Predictive Value of Modified Early Warning Scoring System for Identifying Critical Patients with Malignancy in Emergency Department.

BACKGROUND: Identification of critically ill patient is particularly important in the emergency department (ED). The prolonged duration from hospital admission to delivering intensive care service is related to increased mortality. The aim of this study is to evaluate the effectiveness of Modified Early Warning Score (MEWS) for identifying critical patients with malignancy in ED settings. METHODS: We evaluated patients with malignancy who were admitted to our ED of a tertiary university hospital in Turkey over a three-month period. We evaluated MEWS on admission as MEWS 1. After the initial treatment depending on the patients' health status in ED, at 2 hours after admission, we evaluated MEWS again and recorded as MEWS 2. All patients were followed up for 30 days after the initial admission. RESULTS: Mean age (SD) was 59.2 (13.5) and male/female ratio was 295/206. MEWS1 was higher than MEWS2, (MEWS1: 3.05 ± 3.31, MEWS2: 2.35 ± 3.17, P < 0.001). A total of 362 patients (72.3%) survived and 139 (27.7%) died within 30 days of initial admission. MEWS1/MEWS2 values for alive and dead patients were 1.66/0.87, and 6.67/6.21, respectively, and the difference was significant (P < 0.001). ROC analysis was performed for MEWS 1; the area under curve (AUC) for hospitalization was 0.768 (95% CI 0.729 to 0.804) and for mortality was 0.900 (95% CI 0.870 to 0.924). ROC analysis revealed a cut-off value of 2 for predicting both hospitalization and mortality in these patients. The sensitivity of the presented cut-off was 77.32% (72.1%-82.0%) for hospitalization and 76.24% (95% CI 71.5-80.5) for mortality; the specificity was 69.52 (95% CI 62.8-75.7) for hospitalization and 90.65 (95% CI 84.65-94.9) for mortality. CONCLUSION: We found in our study that MEWS evaluation for patients with malignancy on admission to ED is predictive of mortality in the subsequent 30 days, and it is a valuable tool for identifying the critical group. Also, AVPU scores alone can predict mortality in patients admitted to ED.

Comparison of Fatal Injuries Resulting from Tractor and High Speed Motorcycle Accidents in Turkey: A Multicenter Study.

AIM: Injuries are among the main causes of mortality and morbidity all over the world, and effective initial triage of these patients can determine the thin line between death and life. Tractor accidents and related injuries are significant problems particularly in rural areas. However, major trauma classification systems do not include tractor accidents as a criterion for trauma team activation or transportation of the patients to a trauma center. This study evaluated the general characteristics and outcomes of tractor accidents in comparison to motorcycle accidents, which are considered as a comparison criterion for major trauma. MATERIALS AND METHODS: This is a multicenter study conducted in 6 emergency departments in 4 cities over a six month period. All cases over 18 years of age who were admitted to emergency service due to tractor or motorcycle accidents and meet the criteria were included in the study. The general characteristics and outcomes of both trauma types were compared to determine whether tractor accident should be considered as major traumas. RESULTS: Eighty-eight patients had a tractor accident, and 339 patients had a motorcycle accident. The tractor accident victims were significantly younger (p<0.001), and the proportion of females was higher in this group (p=0.001). Glasgow coma score (p=0.062), revised trauma score (p=0.201), duration from incident to admission (p=0.481), and route of admission (p=0.810) were similar between both accident types. The rates of thoracic traumas (42% versus 23%, p<0.001) and spinal injuries (17% versus 5.9%, p=0.002) were significantly higher in tractor accidents. The hospitalization rates of the patients were significantly higher in tractor accidents (p=0.008). CONCLUSION: The findings of this study support the hypothesis that tractor accidents should be included in the criteria of ATLS major trauma classification system and trauma team activation procedures.

Discharge of emergency patients to the clinical wards or intensive care units: An assessment of complications and possible shortcomings.

OBJECTIVE: We aimed to evaluate the most common complications and possible shortcomings in the emergency patients who were admitted to the clinical wards or intensive care units. MATERIALS AND METHODS: 1000 patients were included in this study. The patients's complication rates were compared with the clinical diagnosis, age groups, the section of the emergency department initially managed the patients, the time of the shift (daytime or night), the accompanying medical staff and specific type of patient populations. Also the interventions of the complications were recorded. RESULTS: 37.5% of the patients who were included in the study were female and 62.5% were male. The median age of the patients was 54.2 year (min:1 max:92). The vital signs that were recorded prior to transport of the patients did not interfere with the complication rates (p>0.05). Complication rates in the night were found to be higher as more admissions took place during the night shift (p<0.05). The complication rates were found higher in patients who were admitted to coronary care unit. The most frequent complication was the dislocation of the intravenous catheter. Replacing the dislocated intravenous catheter was the most frequently noted intervention. However, initiating inotropic agents to the hypotensive patients was done more frequently in the admitted clinical departments. CONCLUSION: The overall complication rate was low in this series of patients. The majority of them can be prevented by having in house guidelines.

Acute temporal lobe infarction in a young patient associated with marijuana abuse: An unusual cause of stroke.

BACKGROUND: Cardiovascular or cerebrovascular events associated with drug abuse have been frequently reported, particularly in young patients. The drugs include generally cocaine, heroin, and amphetamines. Although marijuana is among the widely used narcotics in the world, stroke associated with the marijuana use is infrequently reported. METHODS: Stroke caused by the use of marijuana was investigated in a 23-year-old man and the importance of inquiry of drug abuse in case of stroke was emphasized. RESULTS: The patient was treated for 7 days in a follow-up, but he was not recovered. The patient was discharged in his existing condition and was directed for physiotherapy and rehabilitation. CONCLUSION: Ischemic stroke is associated with drug abuse and/or substance use, mainly cannabinoids and amphetamines, particularly in young patients.

Value of the Glasgow coma scale, age, and arterial blood pressure score for predicting the mortality of major trauma patients presenting to the emergency department.

BACKGROUND: The purpose of this study is to detect the mortality predictive power of new Glasgow coma scale, age, and arterial pressure (GAP) scoring system in major trauma patients admitted to the emergency department (ED). METHODS: A total of 100 major trauma patients admitted to Uludag University Faculty of Medicine ED who were 18 years of age or more were included in the study. In this prospective study, revised trauma score (RTS), injury severity score (ISS), trauma-related ISS (TRISS), Mechanism, GAP (MGAP) and GAP scores of the patients were calculated. RESULTS: A significant positive correlation was established between ISS, TRISS, MGAP, and GAP in predicting in-hospital mortality (p<0.0001). Short-term (24 hours) and long-term (4-week) mortality prediction rates and area under the curve in receiver operating characteristics analysis were 0.727-0.680 for RTS, 0.863-0.816 for ISS, 0.945-0,911 for TRISS, 0.970-0.938 for MGAP, and 0.910-0.904 for GAP. All calculated trauma scoring systems revealed a significant mortality prediction power (p<0.001). GAP score was found statistically and significantly selective and sensitive in predicting both in-ED and in-hospital mortality (p=0.0001). CONCLUSION: In major trauma patients, GAP score is an easily calculable system both in the field and at the time of admission in the EDs by providing emergency physicians with future decision-making schemes by means of mortality prediction of the patients.

Analysis of appropriate tetanus prophylaxis in an Emergency Department.

BACKGROUND: In this study, our aim was to identify the validity of the prophylaxis indications for patients who received tetanus prophylaxis, determine the ratio of high-risk wounds to the number of patients with immunity, and to evaluate the tetanus immunity of specific age groups. METHODS: Patients who applied to the Emergency Department (ED) between September 2009 and May 2010 and who were considered for tetanus prophylaxis by his/her primary care physician were included in the study. RESULTS: A total of 320 patients were evaluated. The average age of the patients was 40.87 ± 15.83 years. A total of 73.1% of the patients were male and 26.8% were female. A total of 40.3% of the patients knew their vaccination history, while 59.7% had no recollection of their vaccination history. 14.7% of the patients had received their last dose within 5 years and 48.1% within 5-10 years; 37.2% of the patients declared that more 10 years had passed since their last vaccination. In 75% of the patients, the tetanus immunoglobulin (Ig)G level was identified as >=0.1 IU/ml, while 25% of the patients had levels <0.1 IU/ml. The number of patients with protective levels was lower among those who were illiterate or who had only a primary school education, and this difference was statistically significant (p<0.001). CONCLUSION: The vaccination histories can be misleading. Certain equipment can be used at the bedside to determine a patient's tetanus immunization status.

Conditions that mimic stroke in elderly patients admitted to the emergency department.

BACKGROUND: Stroke is the most common neurologic cause for patient admission to the emergency department (ED) and the risk of stroke increases with age. This study aimed to determine the clinical and demographical characteristics of stroke-mimicking patients 65 years or older who were admitted to the ED for stroke. METHODS: After the retrospective file examination, patients 65 years and older who were admitted to the ED with an established final diagnosis of stroke as a result of history, physical examination, imaging, and required consultations were included in the study. RESULTS: After scanning 671 records of patients 65 years or older, 87.3% (n=586) were diagnosed with stroke and 12.7% (n=85) received different diagnoses mimicking stroke. Of these 85 patients, 91.8% (n=78) and 8.2% (n=7) were prediagnosed with ischemic stroke and transient ischemic attack, respectively, by the ED physicians. After complete evaluations and consultations, the patients with stroke were typically diagnosed with vertebrobasilar insufficiency (n=16, 18.8%). Of the patients, 76.5% (n=65) were discharged after treatment and follow-up in the ED, and 21.1% (n=18) were hospitalized. CONCLUSIONS: In older patients, stroke-mimicking conditions can cause signs and symptoms indistinguishable from true stroke, representing about 12.7% of elderly patients admitted to an ED with these diagnoses.

General characteristics of patients with electrolyte imbalance admitted to emergency department.

BACKGROUND: Fluid and electrolyte balance is a key concept to understand for maintaining homeostasis, and for a successful treatment of many metabolic disorders. There are various regulating mechanisms for the equilibrium of electrolytes in organisms. Disorders of these mechanisms result in electrolyte imbalances that may be life-threatening clinical conditions. In this study we defined the electrolyte imbalance characteristics of patients admitted to our emergency department. METHODS: This study was conducted in the Emergency Department (ED) of Uludag University Faculty of Medicine, and included 996 patients over 18 years of age. All patients had electrolyte imbalance, with various etiologies other than traumatic origin. Demographic and clinical parameters were collected after obtaining informed consent from the patients. The ethical committee of the university approved this study. RESULTS: The mean age of the patients was 59.28±16.79, and 55% of the patients were male. The common symptoms of the patients were dyspnea (14.7%), fever (13.7%), and systemic deterioration (11.9%); but the most and least frequent electrolyte imbalances were hyponatremia and hypermagnesemia, respectively. Most frequent findings in physical examination were confusion (14%), edema (10%) and rales (9%); and most frequent pathological findings in ECG were tachycardia in 24%, and atrial fibrillation in 7% of the patients. Most frequent comorbidity was malignancy (39%). Most frequent diagnoses in the patients were sepsis (11%), pneumonia (9%), and acute renal failure (7%). CONCLUSIONS: Electrolyte imbalances are of particular importance in the treatment of ED patients. Therefore, ED physicians must be acknowledged of their fluid-electrolyte balance dynamics and general characteristics.

Is routine pregnancy test necessary in women of reproductive age admitted to the emergency department?

BACKGROUND: This study aimed to determine the necessity of pregnancy test in women of reproductive age admitted to emergency department (ED) in routine practice. METHODS: We retrospectively reviewed the records of patients who presented to the ED between January 1, 2006 and December 31, 2010 and received a pregnancy test. RESULTS: The median age of 1 586 patients enrolled into the study was 27 years. Of these patients, 19.55% had a positive result of pregnancy test. The most common complaint at admission was abdominal pain in 60.15% of the patients, and pregnancy test was prescribed. 15.83% of the patients with abdominal pain had a positive result of pregnancy test. Of the patients, 30.64% had nausea-vomiting at admission, and 11.52% had a positive result of pregnancy test. When other complaints were considered, the most commonly observed complaints were non-specific symptoms such as dizziness, malaise and respiratory problems. Of the patients, 70.93% were not remembering the date of last menstruation, and 9.51% showed a positive result of pregnancy test. Urinary tract infection (UTI) was commonly diagnosed with an incidence of 17.65%, which was followed by non-specific abdominal pain (NSAP) (16.77%) and gastrointestinal disorders such as gastritis and peptic ulcer (6.87%). Of the patients, 88.40% were discharged from ED, and 11.60% were hospitalized. CONCLUSION: Pregnancy test should be given to women of reproductive age as a routine practice in ED in developing countries like Turkey.

General characteristics of patients with electrolyte imbalance admitted to emergency department / 世界急诊医学杂志（英文）

@#BACKGROUND: Fluid and electrolyte balance is a key concept to understand for maintaining homeostasis, and for a successful treatment of many metabolic disorders. There are various regulating mechanisms for the equilibrium of electrolytes in organisms. Disorders of these mechanisms result in electrolyte imbalances that may be life-threatening clinical conditions. In this study we defined the electrolyte imbalance characteristics of patients admitted to our emergency department. METHODS: This study was conducted in the Emergency Department (ED) of Uludag University Faculty of Medicine, and included 996 patients over 18 years of age. All patients had electrolyte imbalance, with various etiologies other than traumatic origin. Demographic and clinical parameters were collected after obtaining informed consent from the patients. The ethical committee of the university approved this study. RESULTS: The mean age of the patients was 59.28±16.79, and 55% of the patients were male. The common symptoms of the patients were dyspnea (14.7%), fever (13.7%), and systemic deterioration (11.9%); but the most and least frequent electrolyte imbalances were hyponatremia and hypermagnesemia, respectively. Most frequent findings in physical examination were confusion (14%), edema (10%) and rales (9%); and most frequent pathological findings in ECG were tachycardia in 24%, and atrial fibrillation in 7% of the patients. Most frequent comorbidity was malignancy (39%). Most frequent diagnoses in the patients were sepsis (11%), pneumonia (9%), and acute renal failure (7%). CONCLUSIONS: Electrolyte imbalances are of particular importance in the treatment of ED patients. Therefore, ED physicians must be acknowledged of their fluid-electrolyte balance dynamics and general characteristics.

Prospective validation of the Glasgow Blatchford scoring system in patients with upper gastrointestinal bleeding in the emergency department.

BACKGROUND/AIMS: This study aimed to allow decision-making about hospitalization or discharge using the Glasgow Blatchford Scoring system, a risk analysis performed using basic laboratory and clinical variables, in patients presenting to the Emergency Department with upper gastrointestinal system bleeding. MATERIALS AND METHODS: This prospective, observational study conducted in the Emergency Department of a university hospital enrolled patients aged ≥18 years, who presented to the Emergency Department with upper gastrointestinal system bleeding between June 2009 and December 2010. For all patients, Glasgow Blatchford Scoring scores were calculated, and the patients were classified into two groups as high-risk and low-risk patients. RESULTS: A total of 160 subjects with upper gastrointestinal system bleeding were enrolled in the study. Mean Glasgow Blatchford Scoring scores were 7.1 ± 3.8 for 71 low-risk subjects and 11.7 ± 2.9 for 89 high-risk subjects, and the difference between the two groups was statistically significant (p<0.001). When the performance of the Glasgow Blatchford Scoring system was evaluated in the determination of high risk, the sensitivity and specificity were 100% and 1.41%, respectively, for a cut-off value of Glasgow Blatchford Scoring >0, 100% and 16.9% for a cut-off value of Glasgow Blatchford Scoring >3, 96.63% and 36.62% for a cut-off value of Glasgow Blatchford Scoring >5, and 86.52% and 69.01% for a cut-off value of Glasgow Blatchford Scoring >8. In the receiver operating characteristic curve analysis, for Glasgow Blatchford Scoring in the high-risk estimation, the area under the curve was found to be 0.82 (95% CI: 0.75-0.88), and this value was statistically significant (p=0.0001). CONCLUSIONS: The Glasgow Blatchford Scoring system, which may be easily calculated based on laboratory and clinical variables, seems to be a useful scoring system for risk analysis of all patients with upper gastrointestinal system bleeding admitted to the Emergency Department.

Predictive value of the modified Early Warning Score in a Turkish emergency department.

OBJECTIVE: The modified Early Warning Score (mEWS) is a triage instrument that promises to predict patient disposition and clinical outcome in emergency departments (EDs). We investigated whether mEWS can predict death, hospital admission, intensive care unit (ICU) admission, and in-hospital deaths in a Turkish setting. METHODS: We conducted an ED-based prospective study of 309 patients who presented to an academic medical center. The mEWS was recorded in all patients on ED admission. A mEWS >4 was used to define patients at high-risk for the study outcomes. RESULTS: Patients categorized as being at high-risk either were admitted to ICU (n=23) or to hospital (n=37) 56.6% of the time, or died in ED (n=16) or in hospital (n=29) 42.4% of the time. Patients categorized as being at low-risk either were admitted to ICU (n=25) or to hospital (n=52) 37.4% of the time, or died in ED (n=1) or in hospital (n=4) 2.5% of the time. In multivariate regression analysis, patients with a mEWS of 5 or more were 1.95 times more likely to be admitted to ICU than those with a score less than 5. Patients with high-risk mEWS were 35 times more likely to die in ED and 14 times more likely to die in hospital than those presenting with a low-risk score. CONCLUSION: We conclude that scores on the mEWS predict ICU admission as well as ICU and in-hospital deaths.

Frequency of post-traumatic stress disorder among relief force workers after the tsunami in Asia: do rescuers become victims?

OBJECTIVE: The objective of this study was to evaluate the frequency of posttraumatic stress disorder (PTSD) among the participants of the Turkish Red Crescent Disaster Relief Team after the Tsunami in Asia. METHODS: The Clinician Administered PTSD Scale-1 (CAPS-1) was administered to 33 of 36 team members one month after their Disaster Relief Team duty. Along with the CAPS-1 interview, demographic features, profession, previous professional experience, previous experience with traumatic events and disasters also were recorded. To be classified as present, a symptom must have a frequency score of "1" and an intensity score of "2" at the CAPS-1 interview. For a diagnosis of PTSD, at least one re-experiencing, three avoidance and numbing, and two increased arousal symptoms should be present. RESULTS: The PTSD was diagnosed in eight of the 33 (24.2%) participants. No significant difference was detected in the distribution of PTSD diagnosis according to gender, age, profession, professional experience, previous disaster experience, and/or previous experience of traumatic events. However, the severity of PTSD symptoms as measured by the CAPS-1 score was significantly higher in women, nurses, and participants with <3 previous disaster duty experiences. CONCLUSION: Post-traumatic stress disorder is prevalent within disaster teams and healthcare workers, and measures should be taken to prevent PTSD within this group.

Intramuscular tramadol vs. diclofenac sodium for the treatment of acute migraine attacks in emergency department: a prospective, randomised, double-blind study.

The aim of this prospective, randomised, double-blind study was to evaluate the efficacy of intramuscular (IM) tramadol 100 mg in emergency department treatment of acute migraine attack and to compare it with that of IM diclofenac sodium 75 mg. Forty patients who were admitted to our emergency department with acute migraine attack according to the International Headache Society criteria were included in the study. Patients were randomised to receive either tramadol 100 mg (n=20) or diclofenac sodium 75 mg (n=20) intramuscularly. Patients rated their pain on a four-point verbal scale (0=none, 1=mild, 2=moderate, 3=severe) at the beginning of the trial and at 30, 60, 90 and 120 min. At each time interval, severity of associated symptoms were also questioned and recorded. Global evaluation of the drugs by patients and doctors were also recorded. Patients were also asked if they would prefer the same injection in future visits. Any adverse events, whether related to the drug or not, were also recorded. Patients were followed up by telephone 48 h later to check for any headache recurrence. Two-hour pain response rate, which was the primary endpoint, was 80% for both tramadol and diclofenac groups. There were no statistically significant differences among groups in terms of 48-h pain response, rescue treatment, associated symptoms' response, headache recurrence and adverse event rates. Fifteen (75%) patients in the tramadol group and 16 (80%) patients in the diclofenac group stated that they may prefer the same agent for future admissions. In selected patients, tramadol 100 mg IM may be an effective and reliable alternative treatment choice in acute migraine attacks.

Acute poisoning in adults in the years 1996-2001 treated in the Uludag University Hospital, Marmara Region, Turkey.

BACKGROUND: Acute poisonings are frequent causes of admission to emergency departments and these cases may have hazardous outcomes. METHODS: In the present study, medical records of 1818 poisoned patients admitted to Uludag University Medical School's Emergency Department between January 1996 and December 2001 were investigated. The age, sex, outcomes of the patients, and type of poisoning are described. RESULTS: . The mean age for females (63% of the patients) was 27 years, whilst the mean age of male patients was 31 years. The major types of poisonings were ingestions of medications (59.6%), mushrooms (3.3%), corrosives (2.5%), organophosphates (3.2%), and methyl alcohol (0.4%). Carbon monoxide accounted for 6.9% of intoxications. Approximately 65% of the patients survived, while the methyl alcohol and corrosive ingestions led to the highest fatality averages (100% and 14.8%, respectively). CONCLUSIONS: The demographic and diagnostic features of acute poisoning cases treated in our hospital are similar to those reported in the literature. Adults and women are in a high-risk group for acute poisonings and medicine poisoning, which is the most common type of poisoning.

Compliance with protocols in transferring emergency patients to a tertiary care centre.

STUDY OBJECTIVES: We evaluated compliance with standard patient transfer protocols in a pre- and post-interventional study among patients transferred from other hospitals to our tertiary care university hospital. METHODS: In the first phase, transfer information was recorded on the arrival in 174 consecutive patients transferred to our emergency department (ED) over a 2-month period in 1999. Emergency caregivers throughout the province then received education about proper transfer procedures. This training was provided through monthly citywide co-ordination and co-operation meetings among the physicians of the emergency medical services (EMS) and the emergency departments of the hospitals in the city and the nearby counties. Fifteen months after the beginning of these educational efforts, the second observational phase was implemented. Over a period of 2 months in early 2001, information was recorded from 180 consecutive patients transferred to our ED. Presence of patient medical records, laboratory results, and X-rays; clearly delineated reason for transfer; prior notification of transfer; and appropriate care during transport from the initial facility were the parameters compared in the pre- and post-intervention periods. RESULTS: Patients in phase-II were found to have had more appropriate care in some respects, such as presence of cervical collar and proper airway management, during transport from the initial facility than patients in phase-I (P < 0.05). However, other parameters were not significantly different between the two phases. CONCLUSION: We have concluded that our monthly meetings and conferences have made a positive impact on compliance with some of the standard transfer protocols. We must however, continue our efforts to increase compliance with other aspects of standard patient transfer guidelines.

[Traumatic aortic rupture: a case report]. / Travmatik aort yirtigi: olgu sunumu.

Aortic injuries can easily be missed in polytraumatized patients due to either associated injuries or vagueness of physical examination findings. Especially in young adults without associated injuries, relatively low atherosclerotic changes may limit the dissection of traumatic descending aortic injuries. We present a 34-year-old male patient who only had a complaint of back pain following a traffic accident. Upon detection of no abnormalities on plain X-ray films, he was discharged home with analgesics. One week later, he presented with dypsnea and dysphagia. Aortography showed rupture of the aorta and a pseudoaneurysm near the isthmus. Following surgical excision of the pseudoaneurysm and aortic repair with a Dacron graft interposition he was discharged with complete relief of symptoms. This case emphasizes the need for a high index of clinical suspicion in timely diagnosis and prompt treatment of traumatic aortic ruptures.

[Does the leukocyte count correlate with the severity of injury?]. / Kan lökosit degeri travmanin siddetini yansitir mi?

BACKGROUND: Injury severity score (ISS), Glasgow coma score (GCS), and revised trauma score (RTS) are the most frequently used methods to evaluate the severity of injury in blunt trauma patients. ISS is too complicated to assess easily and GCS and RTS are easy to assess but somewhat subjective. White blood cell count (WBC) is an easy, quick and objective test. This study was performed to evaluate the significance of the WBC count at presentation in the blunt trauma patients. METHODS: 713 blunt trauma patients, who were admitted to the Uludag University Medical Center Emergency Department between 01.04.2000-31.12.2000, were retrospectively evaluated in terms of ISS, GCS, RTS and white blood cell count at presentation. RESULTS: Statistical analysis revealed that WBC was correlated positively with ISS, but negatively with GCS and RTS. CONCLUSIONS: The leukocyte count at presentation can be used as an adjunct in the evaluation of the severity of injury in blunt trauma patients.