Efficacy of bedside optic nerve sheath diameter measurement in differentiating provoked seizure from unprovoked seizure in the emergency department.

BACKGROUND: Emergency departments (EDs) are typically the first medical contact for seizure patients, and early diagnosis and treatment is primarily the responsibility of emergency physicians. OBJECTIVES: Demonstrate the efficacy of bedside ocular ultrasonography for optic nerve sheath diameter (ONSD) measurement in differentiating provoked seizure from unprovoked seizure in the ED. DESIGN: Prospective observational study SETTINGS: Tertiary care hospital PATIENTS AND METHODS: Patients presenting to the ED with seizure were divided into two groups according to medical history, physical examination, laboratory results, cranial computed tomography findings and electroencephalography results. Patients with seizures that did not have a specific cause (unprovoked) were compared with patients who had seizures caused by underlying pathology (provoked). The measurement of the ONSD was taken at the bedside within 30 minutes of arrival. The study compared the ONSD values, age, sex, type of seizure, and Glasgow Coma Score between the two groups. MAIN OUTCOME MEASURE: Efficacy of ONSD to distinguish between provoked and unprovoked seizures. SAMPLE SIZE: 210 patients RESULTS: One hundred and fourteen (54.3%) patients were in the provoked seizure group and 96 (45.7%) were in the unprovoked seizure group. The ONSD measurements were significantly higher in the provoked seizure group compared with the unprovoked seizure group (median 6.1 mm vs. 5.2 mm, P<.001). The cut-off value of ONSD higher than 5.61 was significantly associated with the prediction of the provoked seizure (P<.001). The area under the curve value was 0.882 (95% CI: 0.830-0.922) with a sensitivity of 86.5 and specificity of 78.9%. CONCLUSIONS: Bedside ONSD measurement by means of ocular ultrasound is an effective method for differentiating provoked seizure from unprovoked seizure. LIMITATIONS: Statistical significance of age on ONSD and exclusion of pediatric patients. CONFLICT OF INTEREST: None.

Abdominal twitches due to ICD lead dislodgement; A case report.

Malfunctions of implantable cardiac devices have the potential to be catastrophic. A 63-year-old patient was admitted to our emergency department with new-onset abdominal pain and sensation of twitching on his abdominal wall. One month ago, an implantable cardioverter-defibrillator (ICD) was implanted in him to prevent malignant ventricular arrhythmias. An electrocardiogram was obtained that showed pace spikes unrelated to QRS complexes. The patient was diagnosed with ICD lead dislodgement and the lead was repositioned in another procedure. In conclusion, emergency physicians should be familiar with the problems of implantable cardiac devices.

Accuracy of Ottawa ankle rules for midfoot and ankle injuries.

Background The management of ankle sprains is common practice in emergency departments. Traditionally, physicians would order radiographs for all ankle injuries although the overall incidence of fractures are less than 15% .  The Ottawa Ankle Rules (OAR) have been developed to predict the necessity of radiographs in acute ankle injuries. Material and Method This is a prospective study of consecutive patients aged 16 years or older with acute non-penetrating ankle or foot injuries and who had a radiography of ankle or foot or both. Results 499 cases were included in the study. 56.90 % of the patients were male and the median age of the patients was 30 (IQR  22,44).  22.85 % (114/499) of patients with ankle or midfoot injuries had fractures.  The sensitivity, specificity, PPV and NPV of OAR for ankle and midfoot injuries  were 100, 45.26, 26.00, 100 and 100, 43.71, 19.92 and 100 respectively. In this study 792 x rays were ordered from 499 patients. According to OAR 509  (%64.27) of them were indicated whereas 283 (% 35.73) were not. When the weight bearing test is sole criteria 303 ( 38.26%) x rays were obtained to find out three fractures. Conclusion OAR should be safely used in emergency departments. Implantation of this rule prevents patients from unnecessary radiation exposure. It is a reasonable approach to reassess the patient if symptoms not resolve several days later  for avoiding unnecessary x ray exposure when the weight bearing test exist as the only positive criteria.

Comparison of pneumonia severity scores for patients diagnosed with pneumonia in emergency department.

BACKGROUND & OBJECTIVES: : Sepsis due to pneumonia or pneumonia itself is one of the main causes of deaths in patients despite the advanced treatment methods. The optimal prognostic tool in pneumonia is still not clear. This study was aimed to compare the pneumonia severity scores and the possibility of using the new scores in patients who were diagnosed with pneumonia in the emergency department. METHODS: : Demographic data, laboratory and imaging results, confusion, elevated blood urea nitrogen, respiratory rate and blood pressure plus age ≥65 yr (CURB-65), pneumonia severity index (PSI), national early warning score (NEWS), NEWS-lactate (NEWS-L) scores, hospitalization, referral, discharge and 30-day mortality of patients who were diagnosed with pneumonia in emergency department were recorded. RESULTS: : A total of 250 patients were included in the study. The most successful score in predicted mortality was found to be NEWS-L. This was followed by NEWS, CURB-65 and PSI, respectively. Most successful scores in anticipation of admission to the intensive care unit were NEWS-L followed by NEWS. This was followed by CURB-65 and PSI scores, respectively. The most successful score in anticipation of hospital admission was NEWS-L, followed by NEWS, CURB-65 and PSI, respectively. There was a significant difference between all pneumonia severity scores of the patients who died and survived within 30 days. There was a significant difference between the scores of patients in intensive care unit (ICU) and service, compared to non-ICU patients. INTERPRETATION & CONCLUSIONS: : NEWS-L score was found to be the most successful score in predicting mortality, ICU admission and hospitalization requirement. Both NEWS-L and NEWS scores can be used in determining the mortality, need for hospitalization and intensive care of the patients with pneumonia in the emergency department.

Concomitant Substance Use Increases the Toxic Effect of synthetic cannabinoid (Bonsai): A Prospective Study.

OBJECTIVE: In this study, we aimed to contribute to the literature by evaluating bonsai and additional drugs. MATERIALS AND METHODS: This prospective study was conducted on 217 patients who admitted to the emergency department (ED) with bonsai intake between December 20, 2014 and January 1, 2016, according to the patient history obtained from the patients. While 168 patients with negative urinary metabolites results were excluded from the study, 49 patients with positive urinary metabolites were included in the study. Patients were divided into two groups. The first group consisted of patients with only bonsai intake and the second group consisted of patients with bonsai and concomitant drug intake. The groups were compared in terms of symptoms, findings, blood gas values, duration of the symptoms, discharge time, hospitalization, and mortality rate. Data were analyzed using the Chi-square, the Fisher's exacttest, the Student t-test, and the Mann-Whitney U test. Data were evaluated at the 95% confidence interval. P<0.05 was considered statistically significant. RESULTS: The mean age of 49 patients included in the study was 26.7±8.9 years and 91.8% (n=45) of the patients were male. Concomittant drug intake was identified in 69.4% of patients. Concomitant drug use was as follows: cocaine (20.4%, n=10), amphetamines (14.3%, n=7), methamphetamines (8,2%, n=4,) tetrahydrocannabinol (32.7%, n=16), opiates (18.4%, n=9) and alcohol (30.6%, n=15). On admission, Glasgow Coma Score (GCS) of the bonsai with additional substance group was significantly higher (p=0,003). The most common symptom was palpitations (tachycardia) (75.5%, n=37). There were no patients hospitalized in Only Bonsai group (p=0,020). The median time to remission of symptoms and median follow-up time of the patients in the emergency room were 3 hours and 6 hours, respectively. Remission time of the symptoms and hospitalization rates were higher in patients with concomittant drug intake (p <0.05) Conclusion: While the bonsai intake alone is not considered mortal to the patients and most of them can be discharged from the ED after signs and symptoms disappear, concomitant drug use can increase the toxic effects of bonsai intake. That is why follow-up of patients taking concomitant drug and the treatment process should be carried out more carefully.

Comparison of ultrasound and physical examination with computerized tomography in patients with blunt abdominal trauma.

BACKGROUND: In cases of blunt abdominal trauma, the abdomen is the third most affected region. Computerized tomography (CT) is the gold standard for the evaluation of these patients. However, considering its damaging effects and high cost, it may not be proper to refer every patient applying to the emergency unit for a CT examination. In this study, our objective was to compare the accuracy of ultrasonography (US) and physical examination in blunt abdominal trauma patients to the gold standard CT in order to prevent unnecessary CT examinations. METHODS: In this retrospective study, the files and images of 2248 patients, who applied to the emergency department of our hospital were screened. A total of 535 adult patients who underwent CT scanning after the ultrasonographic and physical examinations were included in the study. The findings of the US and physical examinations, the intraabdominal free fluid, and organ lacerations were compared to the results of CT. The compatibility, sensitivity, specificity, positive estimated value, and the negative estimated value of the obtained data were analyzed with statistical methods. RESULTS: The sensitivity of US in the demonstration of the intraabdominal free fluid was comparable with the sensitivity of CT in the patients with blunt abdominal trauma (p=0.302). The sensitivity and specificity of US was 49.6% and 99.3% respectively in the determination of the intraabdominal organ injuries. The sensitivity and specificity of the physical examination was 59% and 87% respectively in the determination of the free fluid and organ injury as compared to CT. Although the sensitivity and specificity of the physical examination were high separately in the organ injuries according to the statistical calculations, they seemed not to have had a statistically significant predictive value (p<0.001). CONCLUSION: Even though US is a reliable method for the determination of the intraabdominal fluid, US and physical examination are not reliable in the determination of the organ injuries as compared to CT.

Endosulfan induced cardiac arrest treated with intravenous lipid emulsion.

OBJECTIVE: Endosulfan is an organochlorine pesticide with high lipophilic features that makes it a well-absorbed agent and penetrates easily to the site of action. Endosulfan toxicities may result in disastrous complications and have high rates of mortality. Several case reports and some researchs discuss the evidence supporting intravenous lipid emulsion (ILE) therapy as a rescue therapy in lipophilic agents' toxicity. CASE REPORT: A 33-years-old healthy woman with  a history of endosulfan ingestion of uncertain quantity in a suicide attempt six hours ago was admitted to our emergency department. Cardiac arrest ensued after one hour of admission. Cardiopulmonary resuscitation was initiated in accordance with advanced cardiac life support (ACLS) algorithm for asystole. During resuscitation, 2 mL/kg bolus of 20% intravenous lipid emulsion (ILE) was administered for three times at five-minute intervals in addition to ACLS guidance. Spontaneous circulation returned after twenty minutes of resuscitation. No additional antidotal or vasopressor therapies were required during the hospital course of the patient. To our knowledge, this is the first reported case with responded use of ILE treatment for endosulfan toxicity. CONCLUSION: This case report indicates that ILE treatment should be considered for life-threatening endosulfan intoxications.

Red blood cell distribution width as a predictor of long-term mortality in patients with carbon monoxide poisoning.

OBJECTIVES: Elevated red blood cell distribution width (RDW) is an independent prognostic factor for cardiovascular events that are major causes of mortality in patients with carbon monoxide (CO) poisoning. Due to the limited number of studies, we aimed to investigate the relationship between RDW levels and long-term mortality for these patients. METHOD: This retrospective study included patients with CO poisoning, who presented to the emergency department. Baseline characteristics, laboratory results and survival status were retrieved from patients' hospital records. The severity of poisoning was determined according to COHb level and/or clinical signs and symptoms. RESULTS: The study included 571 patients (median age was 37.0 years) and less than half of these patients were male (n = 206, 36.1%). There were mild-moderate CO poisoning in 389 (68.1%) patients and severe poisoning in 182 (31.9%). At a median follow-up of 6.2 years, there were 33 deaths (5.8%). Univariate cox-regression analysis demonstrated that age, gender, presence of hypertension or diabetes mellitus, levels of hemoglobin, RDW, creatinine and alanine-aminotransferase, and white-blood-cell count were potential covariates of long-term all-cause mortality. In the multivariate analysis, the median age and RDW level remained independent predictors of mortality (age, Odds ratio [OR]: 1.070 95% confidence interval [CI]: 1.030-1.110, p = 0.001; RDW, OR: 1.221 95% CI: 1.042-1.431, p = 0.013). Patients with higher RDW levels had a significantly worse prognosis in terms of mortality than with lower RDW levels (log-rank test, p = 0.003). CONCLUSION: This study demonstrated that RDW level is an independent predictor of long-term mortality in patients with CO poisoning.

Socio-demographic and clinical profile of substance abuse patients admitted to an emergency department in Ankara, Turkey.

BACKGROUND: Illicit drug abuse is an important health problem around the world. Cannabis is the most commonly used illicit drug, followed by amphetamines, opioids, and cocaine. In this study, we searched the socio-demographic features of drug abusers admitted to an emergency department. MATERIALS AND METHODS: The study was performed in the emergency department of an education and training hospital in Ankara, Turkey. The socio-demographic features, substances commonly consumed, and the reason for the patients' presentation were recorded. RESULTS: The mean age of patients was 28.3±9.2. Of those under study, 93.3% were male; 68.7% were discharged from the emergency department after a short observation period; and 10.4% were hospitalized. The median age of the patients' first experience with illicit substances was 19 (4-56). CONCLUSION: Illicit drug use remains a significant medical health problem, not only in Turkey but also around the world. Abusers frequently seek emergency services, complaining of various symptoms, but generally do not mention their substance abuse. Emergency physicians must ask patients if they use abuse drugs.

Validity of modified early warning, Glasgow Blatchford, and pre-endoscopic Rockall scores in predicting prognosis of patients presenting to emergency department with upper gastrointestinal bleeding.

BACKGROUND: GBS, MEWS, and PER scoring systems are not commonly used for patients presenting to emergency department with GIS bleeding. This study aimed to determine the value of MEWS, GBS, and PER scores in predicting bleeding at follow-up, endoscopic therapy and blood transfusion need, mortality, and rebleeding within a 1-month period. METHODS: A total of 202 consecutive patients with upper GIS bleeding between July 2013 and November 2014 were prospectively enrolled in the study. The relationship between MEWS, GBS, and PER scores and hospital outcome, bleeding at follow-up, endoscopic therapy, transfusion need, rebleeding, and death were examined. RESULTS: The study included a total of 202 subjects, with 84 (41.6 %) females and 118 (58.4 %) males. There was a significant correlation between GBS, MEWS, and PER scores and hospital outcomes (p <0.004, p <0.001, p <0.001, respectively). A GBS score greater than 11 succesfully predicted bleeding at follow-up (p = 0.0237). GBS score's sensitivity for predicting endoscopic therapy was greater than those of other scoring systems. The discriminatory power of each scoring system was significant for predicting transfusion (p <0.0001, p = 0.0470, and p = 0.0014, respectively). A GBS score greater than 13, a MEWS score greater than 2, and a PER score greater than 3 predicted death. A PER score greater than 3 predicted rebleeding (p <0.0001). CONCLUSION: The scoring systems in question can be easily calculated in patients presenting to ED with upper GIS bleeding and may be beneficial for risk stratification, determination of transfusion need, prediction of rebleeding, and decisions of hospitalization or discharge.

Lingual angioedema after alteplase treatment in a patient with acute ischemic stroke.

BACKGROUND: In recent years, thrombolytic therapy has become the main treatment of ischemic stroke. But the increasing use of alteplase in ischemic stroke has made some complications more evident. Angioedema is a rare but potentially life-threatening complication of alteplase treatment. Only a few studies have examined the incidence of angioedema after treatment with alteplase for stroke. METHODS: A 75-year-old man complaining of right hemiparesis was admitted to our emergency department. He was diagnosed as having acute ischemic stroke, and alteplase infusion was given two hours after the onset of stroke symptoms. Immediately after the completion of infusion he was noted to have a large swollen tongue. RESULTS: His neurological symptoms resolved gradually within 4 hours, whereas his upper extremity strength improved to 4/5 and lower extremity 5/5. Lingual edema resolved within 16 hours without any complication. He died from presumed nosocomial infection 5 days later. CONCLUSIONS: Lingual angioedema may appear as a possible complication in patients who were treated with alteplase. The management of these patients should be very careful.

Elevated cardiac enzymes due to mushroom poisoning.

Mushroom poisoning is an important reason of plant toxicity. Wild mushrooms that gathered from pastures and forests can be dangerous for human health. The clinical outcomes and symptoms of mushroom toxicity vary from mild gastrointestinal symptoms to acute multiple organ failure. Toxic effects to kidney and liver of amatoxin are common but cardiotoxic effects are unusual. In this case, we reported the cardiotoxic effect of amatoxin with the elevated troponin-I without any additional finding in electrocardiography, echocardiography and angiography.

Occupational injury patterns of Turkey.

INTRODUCTION AND AIM: Each year, a significant number of people die or become handicapped due to preventable occupational accidents or occupational diseases. The aim of this study was to investigate socio-demographic features, mechanism, causes, injury area, and sectoral features of occupational accidents in patients presented to our department. MATERIALS AND METHODS: The study was carried out retrospectively after local ethics committee approval. Age and sex of the patients, mechanism of injury, type and exact location of injuries were all evaluated. The groups were compared using Chi-Square test, Student's T test and Kruskall-Wallis test. p value <0.05 was accepted as statistically significant. RESULTS: Totally 654 patients were included in the study. 93.4% of patients were male, and mean age was 32.96 ± 5.97 (18-73) years. Sectoral distribution of accidents was statistically significant and mostly occurred in industrial and construction workers (p < 0.05, respectively). There is a statistically significant relationship between educational level and sector of the worker (p < 0.05). While the most frequent cause of admission to emergency department was penetrating injuries (36.4%), the least was due to multiple traumas (0.5%). Distribution of occupational accidents according to injury type was statistically significant (p < 0.05). The mean Injury Severity Score (ISS) was 9.79 ± 8.1. The mean cost of occupational injury was $1729.57 ± 8178.3. There was statistically significant difference between the sectors with respect to cost. Seventy-one patients (10.9%) recovered with permanent sequel and two (0.3%) died in hospital. CONCLUSION: Occupational accidents are most commonly seen in young males, especially in primary school graduated workers, and during daytime period.

Epidemiologic and clinical characteristics and outcomes of scorpion sting in the southeastern region of Turkey.

BACKGROUND: Scorpion sting resulting in envenomation is a life-threatening emergency and causes serious health problems in tropical and subtropical regions. The aim of this study was to present the epidemiologic and clinical features of 123 cases presenting with symptoms of scorpion poisoning, a cause of preventable mortality and morbidity. METHODS: This study retrospectively analyzed the epidemiologic and demographic features of a total of 123 patients who presented to Diyarbakir State Hospital Emergency Service with scorpion sting between January 2008 and December 2009. RESULTS: Among 123 patients who presented to Diyarbakir State Hospital Emergency Service with scorpion sting between January 2008 and January 2009, 62.6% (n=77) were female and 37.4% (n=46) were male. The mean age of the patients was 33.5±17.3 years (2-80), and 27 (22%) patients were younger than 18 years. The place of residence was rural region in 98 (79.7%) patients and the city center in 25 (20.3%). The majority of victims were stung by scorpions while they were at active work (42.3%) or asleep (19.5%) in bed. Eleven (8.95%) patients were stung by a scorpion while putting on their own clothes. CONCLUSION: This simple descriptive study will hopefully help healthcare providers take measures to prevent scorpion stings, which should take into consideration local epidemiological features.

An unusual presentation of ruptured abdominal aorta aneurysm.

PATIENT: Female, 65 FINAL DIAGNOSIS: Ruptured abdominal aorta aneursym Symptoms: - MEDICATION: - Clinical Procedure: After surgery the patient was discharged without sequelae Specialty: Surgery. OBJECTIVE: Unusual clinical course. BACKGROUND: Rupture of an abdominal aortic aneurysm is the most frightening and potentially life threatening complication of an abdominal aorta aneurysm (AAA). PATIENTs present with atypical symptoms such as abdominal or flank pain, gastrointestinal hemorrhage, or shock. CASE REPORT: A 65-year-old woman presented to our emergency department with gradually increasing left flank pain for 4-5 days. Her laboratory, radiologic, and physical examination revealed no significant pathology, so she was discharged, but 3 days later she was readmitted because her symptoms returned. Further research revealed a ruptured AAA and the patient was hospitalized for surgical intervention. CONCLUSIONS: Emergency physicians should keep in mind that AAA and its rupture can present with a wide range of symptoms that appear to be simple.

A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations.

AIM: Scalp lacerations are commonly encountered in patients presenting to emergency department with trauma. Lacerations are repaired with suturing, stapling, adhesive tapes, and tissue adhesives. In this study, we aimed to compare the effectiveness of suturing, stapling, and hair apposition techniques used in repair of scalp lacerations in patients who presented to emergency department with scalp laceration. MATERIALS AND METHOD: After obtaining approval of local ethics committee, we examined the effects of the three technique used to repair scalp lacerations on wound healing, complication rate, and patient satisfaction by recording data. Categorical variables were expressed as n and %. X(2) test was used for statistical analysis. A p value less than 0.05 was accepted statistically significant. RESULTS: Our study included a total of 134 patients of whom were treated 37 (27.6%) with hair apposition technique 49, 48 (35.8%) with suturing, and (36.6%) with stapling. There was a significant difference between the scalp repair technique and 7th and 15th day patient satisfaction rates in favor of the hair apposition technique (p < 0.05). There was a significant difference between the scalp repair technique and cosmetic problems after 15 days (p < 0.05). Cosmetic problems 15 days after the procedure were significantly lower in the hair apposition technique. CONCLUSION: In patients presenting to emergency departments with linear scalp laceration suturing, stapling, and hair apposition techniques can be safely applied. However, hair apposition technique has the advantages of being more satisfying, and having lower cosmetic problem and complication rates compared with other techniques.

Treatment of quetiapine overdose with intravenous lipid emulsion.

We report the case of a 29-year-old woman who attempted suicide by oral ingestion of potentially fatal doses of multiple drugs including quetiapine. Intravenous lipid emulsion (ILE) was administered at a dose higher than that used in the standard management of toxicity. Rapid improvement was observed in the patient's status, and no additional treatment was required during the period of observation. No adverse effect of lipid administration was observed. ILE treatment seems to have great potential in the management of lipophilic drug toxicity in the future.

Gallbladder volvulus.

Gallbladder volvulus or torsion; is an uncommon cause of acute abdomen and occurs by rotation of the gallbladder on its mesentery. The entity commonly misdiagnosed as cholecystitis before laparatomy, although it has some critical findings that alert physician for correct diagnosis. A 47 years old male patient admitted to our emergency department with right upper quadrant pain, and then progressed through abdominal rigidity indicating acute abdomen, was subjected to laparatomy. At surgery; gangrenous and rotated gallbladder was observed and cholecystectomy was performed. Early diagnosis and prompt surgical treatment is mandatory to lower the complications of this entity. Clinical signs and radiographic studies should guide physicians for proper diagnosis of gallbladder torsion.

Role of mean platelet volume in diagnosis of childhood acute appendicitis.

Introduction. Acute appendicitis is the leading cause of abdominal pain in children requiring emergency surgical intervention. The aim of this study is to investigate the diagnostic value of MPV in early diagnosis of acute appendicitis cases in pediatric age group. Methods. This study was performed retrospectively. Three hundred five patients operated on with the diagnosis of appendicitis and pathologically found to be acute appendicitis were classified as Group 1 and 305 healthy children were classified as control Group 2. Results. One hundred ninety-seven of 305 cases in Group 1 are males (64.6%), in Group 2, 151 of 305 cases are males (49.5%). The mean MPV in Group 1 was 7.9 ± 0.9 (fL), and whereas in Group 2 was 7.7 ± 0.8 (fL). There was no statistically significant difference regarding MPV values (P > 0.05). Conclusion. In our study we detected that mean platelet volume has no diagnostic value in pediatric acute appendicitis cases.