Results of an advanced nursing triage protocol in emergency departments.

OBJECTIVES: The increasing number of patients admitted to emergency departments (EDs) and overcrowding of EDs lead to a global problem. Advanced nursing triage is an important solution in facilitating patient and time management, also increasing the efficiency of the ED. This study was conducted to predict the possible effects of applying advanced nursing triage modeling with predetermined protocols during the current nursing triage in the ED. METHODS: This was a descriptive and cross-sectional study. An advanced "triage assessment protocol," which was developed previously, was hypothetically applied for 5 days by triage nurses in the adult ED of a university hospital. The hypothetical application was tested by triage nurses in all shifts. The nurses recorded the examination or treatment options which they thought to apply for the patient on the study form. The data recorded on the advanced triage evaluation protocol form by the triage nurses were compared with the patient outcomes and physician examination/treatment requests in the Hospital Information Management System by the researchers. RESULTS: In the study, it was determined that the rate of examination/treatment that could be requested according to the advanced nursing triage protocol was 46%. There were a good level of agreement on X-ray and a moderate level of agreement on urinary test and urinary beta- Human chorionic gonadotropin (hCG) test between physicians and triage nurses regarding examination/treatment requests. In addition, it was found that there was a 61.2% of agreement on decisions made for patients aged between 18 and 35. The rate of agreement between doctors and nurses regarding a gluco-stick request for patients admitted outside the prime time (92.2%) was found to be significantly higher (87.9%) than for patients admitted during prime time (P = 0.046). CONCLUSION: "Advanced triage" practices recommended for busy EDs were tested "hypothetically" at the national level due to the lack of legal regulations and were found to be compatible with the actual results of physicians' practices at an acceptable level, especially for selected medical conditions. The method used in this study can be useful in planning the transition to "advanced triage" practices. These results can show the readiness of nurses for the transition to this practice.

Utility of ETCO2 to predict hemorrhagic shock in multiple trauma patients.

BACKGROUND: For identifying hemorrhagic shock in trauma patients, some objective data are needed. The use of base excess (BE) and lactate values have been originated. In this study, it was aimed to determine the usability of end tidal carbon dioxide (ETCO2) in patients with multiple trauma for recognizing hemorrhagic shock. METHODS: Patients who were admitted to the emergency department between June 2019 and February 2020 with highenergy multiple trauma were included in the study. ETCO2 and BE values were measured. Correlation coefficients were calculated to determine correlations between ETCO2 and BE levels. RESULTS: One hundred and twenty-two patients were included in the study. Eighty-nine (73%) were men and 33 (27%) were women, and the mean age of the study population was 38.70 ± 19.18. The mortality rate was 14.8% in the study population. The correlation between ETCO2 and BE values was significant (r: 0.27) and in the same range in the Bland-Altmann analysis. ETCO2 levels above 35 were specific for stage 1 hemorrhagic shock. ETCO2 levels below 30 were sensitive for stage 2 and 3 hemorrhagic shocks and when the levels were measured below 22 it was found specific for stage 4 shock. The specificity increased to 99% at levels below 18. The sensitivity for ETCO2 values below 22 for predicting mortality was 33.33%, the specificity was 89.42%, the positive predictive value was 35.29% and the negative predictive value was 88.57%. The sensitivity for BE values below -10 for predicting mortality was 50%, the specificity was 93.27%, the positive predictive value was 56.25% and the negative predictive value was 91.51%.

Epidemiologic Characteristics of Patients Admitted to Emergency Department with Dermatological Complaints; a Retrospective Cross sectional Study.

INTRODUCTION: Dermatological diseases constitute 5-8% of all emergency department (ED) visits. However, little is known about these patients. The aim of this study is to determine the epidemiologic characteristics of patients admitted to ED with dermatological complaints. METHODS: This is a retrospective cross-sectional study conducted in the ED of a university hospital. Patients over 18 years of age who presented to ED with the following complaints were included in the study: rash, pruritus, and edema sensation in the throat or shortness of breath due to an allergic reaction. Demographics, chief complaints, final diagnoses, triage categories, consultations and hospitalization rates were obtained through computerized database of the hospital. RESULTS: 859 patients were included in the final analysis. 511 (59.5%) patients were female and the mean age of patients was 39.03±15 years. The most common complaint and final diagnosis were skin rash with pruritus (50.9%) and urticaria with drug eruptions (84.5%), respectively. Two patients (0.2%) had an emergent triage category. 804 (93.6%) patients were discharged from ED, while 55 (6.4%) received consultations, resulting in 19 (34.5%) hospitalizations. CONCLUSION: Most of the patients admitted to ED with dermatological complaints are non-urgent and can be treated as outpatients. However, physicians should be alert for emergent causes, as well.

Utility of HAPS for predicting prognosis in acute pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is a common abdominal disorder, which requires early diagnosis and treatment. Several prognostic scoring systems introduced to clinical practice are not suitable in emergency department (ED) because these require much time and complex parameters. Recently, the harmless acute pancreatitis score (HAPS) has been introduced to identify AP with a nonsevere course. The aim of this study was to determine the utility of HAPS in predicting the severity of AP. METHODS: All patients aged >16 years who were diagnosed as AP in ED were enrolled in this retrospective study. The study included 144 patients with a mean age of 58.7±15.4 years, and 69 (47.9%) of them were males and 75 (52.1%) were females. Patient data were collected from hospital database. The utility of HAPS was analyzed and compared using the Ranson's score. RESULTS: HAPS was statistically significant for predicting mild disease (p=0.008) and has demonstrated a specificity of 81%, a positive predictive value (PPV) of 96%, and an odds ratio of 5.57 (1.51-20.50). The predictability of Ranson's scores was not significant. The measure of agreement (κ) between the two scores was 0.15, indicating a low agreement. CONCLUSION: HAPS is a simple and useful scoring algorithm to predict the non-severe course of AP in ED. HAPS-0 patients did not require early aggressive treatments and advanced radiological screening tools during the early stages of the disease.

MEFV gene mutations and clinical course in pediatric patients with Henoch-Schönlein purpura. / Mutaciones en el gen MEFV y evolución clínica en pacientes pediátricos con púrpura de Schönlein-Henoch.

OBJECTIVE: To determine the frequency of the MEFV gene mutations in pediatric patients diagnosed with HSP and to assess the effect of the MEFV gene mutations on their prognosis. Material and Methods. Ccross-sectional study; pediatric patients between 2-11 years diagnosed with HSP were included. These cases were investigated for 6 MEFV gene mutations (M694V, M680I, A744S, R202Q, K695R, E148Q). RESULTS: Eighty cases were included in the study of which 55% were male (n= 44). The mean age was 6.44 ± 2.52 years. Disease recurrence occurred in 9 patients, invagination in 5 patients and convulsion in 1 patient during follow-up. Approximately half of the patients received steroids. The MEFV gene mutations was not detected in 44 (55%) of the patients. There was a heterozygous mutation in 19 (22%). E148Q was found in 8 patients, M694V in 5 patients, A744S in 4 patients, and the R202Q heterozygous mutation in 2 patients. The M608I homozygous mutation was detected in 1 patient and the M694V homozygous mutation in 1 patient. The compound heterozygous MEFV gene mutations was found in 15 patients. The presence of the MEFV gene mutations was not correlated with the frequency of renal and gastrointestinal involvement and prognosis, the development of complications and the use of steroids. CONCLUSION: The presence of the MEFV gene mutations does not correlate with the clinical course and complication in Turkish pediatric patients with HSP.

Objetivo. Determinar la frecuencia de mutaciones del gen MEFV en niños con diagnóstico de púrpura de Schönlein-Henoch y evaluar el efecto que tienen en el pronóstico. Materiales y métodos. Estudio transversal que incluyeron pacientes pediátricos de entre 2 y 11 años, con diagnóstico de púrpura de Schönlein-Henoch. Se estudiaron para detectar 6 mutaciones en el gen MEFV (M694V, M680I, A744S, R202Q, K695R y E148Q). Resultados. Se incluyeron ochenta pacientes, de los cuales el 55% eran de sexo masculino (n= 44). La media de edad fue 6,44 ± 2,52 años. Durante el seguimiento, 9 pacientes presentaron recurrencia de la enfermedad, 5 sufrieron invaginación intestinal y 1 paciente tuvo convulsiones. Aproximadamente la mitad de los pacientes recibió corticoides. En 44 pacientes (55%) no se detectaron mutaciones en el gen MEFV. En 19 pacientes (22%) hubo una mutación heterocigota. Se encontró E148Q en 8 pacientes, M694V en 5 pacientes, A744S en 4 pacientes y la mutación heterocigota R202Q en 2 pacientes. En 1 paciente se detectó la mutación heterocigota M608I y en otro paciente se encontró la mutación homocigota M694V. En 15 pacientes se encontraron mutaciones heterocigotas compuestas en el gen MEFV. Las mutaciones en el gen MEFV no se correlacionaban con la frecuencia de compromiso renal y gastrointestinal ni con el pronóstico, desarrollo de complicaciones y uso de corticoides. Conclusiones. Las mutaciones en el gen MEFV no se correlacionan con la evolución clínica ni con las complicaciones en pacientes pediátricos con púrpura de Schönlein-Henoch en Turquía.

Improvement in physician pain perception with using pain scales.

BACKGROUND AND AIMS: Acute pain is the most common reason for visits to the emergency department (ED). The underuse of analgesics occurs in a large proportion of ED patients. The physician's accurate assessment of patients' pain is a key element to improved pain management. The purpose of this study was to assess if physicians' perception of pain can improve with looking at the pain score of the patient marked on VAS. STUDY DESIGN: This was a single-center, cross-sectional prospective observational study, that took place in an academic ED. METHODS: All adult ED patients presenting with a painful condition were enrolled to the study. In the first phase of the study, the physician rated his/her opinion about the patient's pain on a 100 mm VAS, in a blinded fashion to the patient's pain score. In the second phase, the physician rated his/her opinion after looking at the pain scale marked by patient. RESULTS: 587 patients (295, in first and 292, in second phase) were enrolled. The groups were not statistically different for demographic data. The physician's perception of pain was lower than the patient's pain score at both phases of the study. Insight of the patient's pain score on VAS increased the physician's pain perception significantly (p = 0.03). During the second phase, physicians ordered significantly more analgesic medications to the patients (p = 0.03). CONCLUSION: The physicians' perception of the patients' pain differs significantly from the pain that the patient is experiencing. VAS helps to bring the physicians impression of pain perception to the level of pain that the patient is actually experiencing and resulted in ordering more analgesics to the patients. Implementation of a pain assessment tool can raise the physician's perception of the pain and may improve pain management practices and patient satisfaction.

A Retrospective Analysis of the Burn Injury Patients Records in the Emergency Department, an Epidemiologic Study.

INTRODUCTION: Burns can be very destructive, and severely endanger the health and lives of humans. It maybe cause disability and even psychological trauma in individuals. . Such an event can also lead to economic burden on victim's families and society. The aim of our study is to evaluate epidemiology and outcome of burn patients referring to emergency department. METHODS: This is a cross-sectional study was conducted by evaluation of patients' files and forensic reports of burned patients' referred to the emergency department (ED) of Akdeniz hospital, Turkey, 2008. Demographic data, the season, place, reason, anatomical sites, total body surface area, degrees, proceeding treatment, and admission time were recorded. Multinomial logistic regression was used to compare frequencies' differences among single categorized variables. Stepwise logistic regression was applied to develop a predictive model for hospitalization. P<0.05 was defined as a significant level. RESULTS: Two hundred thirty patients were enrolled (53.9% female). The mean of patients' ages was 25.3 ± 22.3 years. The most prevalence of burn were in the 0-6 age group and most of which was hot liquid scalding (71.3%). The most affected parts of the body were the left and right upper extremities. With increasing the severity of triage level (OR=2.2; 95% CI: 1.02-4.66; p=0.046), intentional burn (OR=4.7; 95% CI: 1.03-21.8; p=0.047), referring from other hospitals or clinics (OR=3.4; 95% CI: 1.7-6.6; p=0.001), and percentage of burn (OR=18.1; 95% CI: 5.42-62.6; p<0.001) were independent predictive factor for hospitalization. In addition, odds of hospitalization was lower in patients older than 15 years (OR=0.7; 95% CI: 0.5-0.91; p=0.035). CONCLUSION: This study revealed the most frequent burns are encountered in the age group of 0-6 years, percentage of <10%, second degree, upper extremities, indoor, and scalding from hot liquids. Increasing ESI severity, intentional burn, referring from other hospitals or clinics, and the percentage of burn were independent predictive factors for hospitalization.

EEG as a part of the decision-making process in the emergency department.

STUDY OBJECTIVE: Although electroencephalography (EEG) is a useful diagnostic tool for patients with a suspected seizure, its value in informing the acute care of patients in the emergency department (ED) remains unclear. The aim of this study is to determine the effects of EEG results on subsequent patient management in or from the ED. MATERIALS AND METHODS: This prospective observational study was carried out in the ED of a tertiary-care university hospital. All patients presenting to the ED with seizure or seizure-mimicking symptoms were included in the study. EEG was advised for all patients after an initial evaluation. Before EEG, the ED physician and neurologist were asked clinical questions about the patient. The consistency between the clinical decision of emergency physicians before the EEG report and the final management of patients determined by the consultant neurologist was analyzed. The interobserver reliability of the physicians was determined. RESULTS: Overall, 110 patients were enrolled in the study. The sensitivity and specificity of ED physicians' diagnosis of the presence of seizure were both 88% (95% confidence interval, 79-93 and 62-97%). The interobserver reliabilities and κ values of ED physicians and neurologists were found to be 'moderate'. Patients with abnormal EEG results were prescribed new medication (P=0.003) and changes in therapy (P=0.59) were more than for patients with normal results. CONCLUSION: As seizure is a clinical event, EEG is not essential for diagnosing the presence of a seizure clinically in the ED. However, the results of EEG provide useful information especially for treatment choices. As the timing of the study affects the diagnostic efficacy of the test, EEG recordings should be performed within 24 h either in ED or in the epilepsy clinic.

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.

Foreign body traumas of the eye managed in an emergency department of a single-institution.

BACKGROUND: Superficial corneal foreign bodies (SCFB) are common injuries seen in the ED. The aim of this study was to describe the eye injuries caused by FBs and to determine clinical strategies for the prevention and management of ocular trauma. METHODS: This was a retrospective chart review of the previous two years. Demographic data, timing of the injury, injury type (open- or closed-globe injuries), source of the FB, hospital admission and ophthalmology consultation, treatments, and the long-term complications were recorded for each patient. RESULTS: There were 476 patients, and 83% were male, with an average age of 34.16±14.02 years. 9.7% of the eyes had an open-globe injury, while the rest were closed-globe injuries with or without SCFB. The most common FBs were metal fragments (37.6%) and dust (31.1%). The majority of the patients (72.1%) sustained work-related injuries. 42.4% of the patients were consulted to ophthalmology, and the remaining were treated by the emergency physicians. Only 10% of the patients required hospitalization, and complications were seen in 2.3% of the patients. CONCLUSION: Ocular FB involved mainly young healthy males who had sustained work-related injuries. In view of the large number of eye injuries seen in Eds, ED colleagues should train themselves in order to appropriately recognize, treat and refer the SCFB injuries seen in the ED.

The utility of EEG in the emergency department.

BACKGROUND AND AIM: Seizure-related visits are common in the emergency department (ED) but the clinical situations for ordering emergency electroencephalography (EEG) are unclear. The aim of this study is to identify which clinical conditions meet with the pathological EEG and whether patient management is changed by abnormal results. METHODS: A retrospective chart review study of all patients visiting the ED with a seizure or symptoms mimicking a seizure was performed. Patients who recorded an EEG within 16 h after the initial event were enrolled. Demographic data and EEG results of patients with provoked and unprovoked seizures were recorded and related factors were analysed. RESULTS: A total of 449 patients (219 men) of mean ± SD age of 45.48 ± 21.83 years were evaluated. The seizure was thought to be provoked in 98 patients (21.8%) and unprovoked in 352 (78.2%) patients (31.2% remote symptomatic and 47.4% idiopathic). The EEG results of 281 patients (62.6%) revealed an abnormality, and the abnormal EEG ratio was high in patients with presumed seizure (p<0.001). One hundred and thirty-eight patients (30.7%) were hospitalised and the remainder (n=311, 69.3%) were discharged from the ED. An abnormal EEG was found in 98 (71%) of the hospitalised patients and in 183 (59.5%) of those discharged (p=0.019). CONCLUSION: EEG provides useful diagnostic information and should be considered in all patients presenting to the ED with a seizure. Since the timing of the study affects the diagnostic efficacy of the test, EEG recordings might be done within 24 h either in the ED or epilepsy clinic.

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.

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.

The value of ETCO2 measurement for COPD patients in the emergency department.

We aimed to determine the value of sidestream end-tidal carbon dioxide (SS-ETCO2) measurement in patients with chronic obstructive pulmonary disease (COPD) in the emergency department. Cross-sectional associations between ETCO2 and PaCO2 were examined in the study. This prospective cross-sectional study has been carried out over a 3-month period in a tertiary care university hospital emergency department with an annual census of 75 000 visits. During the study period, simultaneous SS-ETCO2 measurement using a Medlab Cap 10 sidestream capnograph was performed on every COPD patient requiring arterial blood gas analysis. The demographics, diagnosis, vital signs, laboratory test results and clinical outcomes of the patients were recorded. SS-ETCO2 measurement and arterial blood gas analysis were carried out on 118 patients. Mean arterial PCO2 levels were 43.24±14.73 and mean ETCO2 levels were 34.23±10.86 mmHg. Agreement between PCO2 and ETCO2 measurements was 8.4 mmHg and a precision of 11.1 mmHg.As there is only a moderate correlation between PCO2 and ETCO2 levels in COPD patients, ETCO2 measurement should not be considered as a part of the decision-making process to predict PaCO2 level in COPD patients.

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.

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.

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.