PE was ruled out in patients with normal d-dimer concentrations (< 0.55 mg/dl). Patient ETCO2 values were recorded using time versus waveform capnography before performing imaging studies. Capnography was performed for 2 min; however, the average ETCO2 values measured over the final 1 min were recorded in "full continuous" mode. Arterial puncture was performed simultaneously for arterial blood gas analysis. Additionally, AVDSf was calculated according to the Bohr equation. RESULTS: PE was detected in 36 % of patients. Patients were classified into high-, moderate, and low-risk groups according to the Wells and Modified Geneva scores. PE was excluded in 95 % and 100 % of patients with low Wells and Modified Geneva system scores, respectively, when ETCO2 was > 28.5 mmHg. The diagnosis of PE was excluded in 100 % of patients with low Wells and Modified Geneva scoring system scores with AVDSf < 0.128. High wells and Modified Geneva system scores were helpful in diagnosing of PE (100 %) when AVDSf was > 0.128. CONCLUSION: It was possible to exclude/predict PE based on ETCO2 and AVDSf values calculated using capnography when evaluated with clinical prediction rules and d-dimer test using an algorithm.

Adiponectin levels decrease independently of body mass index and diabetes type after the normalization of hyperglycemia

Background/aim: Acute hyperglycemia is generally a frequently encountered condition in the emergency department (ED), because it is seen as a complication of diabetes mellitus (DM). In this study, we aimed to detect the change in adiponectin levels during acute hyperglycemic states and after normalization of blood glucose with insulin treatment. Materials and methods: Forty-eight patients over the age of 18 years who were admitted to the ED with acute hyperglycemia were included in the study. Serum samples were taken from patients on admission and 6 h after the normalization of blood glucose with insulin treatment, and adiponectin levels were measured in both samples. Results: There were 21 female and 27 male patients with a median age of 58.7 ± 18 years. All patients' blood glucose levels were normalized with insulin treatment according to international recommendations. Serum adiponectin levels decreased significantly after the normalization of blood glucose in the whole group. Adiponectin levels decreased from 28.9 ± 16.5 to 12.1 ± 10.9 µg/mL (P < 0.0001) in the whole group. This decrease was independent of diabetes type and body mass index. Conclusion: Normalization of blood glucose in patients with hyperglycemia caused a decrease in adiponectin levels, independent of diabetes type and/or body weight in an acute emergency setting. Inhibited upregulation of adiponectin secretion and/or blunted suppressive effect of insulin due to hyperglycemia or exogenous insulin administration may have caused the decrease in adiponectin levels.

Etiologies and delirium rates of elderly ED patients with acutely altered mental status: a multicenter prospective study.

OBJECTIVES: Altered mental status (AMS) is a challenging diagnosis in older patients and has a large range of etiologies. The aim of this study was to investigate the nature of such etiologies for physicians to be better aware of AMS backgrounds and hence improve outcomes and mortality rates. METHODS: This prospective observational study was conducted at 4 emergency departments. Patients 65 years and older who presented to the emergency department with acute AMS (≤1 week), with symptoms ranging from comas and combativeness, were eligible for inclusion in this study. The outcomes, etiologies, Richmond Agitation and Sedation Scale scores, and the presence of delirium were recorded. RESULTS: Among 822 older patients with AMS, infection (39.5%) and neurological diseases (36.5%) were the most common etiologies. The hospital admission and mortality rates were 73.7% (n = 606) and 24.7% (n = 203), respectively. The mortality rate rose if AMS persisted for more than 3 days. Delirium was observed in 55.7% of the patients; these individuals had higher durations of AMS than those without delirium (median, 24 hours; interquartile range, 3-48 hours; median 6 hours, interquartile range, 3-48 hours, respectively; P = .010). Notably, delirium was observed in more than two-thirds of neurological patients. CONCLUSIONS: The most common causes of AMS were infection and neurological diseases. Delirium was associated with AMS in nearly half the patients. Moreover, the rates of hospitalization and mortality remained high.

Independent factors for prediction of poor outcomes in patients with febrile neutropenia.

BACKGROUND: Febrile neutropenia (FN) is a life-threatening condition that requires urgent management in the emergency department (ED). Recent progress in the treatment of neutropenic fever has underscored the importance of risk stratification. In this study, we aimed to determine independent factors for prediction of poor outcomes in patients with FN. MATERIAL AND METHODS: We retrospectively evaluated 200 chemotherapy-induced febrile neutropenic patients who visited the ED. Upon arrival at the ED, clinical data, including sex, age, vital signs, underlying systemic diseases, laboratory test results, estimated GFR, blood cultures, CRP, radiologic examinations, and Multinational Association of Supportive Care in Cancer (MASCC) score of all febrile neutropenic patients were obtained. Outcomes were categorized as "poor" if serious complications during hospitalization, including death, occurred. RESULTS: The platelet count <50 000 cells/mm3 (OR 3.90, 95% CI 1.62-9.43), pulmonary infiltration (OR 3.45, 95% CI 1.48-8.07), hypoproteinemia <6 g/dl (OR 3.30, 95% CI 1.27-8.56), respiratory rate >24/min (OR 8.75, 95% CI 2.18-35.13), and MASCC score <21 (OR 9.20, 95% CI 3.98-21.26) were determined as independent risk factors for the prediction of death. The platelet count <50 000 cells/mm3 (OR 3.93, 95% CI 1.42-10.92), serum CRP >50 mg/dl (OR 3.80, 95% CI 1.68-8.61), hypoproteinemia (OR 7.81, 95% CI 3.43-17.78), eGFR ≤90 ML/min/1.73 m2 (OR 3.06, 95% CI 1.13-8.26), and MASCC score <21 (OR 3.45, 95% CI 1.53-7.79) were determined as independent risk factors for the prediction of poor clinical outcomes of FN patients. Platelet count, protein level, respiratory rate, pulmonary infiltration, CRP, MASCC score, and eGFR were shown to have a significant association with outcome. CONCLUSIONS: The results of our study may help emergency medicine physicians to prevent serious complications with proper use of simple independent risk factors besides MASCC score.

Comparison of TIMI and Gensini score in patients admitted to the emergency department with chest pain, who underwent coronary angiography.

BACKGROUND: In patients admitted to the emergency department with complaints of chest pain and unstable angina pectoris, ST-elevation MI scoring is done according to risk factors used to calculate risks of urgent revascularization, MI, and death within 14 days. For this calculation, the most widely used scoring system is TIMI risk score. MATERIAL AND METHODS: In this prospective, cross-sectional descriptive study, we evaluated and compared the effectiveness of TIMI and Gensini scores of patients with chest pain who were admitted to Hacettepe University Hospitals Emergency Department between March 2011 and September 2011 and who underwent coronary angiography. RESULTS: The mean (range) age of 165 patients was 62 (31-88) years. Moderate correlation between TIMI and Gensini scores was detected (mean values of Gensini score for TIMI 1 is 53.50, for TIMI 2 it is 52.09, for TIMI 3 it is 102.77, for TIMI 4 it is 113.70, and for TIMI 5 it is 115.43). There was also a positive correlation between TIMI score and the results. CONCLUSIONS: TIMI risk stratification score is safe and easy to use for rapid assessment of mortality and MI risk, despite its low possibility of predicting the outcome.

The epidemiology and cost analysis of patients presented to Emergency Department following traffic accidents.

BACKGROUND: Traffic accidents are ranked first as the cause of personal injury throughout the world. The high number of traffic accidents yielding injuries and fatalities makes them of great importance to Emergency Departments. MATERIAL AND METHODS: Patients admitted to Hacettepe University Faculty of Medicine Adult Emergency Department due to traffic accidents were investigated epidemiologically. Differences between groups were evaluated by Kruskall-Wallis, Mann-Whitney, and Wilcoxon tests. A value of p<0.05 was accepted as statistically significant. RESULTS: We included 2003 patients over 16 years of age. The mean age was 39.6 ± 16.1 and 55% were males. Admissions by ambulance and due to motor vehicle accidents were the most common. In 2004 the rate of traffic accidents (15.3%) was higher than the other years, the most common month was May (10.8%), and the most common time period was 6 pm to 12 am (midnight). About half of the patients (51.5%) were admitted in the first 30 minutes. Life-threatening condition was present in 9.6% of the patients. Head trauma was the most common type of trauma, with the rate of 18.3%. Mortality rate was 81.8%. The average length of hospital stay was 403 minutes (6.7 hours) and the average cost per patient was 983 ± 4364 TL. CONCLUSIONS: Further studies are needed to compare the cost found in this study with the mean cost for Turkey. However, the most important step to reduce the direct and indirect costs due to traffic accidents is the prevention of these accidents.

Mechanical and infectious complications developing due to central venous catheterizations in the Emergency Department.

AIM: To investigate the rate of catheter-related bloodstream infections (CRBSI) and mechanical complications due to central venous catheter (CVC) insertion in the emergency department (ED) and the contributing factors. METHODS: A total of 236 patients who were admitted to our ED and underwent CVC insertion between July 2008 and July 2009 were included in this prospective study. The CVC indications, the urgency of the insertion (emergency or elective), catheter complications (mechanical or CRBSI) and the compliance of the emergency physician placing the catheter with infection control and prevention measures were investigated. RESULTS: The CVC had been inserted urgently in 103 (44%) of the cases and mechanical complication rates in these patients were higher than those receiving it electively (p less 0.05). Our total mechanical complication rate was 27 (11.4%) with the highest rate for femoral catheter (FC). The CRBSI rate was 5/1000 catheter days. None of the physicians inserting a catheter ensured hand hygiene before the procedure. CONCLUSION: The FC is used as the most common access route for a CVC in our ED but CRBSI rate and mechanical complication rate were lower than in the literature. We believe that increasing compliance with infection control and prevention measures, especially hand hygiene, can further decrease the CRBSI rate in the ED.

10-year evaluation of train accidents.

BACKGROUND: Although less frequent than automobile accidents, train accidents have a major impact on victims' lives. METHODS: Records of patients older than 16 years of age admitted to the Adult Emergency Department of Hacettepe University Medical Center due to train accidents were retrospectively evaluated. RESULTS: 44 patients (30 males, 14 females) with a mean age of 31.8±11.4 years were included in the study. The majority of the accidents occurred during commuting hours. 37 patients were discharged, 22 of them from the emergency department. The mortality rate was 7/44 (16%). Overall mean Revised Trauma Score (RTS) was 10.5 (3 in deaths and 11.9 in survivors). In 5 patients, the cause of death was pelvic trauma leading to major vascular injury and lower limb amputation. In 1 patient, thorax and abdomen trauma and in 1 patient head injury were the causes of mortality. Primary risk factors for mortality were alcohol intoxication (100%), cardiopulmonary resuscitation on admittance (100%), recurrent suicide attempt (75%), presence of psychiatric illness (60%), and low RTS. CONCLUSION: In this study, most train accidents causing minor injuries were due to falling from the train prior to acceleration. Nevertheless, train accidents led to a mortality rate of 16% and morbidity rate of 37%. These findings draw attention to the importance of developing preventive strategies.