High-Flow Nasal Cannula versus Bag Valve Mask for Preoxygenation during Rapid Sequence Intubation in the Emergency Department: A Single-Center, Prospective, Randomized Controlled Trial.

OBJECTIVE: Hypoxia is a frequently reported complication during the intubation procedure in the emergency department (ED) and may cause bad outcomes. Therefore, oxygenation plays an important role in emergency airway management. The efficacy of oxygenation with high-flow nasal cannula (HFNC) in the ED has been studied, though the evidence is limited. The study aim was to compare two methods of preoxygenation in patients undergoing rapid sequence intubation (RSI) in the ED: (1) HFNC and (2) bag-valve mask (BVM) oxygenation. METHODS: This is a single-center, prospective, randomized controlled trial (RCT) in adult ED patients requiring RSI. Patients were randomized to receive preoxygenation with either HFNC or BVM. While HFNC therapy was continued during the intubation procedure, BVM oxygenation was interrupted for laryngoscopy. The primary outcome was the lowest peripheral oxygen saturation (SpO2) level during intubation. Secondary outcomes were incidence of desaturation (SpO2<90%) and severe hypoxemia (SpO2<80%) throughout the procedure, intubation time, rate of failed intubation, and 30-day survival rates. RESULTS: A total of 135 patients were randomized into two groups (HFNC n = 68; BVM n = 67). The median lowest SpO2 value measured during intubation was 96% (88.8%-99.0%) in the HFNC group and 92% (86.0%-97.5%) in the BVM group (P = .161). During the intubation procedure, severe hypoxemia occurred in 13.2% (n = 9) of patients in the HFNC group and 8.9% (n = 6) in the BVM group, while mild hypoxemia was observed in 35.8% (n = 24) of the BVM group and 26.5% (n = 18) of the HFNC group. However, there was no statistically significant difference between the groups in terms of hypoxemia development (P = .429 and P = .241, respectively). No significant difference was reported in the rate of failed intubation between the groups. Thirty-day mortality was observed in 73.1% of the BVM group and 57.4% of the HFNC group, with a borderline statistically significant difference (difference 15.7; 95% CI of the difference: -0.4 to 30.7; P = .054). CONCLUSION: The use of HFNC for preoxygenation, when compared to standard care with BVM oxygenation, did not improve the lowest SpO2 levels during intubation. Also, the use of HFNC during intubation did not provide benefits in reducing the incidence of severe hypoxemia. However, the 30-day survival rates were slightly better in the HFNC group compared to the BVM group.

The efficacy of intradermal sterile water application in severe renal colic: a randomised clinical trial.

It is important to do a fast and effective treatment for patients with renal colic pain in emergency departments for both patients' comfort and clinicians' patient management. In this study, we aimed primarily to test the efficacy of intradermal sterile water application as a rapid and effective treatment in severe renal colic. This is a single-centre, prospective, randomised controlled trial. Study group consists of patients with severe renal colic related to urolithiasis. Patients were randomly divided into three groups. The first group received only intramuscular diclofenac sodium, the second group received intramuscular diclofenac sodium and intradermal sterile water, and the third group received intramuscular diclofenac sodium together with intravenous fentanyl. Numerical Rating Scale was used to determine the level of pain before and after the treatment at the 1st, 5th, 15th, 30th, 60th and 120th minutes. 95 out of 201 patients with severe renal colic pain randomly divided into 3 groups. The pre-treatment pain severity of the groups was similar (p = 0.228). We found that the decrease in pain intensity was significantly faster in the intradermal sterile water group than the other groups even in the first minute. Percentages of patients who had 50% pain reduction, which is considered as successful treatment, was higher in the intradermal sterile water group (which had 75.9% success rate) in the first 5 min compared to the IM diclofenac sodium group (which had 7.1% success rate) and IV fentanyl group (which had 25% success rate) (p < 0.001). According to the results, pain control was achieved much faster than the other methods with intradermal sterile water injection. All methods were found to be effective in relieving the pain of the patients.

Comparison of the Arterial PaCO 2 Values and ETCO 2 Values Measured with Sidestream Capnography in Patients with a Prediagnosis of COPD Exacerbation.

Background Aim of this study is to investigate whether end-tidal carbon dioxide (ETCO 2 ) values can be used instead of partial pressure of carbon dioxide (PaCO 2 ) values in guiding treatment, and determining treatment benefits in patients that received a pre-diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation at the emergency department. Methods This observational prospective study was conducted with patients who presented to the emergency department with the complaint of shortness of breath and were diagnosed with COPD exacerbation. ETCO 2 was measured with the sidestream method during blood gas analysis in patients with indications for this analysis. Measurements were repeated at hour 1 after treatment. Results The study included a total of 121 cases. There was a positive correlation between the PaCO 2 and ETCO 2 values measured before and after treatment ( r = 0.736, p < 0.01 and r = 0.883, p < 0.01, respectively). High ETCO 2 values were accompanied by high PaCO 2 values. When the measurements before and after treatment were evaluated using the Bland-Altman method, most of the result were within the limits of agreement (-4.9 and +31.4/- 2.6 and +9.4), with mean differences being calculated as 13.2 and 8.4, respectively. Conclusions Although ETCO 2 and PaCO 2 were statistically consistent according to the results of our study, due to the high averages of differences between these two parameters, the ETCO 2 value has limited clinical use in COPD cases compared to PaCO 2 . However, high ETCO 2 values may indicate that noninvasive mechanical ventilation should be included in the treatment of COPD cases without waiting for the results of blood gas analysis, and they can also be when needed for inpatient treatment.

The middle cerebral artery density and ratio for the diagnosis of acute ischaemic stroke in the Emergency Department.

PURPOSE: Non-contrast computed tomography (ncCT) is the first-line imaging modality for acute ischaemic stroke diagnosis. Recognition of the early diagnostic signs of a stroke on computed tomography (CT) is crucial. The hyperdense middle cerebral artery (MCA) sign is one of these findings. We investigated the diagnostic utility of absolute MCA density (MCAD) in patients with acute MCA stroke confirmed with diffusion-weighted magnetic resonance imaging (dwMRI). METHODS: We retrospectively included all patients who presented to the Emergency Department with symptoms related to an acute stroke and confirmed with a dwMRI and ncCT to this diagnostic case-control study. An expert radiologist with more than four years of experience in neuroradiology re-evaluated all ncCT images. The evaluation of MCAD and ratio were measured on axial images in Hounsfield units (HU). RESULTS: We included 407 patients in our study (MCA infarction: 55%, n = 225; Control: 45%, n = 182). We calculated the threshold for the highest sensitivity (20%) and specificity (94%) as 49 HU with the Youden J index test for MCAD and as 1.1 for MCAD ratio (sensitivity 20% and specificity 95%). MCAD >49 HU or MCAD ratio >1.1 alone or joint use of MCAD >47 HU and MCAD ratio >1.1 are useful markers to confirm the diagnosis of MCA AIS with a specificity of at least 94%. Higher MCAD values are associated with larger infarction volumes. CONCLUSION: MCAD and MCAD ratio can be used to identify patients who need early treatment, especially in situations where computed tomography angiogram or dwMRI are not readily available.

Admission blood lactate levels of patients diagnosed with cerebrovascular disease effects on short- and long-term mortality risk.

OBJECTIVE: Our study was carried out on patients admitted to the emergency ward with acute stroke symptoms that were subsequently diagnosed with cerebrovascular disease. We aimed to examine the relationship between these patients' admission lactate levels and their 1-, 3-, and 12-month mortality rates in order to evaluate the prognostic value of lactate levels. METHODS: Our data were obtained retrospectively from 568 patients diagnosed with acute ischemic stroke at our emergency department between 1 January 2017 and 1 January 2018. Patient data were accessed via the hospital patient database. Included patients' files were assessed for examination and history taken at admission, comorbid diseases, demographic characteristics, treatments utilized, and laboratory results. Hyperlactatemia was defined as a lactate level of over 2 mmol/L. The relationship between lactate levels and survival was investigated. Patients' complication rates after discharge were assessed alongside their 1-, 3-, and 12-month mortality. RESULTS: Our study assessed 568 patients. Out of these patients, 400 patients met our inclusion criteria and constituted the study population. These patients were separated into two groups according to their lactate levels. The hyperlactatemic group had a statistically significant increase in 1-, 3-, and 12-month mortality rates in comparison to the other group. CONCLUSIONS: Our study found that hyperlactatemia was associated with a higher risk of 1-, 3-, and 12-month mortality, suggesting that it has predictive prognostic value. In the future, we believe that prospective observational studies and/or large-scale retrospective studies will be of great value in providing more insight into this topic.

Predictors of false negative diffusion-weighted MRI in clinically suspected central cause of vertigo.

INTRODUCTION: Vertigo is classified as peripheral and central. Differentiation of stroke mimics is the most important diagnostic challenge. There is no clinical guidance for the indications of neuroimaging in isolated vertigo patients. The primary aim of this study is to test the diagnostic value of a DWI-MRI protocol to rule-out a central cause in patients with acute isolated vertigo in the ED. METHODS: We prospectively enrolled 144 patients who were presented with isolated vertigo to the ED. A detailed neurological examination and maneuvers were performed for differential diagnosis. All patients underwent CT and/or DW-MRI either during ED visit or at the follow-up, if necessary. Out-patient follow-up exams and evaluations were repeated until all patients had a definitive diagnosis. RESULTS: In the study, 137 of the 144 patients completed the follow-up period, and 34 of 137 patients were diagnosed with central vertigo. Six of 34 central vertigo patients had normal DW-MRI findings. One was diagnosed with migraine headache and five with vertebra-basilar insufficiency during the out-patient follow-up. One of the 28 patients with a pathological MRI was diagnosed with mass and the rest was stroke. The utility of DW-MRI in vertigo patients was moderately high (sensitivity: 82%, specificity: 100%). We found that age, history of HT, history of CAD and vertigo unresponsive to ED treatment were significantly associated with a central cause of vertigo. CONCLUSION: We suggest that unresponsiveness to ED treatment, especially in patients with a history of HT and CAD, should alert physicians for central causes and warrant DW-MRI imaging.

Assessment of intra-interobserver reliability of the sonographic optic nerve sheath diameter measurement.

Diagnosis and measuring the level of increase in intracranial pressure (ICP) is critical, especially for the management of trauma patients in the emergency department and intensive care unit. However, measurements are operator-dependent as in all of the sonographic diagnoses. The aim of this study is to assess the operator variations in the measurement of optic nerve sheath diameter (ONSD). There were four emergency medicine specialists involved in the study. Each had at least 1 year of experience of ultrasound scans and performed at least 25 prior ocular scans examining the ONSD. Two measurements were made 1 week apart from both axial and longitudinal planes. Sixty healthy adults were involved in the study and every investigator obtained four measurements from each. Intra-interobserver reliabilities were tested. The investigators performed 60 ocular ultrasounds on individual healthy adults and obtained two measurements in axial and longitudinal planes 1 week apart. Therefore, 960 measurements were analyzed. The levels of compatibilities for most of the measurements were found at acceptable levels statistically. However, it is not possible to say that there was a perfect compatibility among the sonographers according to the previously conducted reliability studies of ultrasound measurements. According to our results, it is hard to say that sonographic measurement of the ONSD is a highly reliable method both in longitudinal and transverse planes.

Wellens' Syndrome - Report of two cases.

Wellens' Syndrome is a pattern of electrocardiographic T-wave changes associated with critical, proximal left anterior descending (LAD) artery stenosis. Diagnostic criteria of Wellens' Syndrome are history of chest pain, little or no cardiac enzyme elevation, little or no ST-segment elevation, no loss of precordial R waves, no pathologic precordial Q waves and typical T-wave changes. Urgent cardiac catheterization is vital to prevent myocardial necrosis. Here we are presenting two cases with Wellens' Syndrome who had been sent for catheterization before marked myocardial infarction developed. The first case was 63 years old woman admitted to emergency room with a typical chest pain lasting for 7 h. Electrocardiography (ECG) revealed characteristic Type A Wellens' Syndrome. The second case was also a 64 years old female patient. She was admitted to emergency room with a chest pain lasting for 2 days. Type B Wellens' Syndrome was considered according to ECG and clinical findings. Emergency angiography revealed critical LAD occlusions which were resolved before marked MI occurred in both of the cases. It is important for the emergency physicians, to recognize the typical ECG findings of Wellens' Syndrome, because these characteristic ECG findings are considered as a marker for critical LAD occlusions.