Pharmacologic anisocoria due to nebulized ipratropium bromide: A diagnostic challenge.

Anisocoria may be physiological or seen in fatal conditions, such as intracranial hemorrhage. Newly developing anisocoria may cause confusion and diagnostic difficulty in the emergency department (ED). A 35-year-old female was admitted to the ED with an asthma attack and dyspnea. On examination, the patient was observed to have bilateral rhonchi and was treated with nebulized albuterol (salbutamol) and ipratropium bromide. After the treatment, the dyspnea improved, and mydriasis developed in the left eye (left pupil diameter 9 mm, right 4 mm). An examination revealed that the left pupil was dilated and unreactive to light, but there was no neurological finding. Afterwards, the patient reported that, during the treatment, some aerosol had leaked from the left side of the mask and may have come into contact with her left eye. Given this information, a pilocarpine test was performed, and the patient was diagnosed with pharmacologic anisocoria. The pupil returned to normal within 24 h. Ipratropium bromide is a drug frequently used in patients presenting to the ED with dyspnea. During treatment, nebulized ipratropium may leak from the edge of the facial mask into the ipsilateral eye and may cause mydriasis. A pilocarpine test can be used to differentiate pharmacological anisocoria from other causes, such as third nerve palsy and Adie's pupil. Through the awareness of emergency physicians and the use of the pilocarpine test, a diagnosis can be made without engaging in time-consuming and costly analyses. In addition, this complication can be prevented using masks that better fit the face, as well as protective goggles or eye patches, during treatment.

Blue code: Is it a real emergency?

BACKGROUND: Cardiac arrests in hospital areas are common, and hospitals have rapid response teams or "blue code teams" to reduce preventable in-hospital deaths. Education about the rapid response team has been provided in all hospitals in Turkey, but true "blue code" activation is rare, and it is abused by medical personnel in practice. This study aimed to determine the cases of wrong blue codes and reasons of misuse. METHODS: This retrospective study analyzed the blue code reports issued by our hospital between January 1 and June 1 2012. A total of 89 "blue code" activations were recorded in 5 months. A "blue code" was defined as any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital alert. Adherence to this definition, each physician classified their collected activation forms as either a true or a wrong code. Then, patient data entered a database (Microsoft Excel 2007 software) which was pooled for analysis. The data were analyzed by using frequencies and the Chi-square test on SPSSv16.0. RESULTS: The patients were diagnosed with cardiopulmonary arrest (8), change in mental status (18), presyncope (11), chest pain (12), conversive disorder (18), and worry of the staff for the patient (22). Code activation was done by physicians in 76% of the patients; the most common reason for blue code was concern of staff for the patient. CONCLUSION: The findings of this study show that more research is needed to establish the overall effectiveness and optimal implementation of blue code teams.

The effects of adrenomedullin in traumatic brain injury.

Traumatic brain injury (TBI) is a common cause of death and disability throughout the world. A multifunctional peptide adrenomedullin (AM) has protective effects in the central nervous system. We evaluated AM in an animal model as a therapeutic agent that reduces brain damage after traumatic brain injury. A total of 36 rats was divided into 3 groups as sham, head trauma plus intraperitoneal (ip) saline, and head trauma plus adrenomedullin ip. The diffuse brain injury model of Marmarou et al. was used. Blood samples were taken from all groups at the 1st, 6th and 24th hours for analysis of TNF-α (tumor necrosis factor-α), IL-1ß (interleukin-1ß) and IL-6 (interleukin-6) levels. At the end of the study (at the 24th hour) a neurological examination was performed and half of the rats were decapitated to obtain blood and tissue samples, the other half were perfused transcardiacally for studying the histopathology of the brain tissue. There were no statistically significant changes in plasma levels of IL-1ß, IL-6 and TNF-α relative to the sham group. Also, changes in tissue levels of malonedialdehyde, myeloperoxidase and glutathione were not statistically significant. However, neurological scores and histopathological examinations revealed healing. AM individually exerts neuroprotective effects in animal models of acute brain injury. But the mechanisms of action remain to be assessed.

Evaluation of non-urgent visits to a busy urban emergency department.

OBJECTIVE: To identify the proportion of patients who were taken into the emergency room on the basis of legal regulations and non-urgent medical procedures. METHODS: This prospective study was conducted in the Emergency Department, Toros State Hospital, Mersin, Turkey. Data were collected over 4 weeks (January 2011) and then analyzed using the Kolmogorov-Smirnov, Analysis of Variance, and Kruskal-Wallis H tests. RESULTS: During the study period, 21,014 patients visited the Emergency Department. The applications were measured during a 3-shift schedule (08-16, 16-00, 00-08 hours). The total number of ordinary emergency admissions was 16,370. Of the total, 4,644 (22.1%) of the visits were evaluated as inappropriate. According to our study, inappropriate use of the emergency department was 51.1% more frequent during the 08-16 hours shift than the others. CONCLUSION: Inappropriate use of EDs with non-urgent applications makes it difficult to guarantee access for real emergency cases, decreases the readiness for care, and produces negative spillover effects on the quality of emergency services.