How Should We Approach Syncope in the Emergency Department? Current Perspectives.

Syncope is a clinical picture that can affect all age groups and has an important place in admissions to the emergency department. There is an important diagnostic challenge in cases where there are different clinical presentations and patients cannot express the situation clearly. Although the emergency department facilities for the diagnosis of syncope are limited, the diagnosis of many patients can be differentiated from life-threatening conditions with a detailed history and physical examination. High-risk patients should be identified and directed for definitive treatment by emergency medicine physicians. This review contains information about the management of the syncope patient in the emergency department.

Vaccine-Induced Myocarditis in Two Intern Doctors in the Same Night Shift.

The coronavirus disease 2019 (COVID-19) pandemic has affected millions of people around the globe and vaccines against the disease have started to develop. Side effects of the vaccine have been reported in the literature, including myocarditis, which has a very low incidence and with a good prognosis. This case report aims to present two medical students' vaccine-induced myocarditis cases after the first doses of BNT162b2.These patients were young males with no previous medical history and both of them had good recovery after the disease. Both of them had their vaccine very recently before the event. These cases show that myocarditis can be seen after the first dose as well.Global vaccination is the most effective prevention method against COVID-19. Considering the fact that morbidities after the disease occur more than the side effects of the vaccine, they are still the best option against the current pandemic.

Evaluation of the Relationship between Occupational Accidents and Obstructive Sleep Apnea Risk among Employees of a University Hospital.

Context: Occupational accidents are still one of the important causes of morbidity and mortality. Sleep apnea is a significant risk factor for occupational accidents in hospitals. Aims: To determine the frequency of occupational accidents and their relationship with the risk of obstructive sleep apnea (OSAS). Settings and Design: Cross-sectional study in a hospital setting. Methods and Material: This study was conducted on 331 hospital workers between 2019-2020. Accidents from the Social Security Institution records were used. The risk of OSAS was evaluated with Berlin Survey, daytime sleepiness with Epworth Sleepiness Scale, sleep quality with Pittsburg Sleep Quality Scale. Statistical Analysis: The Chi-square test was used for analysis; P < 0.05 was accepted as a statistical significance value. Results: Of the participants, 231 (69.8%) were female. Their ages ranged between 19 and 55; the mean age was 33.8 ± 8.0 years. The frequency of occupational accidents was 8.8%, 51.4% had a high risk of OSAS, 80.4% had high daytime sleepiness, and 53.5% had poor sleep quality. Conclusion: The study group had a high risk of sleep disorders. No relationship was found between sleep disorders and occupational accidents. More comprehensive studies are needed to clarify this relationship.

Outcomes of Cardiopulmonary Resuscitation of Oncologic Patients in Emergency Department.

OBJECTIVE: To evaluate the outcomes of cardiopulmonary resuscitation (CPR) of oncological cases versus non-oncological admitted to the emergency department as out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Emergency Department (ED) of Eskisehir Osmangazi University Hospital, between January 2014 to January 2020. METHODOLOGY: Victims over the age of 18 years who had OHCA and IHCA were inducted. The outcomes of 109 patients with an oncological diagnosis and 109 controls without cancer underwent CPR and were compared. RESULTS: The median age of the participants was 65 (58-76) years. Patients with an oncological diagnosis were more likely to have an IHCA [OR: 2.98 (95% CI: 1.68-5.30), p <0.001]. The IHCA and OHCA rates of patients without an oncological diagnosis were similar. Solid-organ malignancies were observed in 102 patients (93.6%). The initial rhythm of 88 patients (80.7%) in the oncological arrest group was asystole versus 77 patients (70.6%) in the control group. Pulseless electrical activity was observed in 17 patients (15.6%) in the study group and in 24 patients (22.0%) in the control group. Although the non-oncological group was found to have a longer stay. No statistically significant difference was found between the study and control groups regarding duration of stay in the intensive care unit. Only one patient (2.0%) with cancer was discharged in stable state as against 10 (21.3%) of non-oncological arrests [OR: 12.97 (95% CI: 1.59-105.93), p = 0.008]. CONCLUSION: The presence of cancer is not a favourable prognostic factor for the success of CPR. KEY WORDS: Oncology, Cardiac arrest, IHCA, OHCA, Emergency department.

The diagnostic value of laboratory tests in detecting solid organ injuries in pediatric patients with blunt abdominal trauma.

BACKGROUND: Computed tomography of the abdomen (CT) is used as the gold standard for detecting solid organ injuries (SOI) after blunt abdominal trauma (BAT). However, patient selection for CT is still controversial due to its potential risks. In this study, we aimed to investigate the usefulness of laboratory tests in the detection or exclusion of SOI in pediatric patients evaluated in the emergency department due to BAT. METHODS: The study was planned as a prospective, observational study and was conducted in the emergency department of a university hospital between February 2018 and February 2019. Patients under the age of 18 who were evaluated for BAT in the emergency department were included in the study. In the study, the diagnostic value of abnormal laboratory tests in detecting SOI was calculated by accepting CT results as the gold standard. RESULTS: Of the 323 patients included in the study, 118 (36%) were male. There were 283 patients who underwent CT. SOI was detected in 18 (6%) patients. Abnormal alanine aminotransferase, aspartate aminotransferase, amylase and lipase tests were found to be statistically significant in predicting SOI (p < 0.05). However, none of the tests were found to have sufficient sensitivity and specificity. Hemoglobin, hematocrit, lactate and base excess values were not found to be statistically significant in predicting SOI (p > 0.005). CONCLUSIONS: The hematologic laboratory tests are insufficient to rule out solid organ injury in pediatric patient with BAT.

The evaluation of intracranial pressure evaluation by optic nerve sheath diameter measurement on bedside ultrasonography after ischemic stroke.

INTRODUCTION: We aimed to predict intracranial pressure(ICP)after cerebral ischemic stroke by measuring diameter of the optic nerve sheath(ONSD)with bedside ultrasonography(US). In order to see the ICP changes,it was planned to record delta ICP changes at the 3rd and 5th day follow-up of the patients METHOTS: Patients aged 18 years or older who were admitted to the emergency department(ED)with stroke symptoms for one year were included.Demographic data,time elapsed since the onset of symptoms,neurogical status assesment scales,ONSD values measured by US in three time periods(the day the patient was admitted to the ED,the 3rd and 5th days of hospitalization),MDCT findings when the patient was admitted,ONSD values in MDCT,whether they received tissue plasminogen activator(tPA)and whether they underwent decompression surgery were recorded. RESULTS: The average age of the 82 patients was 67.5(range 33-89)years.Forty-two patients(51.2%)were male.On both the right and left sides,ONSD on the 3rd day was larger(>5 mm)than on first day(p < 0.05). ONSD on the 5th day was larger than on the first day(p > 0.05). All ONSD results measured using both US and MDCT showed a positive correlation between the same eye and contralateral eye measurements(p < 0.05). DISCUSSION: CT is the most critical radiological method for stroke patients.Transport to radyology unit in unstable patients carries risk and is not recommended.Optic nerve US can be used in the early diagnosis of ICP increase and provides early treatment.The ease of use and safety in unstable patients have increased its popularity. CONCLUSION: We believe that measuring ONSD using US is an appropriate choice on ICP management in stroke patients.

Diagnostic Value of Hounsfield Unit and Hematocrit Levels in Cerebral Vein Thrombosis in the Emergency Department.

BACKGROUND: Unenhanced computed tomography (CT) is a frequently used imaging method in patients who are evaluated in the emergency department with suspected cerebral vein thrombosis (CVT). OBJECTIVES: The aim of this study was to investigate the usefulness of the Hounsfield unit (HU) value determined by CT and its ratio to the patient's hematocrit (Htc) value in the diagnosis of cerebral vein thrombosis. METHODS: This retrospective study evaluated 41 patients with acute cerebral venous sinus thrombosis and 41 age- and sex-matched control participants. Two experienced observers independently evaluated the CT scan and measured the attenuation of the dural sinuses. RESULTS: There was no significant difference in age, gender, hemoglobin, and Htc values between the two groups. The mean HU value was 75 ± 7 HU in the CVT group and 52 ± 6 HU in the control group (p < 0.001). The mean HU/Htc ratio was 1.9 ± 0.3 in the CVT group and 1.3 ± 0.1 in the control group (p < 0.001). The optimal threshold value for HU was determined as 66, and sensitivity at this value was 93%, and specificity was 98%. The optimal threshold value for HU/Htc was determined as 1.64, and the sensitivity at this value was 90% and the specificity was 100%. CONCLUSION: Hyperattenuation in the dural sinuses and the HU/Htc ratio in unenhanced brain CT scans have high diagnostic value in detecting CVT.

Computed Tomographic Findings of Injuries After Mechanical and Manual Resuscitation: A Retrospective Study.

Introduction Cardiopulmonary resuscitation (CPR)-related injuries are complications of chest compressions during CPR. This study aimed to investigate the differences and complications between mechanical and manual CPR techniques by using computed tomography (CT). Methods Patients in whom return of spontaneous circulation was achieved after CPR and thorax CT imaging were performed for diagnostic purposes were included in the study. Results A total of 178 non-traumatic cardiac arrest patients were successfully resuscitated and had CT scans in the emergency department. The complications of CPR are sternum fracture, rib fracture, pleural effusion/hemothorax, and pneumothorax. There were no statistically significant differences in terms of age, first complaint, cardiac arrest rhythm, CPR duration, and complications between mechanical and manual CPR. The number of exitus in the emergency department was similar (p=0.638). The discharge from hospital rate was higher in the mechanical CPR group but there was no statistically significant difference (p=0.196). The duration of CPR was associated with the number of rib fractures and lung contusion, but it did not affect other CPR-related chest injuries. Conclusion There was no significant difference observed in terms of increased complications in patients who received mechanical compression as compared with those who received manual compression. According to our results, mechanical compression does not cause serious complications, and the discharge from hospital rate was higher than for manual CPR; therefore, its use should be encouraged.

Therapeutic Dilemmas Regarding Anticoagulation, Pulmonary Embolism, and Diffuse Alveolar Hemorrhage Due to Behçet's Disease.

The use of anticoagulants is still a matter of debate in deep venous thrombosis (DVT) and other thrombotic events in Behcet's disease (BD). Anticoagulant therapy is an integral part of treatment in cases of a pulmonary embolism (PE) that develops in other disorders. The issue of how to act when a pulmonary artery thrombosis is reported in the Behçet's patient may pose a major dilemma among emergency physicians. A 61-year-old male came to our ED with a complaint of chest pain and hemoptysis. The patient had tachypnea, dyspnea, tachycardia, a decrease of breath sounds in the basal regions of both lungs, and a few crackling rales were heard in the left lung field. Chest CT angiography showed pulmonary thromboembolism in the right middle and lower lobe segment arteries with pulmonary infarction as well as ground glass densities compatible with alveolar hemorrhage. High-dose steroid and cyclophosphamide were administered immediately without anticoagulant therapy based on pulmonary vasculitis and de novo clot formation in the pulmonary circulation. Clinical improvement was observed after four days of admission. The patient remained under observation with oral prednisolone and cyclophosphamide monthly. PE is almost non-existent in patients with BD, and signs of pulmonary artery thrombosis are associated with pulmonary vasculitis. Delaying immunosuppressive therapy may result in unwanted results in these kinds of patients. This case underlines the importance of recognizing this manifestation early to prevent potentially fatal consequences.

The Flatness Index of Inferior Vena Cava can be an Accurate Predictor for Hypovolemia in Multi-Trauma Patients.

INTRODUCTION: Shock is the leading cause of death in multi-trauma patients and must be detected at an early stage to improve prognosis. Many parameters are used to predict clinical condition and outcome in trauma. Computed tomography (CT) signs of hypovolemic shock in trauma patients are not clear yet, requiring further research. The flatness index of inferior vena cava (IVC) is a helpful method for this purpose. METHODS: This is a prospective, cross-sectional study which included adult multi-trauma patients (>18 years) who were admitted to the emergency department (ED) and underwent a thoraco-abdominal CT from 2017 through 2018. The main objective of this study was to investigate whether the flatness index of IVC can be used to determine the hypovolemic shock at an early stage in multi-trauma patients, and to establish its relations with shock parameters. The patients' demographic features, trauma mechanisms, vitals, laboratory values, shock parameters, and clinical outcome within 24 hours of admission were recorded. RESULTS: Total of 327 (229 males with an average age of 40.9 [SD = 7.93]) patients were included in the study. There was no significant difference in the flatness index of IVC within genders (P = .134) and trauma mechanisms (P = .701); however, the flatness index of IVC was significantly higher in hypotensive (systolic blood pressure [SBP] ≤90 mmHg and/or diastolic blood pressure [DBP] ≤60 mmHg; P = .015 and P = .019), tachycardic (P = .049), and hypoxic (SpO2 ≤%94; P <.001) patients. The flatness index of IVC was also higher in patients with lactate ≥ 2mmol/l (P = .043) and patients with Class III hemorrhage (P = .003). A positive correlation was determined between lactate level and the flatness index of IVC; a negative correlation was found between Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) with the flatness index of IVC (for each of them, P <.05). CONCLUSION: The flatness index of IVC may be a useful method to determine the hypovolemic shock at an early stage in multi-trauma patients.

Hemodynamic Instability in Emergency Department: Giant Rectus Sheath Hematoma and Point-of-Care Ultrasonography.

Iatrogenic rectus sheath hematoma (RSH) developed after paracentesis is a rare but life-threatening complication. Mortality rates of patients may increase due to delays in treatment and comorbid conditions. In this article, we present the case of a patient who was unstable in the emergency department and was diagnosed with RSH using point-of-care ultrasonography (POCUS). The importance of POCUS has increased as hematoma manifestations of patients with severe ascites tend to be obscured. POCUS has varied uses in the emergency department, and in this article we emphasize the use of POCUS in a life-threatening case of RSH.

A Cross-Sectional Study: Patient Privacy According to Doctors and Nurses.

Confidentiality is fundamental in building trust between patients and healthcare professionals. This research aims at presenting healthcare professionals' opinions on patient privacy, using a 5-point Likert-type scale titled "Opinion of the Healthcare Professionals on Patient Privacy," and 262 physicians' and 231 nurses' opinions were evaluated. Results showed that nurses and doctors working at emergency services got higher mean scores than those working at other units. Results revealed that doctors had the highest mean score for the item "It is important that the patient's body is not seen by other patients and professionals during the treatment," while nurses had the highest mean score for the item "I approach with due care to protect privacy in the work environment." Results of this work highlight that patient's right to privacy constitutes one of the most significant issues to be noted by healthcare professionals.

Comparison of Endotracheal Intubation Skills With Video Laryngoscopy and Direct Laryngoscopy in Providing Airway Patency in a Moving Ambulance.

BACKGROUND: Early and successful management of the airway in the prehospital and hospital settings is critical in life-threatening situations. OBJECTIVE: We aimed to perform endotracheal intubation (ETI) by direct laryngoscopy (DL) and video laryngoscopy (VL) on airway manikins on a moving track and to compare the properties of intubation attempts. METHODS: Overall, 79 participants with no previous VL experience were given 4 h of ETI training with DL and VL using a standard airway manikin. ETI skill was tested inside a moving ambulance. The number of attempts until successful ETI, ETI attempt times, time needed to see the vocal cords, and the degree of convenience of both ETI methods were recorded. RESULTS: Overall, 22 of 79 individuals were men; mean age was 30.3 ± 4.5 years. No difference was found in the comparison of the two methods (p = 0.708). Time needed to see the vocal cords for those who were successful in their first attempt were between 1 and 8 s in both methods. In the VL method, time needed to see the vocal cords (p = 0.001) and the intubation time (p < 0.001) in the first attempt were shorter than in the DL method. The VL method was easier (p < 0.001). The success rate was 97.5% in DL and 93.7% in VL. CONCLUSIONS: The VL method is rapid and easier to see the vocal cords and perform successful ETI. Therefore, it might be preferred in out-of-hospital ETI applications.