Comparison of Early Warning Scores in Determining the Prognosis of COVID-19 Patients.

OBJECTIVE:  To compare the effectiveness of early warning score systems in predicting 30-day poor outcomes in Coronavirus Disease (COVID-19) patients admitted to the emergency department. STUDY DESIGN: Descriptive study. Place and and Duration of the Study: Fatih Sultan Mehmet Education and Research Hospital, Istanbul, Turkiye, from March 2020 to March 2021. METHODOLOGY: The patients who presented to the emergency department, diagnosed with COVID-19 and tested positive for polymerase chain reaction were analysed. The study included the calculation of the rapid emergency medicine score, risk stratification in the emergency department in acutely ill older patients score, 4C mortality score, and modified early warning score for the patients. These scores were then compared in terms of their ability to predict adverse outcomes, defined as intensive care admission and/or mortality. RESULTS: During the study period, 10,281 COVID-19 patients were admitted to the emergency department. Out of them, 1,826 patients were included in the study. There were 159 (8.7%) cases with poor outcomes. The risk stratification in the emergency department in acutely ill older patients Score was the most successful in poor prognosis. CONCLUSION: Based on the findings of this study, the risk stratification in the emergency department in acutely ill older patients score demonstrated greater efficacy compared to other early warning scores in identifying patients diagnosed with COVID-19 who had an early indication of a poor prognosis. KEY WORDS: Early warning score, 4C mortality score, REMS, Rise-up score, MEWS, Emergency department, COVID-19.

The effect of the COVID-19 pandemic on forensic cases admitted to an emergency department.

INTRODUCTION: The COVID-19 disease has given rise to various negative effects on human life in terms of health and economic and social well-being. We believe that these negative effects may have led to increased forensic incidents such as violence and suicide. Therefore, in this study, we sought to examine the effects of COVID-19 in forensic cases admitted to an emergency department. Methods: This is a retrospective observational study, performed at the emergency department of Fatih Sultan Mehmet Education and Research Hospital. Forensic cases admitted between March and June 2020 (pandemic period) and forensic cases admitted between March and June 2019 (pre-pandemic period) were compared in the study. Results: A total of 4296 patients were included in the study, of which 3011 were admitted during the pre-pandemic period and 1285 during the time of the COVID-19 pandemic. While the percentages of suicide attempts (3.6%), motorcycle traffic accidents (7.4%), and violent incidents (29.4%) were higher during the pandemic period, the percentages of in-vehicle traffic accidents (5.4%) and pedestrian traffic accidents (2.2%) were lower (respectively, p = 0.035, p = 0.005, p < 0.001, p = 0.015, p = 0.008). At the time of the pandemic, the percentages of incidents of violence against women (44.2%) and traffic accidents with a motorcycle involving men (9.3%) were higher than during the time before the pandemic (p < 0.001 and p < 0.001, respectively). Conclusions: The effects of the pandemic on our lifestyle are indisputable. This study reveals that the pandemic also affected patients who were admitted to the emergency department for forensic reasons. In addition, the increase in the percentages of suicide and violent events indicates that pandemics probably increase feelings of fear, loss, and hopelessness, and special precautions should be taken to maintain order in the society.

Investigation of the usability of the REMS, RAPS, and MPM II0 scoring systems in the prediction of short-term and long-term mortality in patients presenting to the emergency department triage.

BACKGROUND: Appropriate triage is an important component of patient management in emergency departments. The risk scoring system used for triage purposes in emergency departments should be obtained quickly and based on parameters directly related to prognosis. AIMS: To investigate the success of the Rapid Emergency Medicine Score (REMS) and Rapid Acute Physiology Score (RAPS) as triage scoring systems and the Mortality Probability Model (MPM II0) as an intensive care scoring system in identifying critical patients visited to the emergency department (ED) triage and predicting mortality, and to evaluate their superiority over each other, if any. METHODS: This research was planned as a single-center and prospectively. The data of the study were obtained by screening the medical records of all patients who presented to the ED triage between January 1, 2020 and January 31, 2020. Patients under the age of 18 years, those with missing information in their files and pregnant women were not included in the study. Only the patients for whom the REMS, RAPS, and MPM II0 scores could be calculated were included in the sample. RESULTS: After excluding the patients who did not meet the inclusion criteria, the study was completed with 12,210 patients. The mean age of these patients was 44.7 ± 18.7 years, and 47.3% were male. The area under the receiver operating characteristics curve values for the prediction of 24-h, 30-day, 90-day, and 180-day mortality were determined as 0.979, 0.921, 0.904, and 0.897, respectively, for REMS; 0.929, 0.778, 0.75, and 0.725, respectively, for RAPS; and 0.925, 0.888, 0.866, and 0.861, respectively, for MPM II0. CONCLUSIONS: In this study, it was concluded that the REMS score was superior to the MPM II0 and RAPS scores in predicting the short-term and long-term mortality status of patients and determining the discharge and hospitalization status of the patients.

Respiratory variability of inferior vena cava at different mechanical ventilator settings.

BACKGROUND: Assessment of the respiratory changes of the inferior vena cava (IVC) diameter have been investigated as a reliable tool to estimate the volume status in mechanically ventilated and spontaneously breathing patients. Our purpose was to compare the echocardiographic measurements the IVC diameter, stroke volume and cardiac output in different positive pressure ventilation parameters. METHODS: This prospective clinical study with crossover design was conducted in the Intensive Care Unit (ICU). Twenty-five sedated, paralyzed, intubated, and mechanically ventilated patients with volume control mode (CMV) in the ICU due to respiratory failure were included in the study. Positive End-Expiratory Pressure (PEEP) and Tidal Volume (TV) were changed in each patient consecutively (Group A: TV 6 ml/kg, PEEP 5 cmH20, B: TV 6, PEEP 8, C: TV 8, PEEP 5, D: TV 8, PEEP 8) and the changes in vital parameters, central venous pressure (CVP) and ultrasonographic changes in IVC and cardiac parameters were measured. All measures were compared between groups by robust repeated measures ANOVA with trimmed mean. RESULTS: The respiratory changes of the IVC diameter and echocardiographic parameters showed no significant difference in separate mechanical ventilator settings. Significant difference was found in peak and plateau pressure values among groups (p < 0.05). CONCLUSION: The results of our study suggest that IVC related parameters are not affected with different ventilatory settings. Further studies are needed to confirm the reliability of these parameters as a predictor of fluid assessment.

Relationship between brain computed tomography findings and bispectral index score in patients presenting with head trauma.

OBJECTIVE: Head trauma is one of the most important emergency health problems both in the world and in our country. The objective in our study is to (i) state the correlation between the findings of bispectral index score (BIS) and computed tomography (CT), which are used to evaluate the level of consciousness of patients with isolated head trauma, and (ii) investigate objective results about the patient's level of consiousness/alertness according to the CT modality, which is used frequently. METHODS: This prospective study was carried out between 03.01.2014 and 09.01.2014 in the emergency department of Fatih Sultan Mehmet Education and Research Hospital. The average BIS scores were correlated with the Glasgow Coma Scale (GCS) point, the Canadian CT Head Rule major and minor criteria, and the pathologic findings in CT imaging. The patients' demographic features, vital signs at admission, and arrival times at the hospital were investigated. RESULTS: In our study, 64 (31.7%) patients were female, and 138 (68.3%) patients were male. The mean BIS scores were 84.99±11.20 (86.05) and 93.78±3.80 (95.05) in patients with and without CT pathologies, respectively. The correlation between CT pathology and BIS scores was statistically significant: BIS scores were lower in patients with CT pathologies (p=0.001; p<0.01). There was a statistically significant positive correlation between the BIS and GCS scores (45.6%) (p<0.05). CONCLUSION: We showed that most head traumas occur after dangerous accidents, and according to the results, we can predict that males are more frequently affected than females. There was a statistically significant positive correlation between BIS scores and GCS points. In our study, the BIS scores were statistically significantly lower in patients with CT pathology than in patients without. We can predict that if the BIS score of the patient is low, then there will be the presence of pathology on CT imaging.

The Role of Intralipid Emulsion in the Rat Model of Digoxin Intoxication.

Although the mechanism of action is not well known, intravenous lipid emulsion (ILE) has been shown to be effective in the treatment of lipophilic drug intoxications. It is thought that, ILE probably separates the lipophilic drugs from target tissue by creating a lipid-rich compartment in the plasma. The second theory is that ILE provides energy to myocardium with high-dose free fatty acids activating the voltage-gated calcium channels in the myocytes. In this study, effects of ILE treatment on digoxin overdose were searched in an animal model in terms of cardiac side effects and survival. Forty Sprague-Dawley rats were divided into five groups. As the pre-treatment, the groups were administered saline, ILE, DigiFab and DigiFab and ILE. Following that, digoxin was infused to all groups until death except the control group. First arrhythmia and cardiac arrest observation times were recorded. According to the results, there was no statistically significant difference among the group in terms of first arrhythmia time and cardiac arrest times. However, when the saline group compared with ILE-treated group separately, significant difference was observed. DigiFab, ILE or ILE-DigiFab treatment make no significant difference in terms of the first arrhythmia and cardiac arrest duration in digoxin-intoxicated rats. However, it is not possible to say that at the given doses, ILE treatment might be successful at least as a known antidote. The fact that the statistical significance between the two groups is not observed in the subgroup analysis, the study should be repeated with larger groups.

TRIMETHOPRIM-SULFAMETHOXAZOLE RESISTANCE AND FOSFOMYCIN SUSCEPTIBILITY RATES IN UNCOMPLICATED URINARY TRACT INFECTIONS: TIME TO CHANGE THE ANTIMICROBIAL PREFERENCES.

Urinary tract infections (UTIs) are among the most common bacterial infections in adult population. They are prevalent in all age groups both in women and men. Also, UTIs are the most frequent indication for empirical antibiotic treatment in emergency department. The aim of this study was to determine the antibiotic resistance rates in the treatment of uncomplicated UTIs. Adult patients admitted to emergency department with uncomplicated UTIs were included in this cross-sectional study. Mid-stream urine samples were obtained under sterile conditions and cultured quantitatively. After 24 hours, the samples showing 10(5) colony forming unit per milliliter (CFU/mL) were tested for antibiotic susceptibility. Resistance to fosfomycin-trometamol (FT), amoxicillin-clavulanic acid (AC), ciprofloxacin (CIP), trimethoprim-sulfamethoxazole (TMP-SMX) and cefpodoxime (CEF) was tested by Kirby-Bauer disc diffusion system. Escherichia (E.) coli accounted for the vast majority (93.4%) of the organisms isolated in the study. Among the E. coli positive patients, resistance to TMP-SMX was the most common antibiotic resistance. The E. coli species detected in our study group were least resistant to FT (2.4%). The resistance rates, especially to CEF, AC and CIP, were significantly higher in patients over 50 years of age. In conclusion, in the treatment of uncomplicated UTIs, TMP-SMX should be excluded from empirical treatment, while fosfomycin could be a viable option in all age groups.

A challenging differential diagnosis of optic neuropathy in ED: CSD.

Optic neuropathy due to cat scratch disease (CSD) is a rare occurrence associated with macular star formation and is characterised by sudden mostly unilateral painless loss of vision. The aetiological agent in CSD is Bartonella henselae. Ocular complications present in up to 10% of patients and include neuroretinitis, conjunctivitis or uveitis. Ocular bartonelosis is usually self-limited. A case of a man patient with neuroretinitis caused by B. henselae is reported.

Evaluation of the prescriptions written for upper respiratory tract infections.

OBJECTIVE: We aimed to determine frequency of antibiotic use and retrospectively evaluate prescriptions written for the patients with diagnosis of acute pharyngitis, acute nasopharyngitis and acute tonsillitis by our hospital emergency department physicians in January 2014. METHODS: Records of the patients who were admitted to the education and research hospital between January 1st, 2014 to January 31st 2014 were analyzed in this study. Records of all the patients with the diagnosis of acute nasopharyngitis (J.00), acute pharyngitis (J.02) and acute tonsillitis (J.03) were analyzed, and patients with a second diagnosis or haven't any prescription were excluded from the study. Frequency of antibiotic and other symptomatic medications use were analyzed in prescriptions of 5261 patients. RESULTS: Antibiotics were prescribed for 63.5% of the patients included in the study, and the most preferred antibiotics were penicilin and beta-lactamase combination (38.8%) and cephalosporins (26.2%). Combined preparations were the most preferred medications in symptomatic treatment (65.9%). Dexketoprofen was the most preferred among nonsteroidal anti-inflammatory drugs (63%). In each prescription, average number of 3.26 drugs were prescribed. CONCLUSION: Excessive and improrer use of antibiotics in the treatment of respiratuary tract infection is a global problem. The use of excess agents in symptomatic medication leads to polypharmacy. Training of physicians and patients on principles of rational drug use will contribute to the solution of this problem.

Hepatitis B, Hepatitis C and HIV seroprevalence in critically ill emergency medicine department patients in a tertiary inner city hospital in Istanbul, Turkey.

OBJECTIVE: Emergency medicine staff is working at risk of blood-borne infections during their daily practice every time. The risk of transmission is higher when dealing with critically ill patients. Our objective was to find out the prevalence of Hepatitis B, Hepatitis C, and HIV, in critically ill red-coded emergency department patients. METHODS: The study was carried out as prospective observational study between 1 September 2012 and 31 January 2013 in a tertiary inner city hospital emergency department in Istanbul, Turkey. Red triage coded patients managed in resuscitation room were enrolled. RESULTS: One thousand patients were included during the study period. Fifty of them were HBV positive. Eighteen patients were HCV positive and 2 had both HBV and HCV. HIV was not recorded. Forty one of them were trauma patients. There were 226 unconscious or uncooperative patients. Prior blood transfusion history was present in 92 of the patients and among them 11 had HBV and 3 had HCV. Four patients or their relatives were aware of their HCV positivity. HBV positivity was already known by the patients or their relatives. Total HBV vaccination ratio was 7.4%. CONCLUSION: Prevalence of HCV (1.8%) and HBV(5%) seroprevalence in our study group was very low which correlated with the recent literature regarding the Turkish population. HIV was not detected during the study period. This may also be accepted as consistent with the very low number of reported cases in Turkey.

Potassium permanganate ingestion as a suicide attempt.

Potassium permanganate is a highly corrosive, water-soluble oxidizing antiseptic. A 68-year-old female patient was admitted to our Emergency Department after ingestion of 3 tablets of 250 mg potassium permanganate as a suicide attempt. The physical exam revealed brown stained lesions in the oropharynx. Emergency endoscopy was performed by the gastroenterologist after the third hour of ingestion. Emergency endoscopy revealed multiple superficial (Grade I-II) lesions on the esophagus and cardia, which were considered secondary to the caustic substance. The mainstay in the treatment of potassium permanganate is supportive and the immediate priority is to secure the airway. Emergency endoscopy is an important tool used to evaluate the location and severity of injury to the esophagus, stomach and duodenum after caustic ingestion. Patients with signs and symptoms of intentional ingestion should undergo endoscopy within 12 to 24 h to define the extent of the disease.

Spontaneous isolated celiac artery dissection.

Dyspepsia with mild, stabbing epigastric discomfort without history of trauma is a very common symptom that emergency physicians see in their daily practice. Vascular emergencies, mostly the aortic dissection and aneurysm, are always described in the differential diagnosis with persistent symptoms. Isolated celiac artery dissection occurring spontaneously is a very rare diagnosis. The involvement of branch vessels is generally observed and patients show various clinical signs and symptoms according to the involved branch vessel. Here we are presenting a case with spontaneous isolated celiac artery dissection, without any branch vessel involvement or visceral damage, detected by computed tomography scans taken on admission.

Can NT-proBNP be used as a criterion for heart failure hospitalization in emergency room?

BACKGROUND: Heart failure is a common health problem with poor prognosis. The gold standard for diagnosis is echocardiography but it is not always reachable, especially in emergency conditions. NT-pro-brain natriuretic peptide (NT-proBNP) is a novel indicator for the diagnosis of heart failure and is being used in routine tests in emergency rooms. This study was conducted to compare NT-proBNP levels between hospitalized congestive heart failure (CHF) patients and outpatients. METHODS: This study was designed as a single-centre, prospective, and controlled trial. Blood samples and data were collected from a total of 119 patients with shortness of breath admitted to Department of Emergency, School of Medicine, Marmara University. Patients were primarily diagnosed with decompensated heart failure according to the Framingham criteria and aged above 18 years. A total of 92 patients were included in the study after exclusions. NT-proBNP measurements were made by immune fluorescent method. Available data were compared between hospitalized patients and outpatients. RESULTS: NT-proBNP levels were significantly higher in hospitalized patients compared to outpatients, and this finding was correlated with the clinical status of the patients. The mean NT-proBNP value of the patients was 9741.9 ± 8973 pg/ml (range: 245-35000) while the mean NT-proBNP value of patients diagnosed with non-decompensated congestive heart failure was 688.9 ± 284.5 pg/ml (range: 115-1450.65). CONCLUSIONS: NT-proBNP can be used as an easy diagnostic method for congestive heart failure. A certain cut-off value may be determined in further multi-centre controlled trials with larger patient groups.

Perimortem caesarean section following maternal gunshot wounds.

Perimortem caesarean section is an ethically difficult decision for emergency medicine resuscitation teams. A 34-years-old woman was attacked by her husband with a gunshot. At the time arrival to the emergency room, there was no pulse, no spontaneous breath and blood pressure was unobtainable. Although extensive advanced cardiopulmonary resuscita-tion was performed for 7 minutes, no cardiac activity was regained. During the cardiopulmonary resuscitation efforts, an abdominal ultrasonography was performed and revealed a fetal heart rate with bradycardia. Low segment caesarean section was performed by the obstetrician in the resuscitation room and a female newborn was delivered within less than one minute of the skin incision. Decision on terminating the CPR efforts should not be made in maternal cardiac arrests older than 28 weeks' gestational age, unless the viability of the fetus had been evaluated.