Tetanus immunity status among adult trauma patients in an ED.

OBJECTIVES: Tetanus is a vaccine-preventable infectious disease. It is caused by the bacterium Clostridium tetani. The aim of this study was to investigate tetanus immunity among adult trauma patients. MATERIAL AND METHODS: This study was performed with 267 trauma patients who were admitted to the emergency department of Tepecik Training and Research Hospital in Izmir City, Turkey over a six month period. After obtaining a written informed consent from each patient, a questionnaire concerning demographic information and tetanus vaccination history was filled in by the physician. Patients' blood samples (4-5 cc) were drawn into a test tube while creating an intravenous (IV) access prior to making any attempt for therapy. And the tetanus antibody level (IgG) was measured using the enzyme-linked immunosorbent assay method. Tetanus antibody levels ≥0.1 IU/mL were considered protective. RESULTS: Among 267 patients, 192 and 75 of the cases (71.9% and 28.1%) were male and female, respectively. The median age of the patients was 39 (IQRs = 28-52). Seventy-five percent of the patients (n = 201) had protective immunity rates for tetanus. DISCUSSION AND CONCLUSION: In our study, which was conducted among adults, it was found that the protective ratio of tetanus immunity decreased with age with an additional, significant decline in elderly patients.

The diagnostic and prognostic value of the optic nerve sheath diameter on CT for diagnosis spontaneous subarachnoid hemorrhage.

INTRODUCTION: The aim of this study was to investigate the relationship between the optic nerve sheath diameter (ONSD) measured on non-contrast head computed tomography (CT) and the diagnosis and prognosis of spontaneous subarachnoid hemorrhage (SAH) on emergency department (ED) patients. METHOD: We used a matched control group of patients with the same age and gender who were diagnosed in the ED with spontaneous SAH and who admitted to the ED with headache. Four emergency medicine attending physicians made the ONSD measurements. For measurements, the 3-mm posterior location where the optic nerve enters the eyeball was used. RESULTS: This study was done with 61 spontaneous SAHs with an equal number of control patients. The median ONSD for control and spontaneous SAH groups was 5.76 [interquartile range (IQR): 0.96] mm and 6.72 (IQR: 1.42) mm, respectively (p<0.001). The area under the receiver operating characteristic curve was determined as 0.791 (confidence interval 95% 0.710-0.872). At an ONSD threshold value of 6.1 mm, the sensitivity and specificity of SAH was 72%. There was no significant relationship between ONSD and in-hospital mortality in spontaneous SAH patients (p>0.05). The intra-class correlation coefficients for inter and intra-rater reliability were 0.84 and 0.95, respectively. CONCLUSION: In patients with spontaneous SAH, the ONSD measured in the orbital sections of a head CT is strongly correlated with a SAH diagnosis. Assessment of ONSD in head CTs taken with spontaneous SAH suspicion may contribute to the diagnoses of spontaneous SAH.

The diagnostic value of complete blood count parameters in patients with subarachnoid hemorrhage.

OBJECTIVES: Diagnosis of subarachnoid hemorrhage (SAH) in patients presenting with headache is challenging and there has been any biomarker studied for excluding of SAH in those patients. We aim to determine the sensitivity of leukocytosis or left shift to exclude the diagnosis of SAH in ED patients presenting with headache. METHOD: Adult patients with headache who received a computed tomography (CT) with the diagnosis of SAH and had a complete blood count (CBC) represent the case group, headache patients with normal CT and had a CBC represent the control group. The white blood cell (WBC) count and percentage of polymorphonuclear cells (PMNs%) taken during admission and within the first 6 and 12 h of admission were recorded. RESULTS: A hundred ninety seven patients with SAH and 197 patients without SAH were enrolled in to study. Sensitivity, specificity, NPV and PPV of leukocytosis or increase in PMNs% (left shift) in the diagnosis of SAH was 89.8% (84.5-93.5, 95% CI), 46.7% (39.6-53.9, 95% CI), 82.1% (73.5-88.4, 95% CI) and 62.8% (56.8-68.4, 95% CI) respectively on initial emergency department (ED) admission. CONCLUSION: CBC should be considered as a noninvasive test for the exclusion of SAH in ED patients with 6 h observation.

Asymptomatic traumatic common carotid artery dissection.

Common carotid artery (CCA) dissection is a rare emergency condition. Early diagnosis of these cases is important to prevent the ischemic emergencies. We presented a CCA dissection case, who was admitted to the hospital after taken out from under rubble with satisfactory outcome.

The accuracy of bedside ultrasonography as a diagnostic tool for fractures in the ankle and foot.

OBJECTIVES: Ultrasonography (US) has been shown to be helpful in diagnosing fractures in the emergency department (ED) setting. The aim of this study was to determine the diagnostic accuracy of US for fractures in patients presenting to the ED with foot and/or ankle sprain and positive Ottawa foot and ankle rules. METHODS: This was a prospective study of consecutive patients aged 18 years and over were admitted to the ED with acute foot and/or ankle sprain and positive Ottawa foot and ankle rules. After the patients by were examined by bedside US, anteroposterior and lateral ankle radiographs were obtained, as well as anteroposterior and oblique foot radiographs. The films were evaluated by an orthopedic surgeon who was blinded to the US examination results. The orthopedic surgeon's evaluation was considered the criterion standard for diagnosing a fracture. RESULTS: A total of 246 patients were included in the study. In 76 (30.9%) of the patients, a total of 79 fractures were detected by radiography. Ten false-negative and nine false-positive results were obtained by US examination. Only one patient, whose US showed a fracture but whose radiographs were normal, had a fracture detected by computed tomography (CT). The sensitivity and specificity of US scanning in detecting fractures were 87.3% (95% confidence interval [CI] = 77.5% to 93.4%) and 96.4% (95% CI = 93.1% to 98.2%), respectively. CONCLUSIONS: Ultrasound had good sensitivity and specificity for diagnosing fifth metatarsal, lateral, and medial malleolus fractures in the patients with foot and/or ankle sprain. However, sensitivity and specificity of US for navicular fractures were low.

Can venous blood gas analysis be used for predicting seizure recurrence in emergency department?

BACKGROUND: Epileptic seizures account for 1%-2% of all admissions of patients to the emergency department (ED). The present study aimed to determine whether venous blood pH, bicarbonate, base excess, and lactate levels taken within 1 hour of the last seizure episode help to determine seizure recurrence in emergency departments. METHODS: A cross-sectional study was conducted in the emergency department (ED) between January and July, 2012. Patients who were admitted to the emergency department consecutively were included in the study if they were 14 years or older and within 1 hour after last seizure. Demographics, seizure type, use of antiepileptic drugs, observation period at the emergency department, seizure recurrence, pH, bicarbonate, base excess, and lactate levels from venous blood gas analysis were determined. RESULTS: A total of 94 patients aged 14 years or older were included in the study. Of these patients, 10.6% (n=10) experienced recurrent seizures in the observation period at the emergency department. To predict recurrent seizures in ED, threshold venous blood gas values were determined as follows: pH<7.245 [sensitivity 80% (95%CI: 44-96), negative predictive value 96.9% (95%CI: 88.3-99.4)], bicarbonate<17.1 mmol/L [sensitivity 80% (95%CI: 44-96), negative predictive value 97% (95%CI: 89-99.5)], base excess<-11.1 mEq/L [sensitivity 80% (95%CI: 44-96), negative predictive value 97% (95%CI: 89-99)], and lactate>7.65 mmol/L [sensitivity 80% (95%CI: 44-96), negative predictive value 96.6% (95%CI: 87-99)]. CONCLUSION: If venous blood gas analysis is made on pH, base excess, lactate and bicarbonate immediately one hour after the last epileptic seizure episode, it is possible to predict whether the patient will have seizure recurrence.

Retrograde cerebral air embolism.

Pneumocephalus is a clinical condition caused by dysbarism, trauma, and iatrogenic causes. The most common iatrogenic causes of pneumocephalus are major interventions as a neurosurgery and cardiovascular operations, endoscopy, and minor interventions as a peripheral and central venous access. Especially during insertion of central venous line and intravenous drug and fluid infusion, the venous air embolism may occur in emergency department. In these patients, retrograde pneumocephalus occurs as a result of the air entering the right atrium to the brain. Clinical effects of the air delivery rates are known to be more specific than the total amount of air. In general, intravenous administration of 300 to 500 mL air in the speed of 100 mL/min is considered to be lethal. Large amounts of air embolism can cause hypotension and acute circulatory collapse with intracardiac obstruction. The most common symptoms of venous air embolism are anxiety, dyspnea, chest pain, cyanosis, tachycardia, tachypnea, headache, confusion, agitation, syncope, slurred speech, blurred vision, seizures, and ataxia. The mortality of pneumocephalus caused by central venous catheters in patients presented with symptoms of focal neurologic was 8%, whereas the mortality of pneumocephalus in patients presented with encephalopathy was 36%. In our report, a case of pneumocephalus secondary to disconnection of catheter cap in chronic renal failure patient who has hemodialysis via catheter has been presented.

The accuracy of bedside ultrasonography as a diagnostic tool for the fifth metatarsal fractures.

OBJECTIVES: Musculoskeletal ultrasonography is a technique that is becoming more popular in diagnosing injuries of emergency department (ED) patients especially for the diagnosis of fractures. In this study, we determined the reliability of ultrasonography for the diagnosis of fractures of the fifth metatarsal. METHOD: This is a prospective blind study. Patients over 14 years old who were admitted to the ED with acute foot injury and who had tenderness on the fifth metatarsal were consecutively enrolled into the study. A bedside ultrasonography exam was performed by an emergency physician, and antero-posterior and oblique views were obtained. X-rays were blindly evaluated by an orthopedic surgeon and were considered to be the gold-standard for diagnosing fractures. In patients with noncomminuted fractures, bone displacement was measured by both radiologically and sonographically. RESULTS: Eighty-four patients were included in this study. Their mean age was 36.0, and 42.9% were male. Fractures were diagnosed by both x-ray and ultrasonography in 33 patients. In one patient, the x-ray was positive for fracture, while ultrasonography yielded a negative result. For the fractures of fifth metatarsal, the diagnostic sensitivity of ultrasonography was 97.1%, the specificity was 100%, the positive likelihood ratio was infinity, the negative likelihood ratio was 0.03. Mean displacement was 1.2 ± 0.7 mm with x-ray and 1.8 ± 1.5 mm with ultrasonography. The intraclass correlation coefficient of displacement measured by x-ray and ultrasonography was κ: 0.388. CONCLUSION: Ultrasonography is a reliable diagnostic tool for acute fifth metatarsal fractures.

Determination of a predictive cutoff value of NT-proBNP testing for long-term survival in ED patients with acute heart failure.

OBJECTIVE: The main objective of this study was to determine a predictive cutoff value for plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) that could successfully predict the long-term (4-year) survival of patients with acute heart failure (HF) at the time of admission to the emergency department (ED). To our best knowledge, our study is the first research done to identify a predictive cutoff value for admission NT-proBNP to the prescriptive 4-year survival of patients admitted to ED with acute HF diagnosis. METHODS: NT-proBNP levels were measured in plasma obtained from 99 patients with dyspnea and left ventricular dysfunction upon admission to the ED. The end point was survival from the time of inclusion through 4 years. RESULTS: The mean age of the patients in this study was 71.1 ± 10.3 years; 50 of these patients were female. During the 4-year follow-up period, 76 patients died; survivors were significantly younger than non-survivors (64.26 ± 11.42 years vs 72.83 ± 11.07 years, P = .002). The optimal NT-proBNP cutoff point for predicting 4-year survival at the time of admission was 2300 pg/mL, which had 85.9% sensitivity and 39.1% specificity (95% confidence interval, area under the curve: 0.639, P = .044). CONCLUSION: Elevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute HF 4 years after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 4-year survival had high sensitivity. However, especially in the case of long-term survival, additional prospective, large, and multicenter studies are required to confirm our results.

The interrater reliability of ultrasound imaging of the inferior vena cava performed by emergency residents.

OBJECTIVE: Ultrasonography (US) has gained popularity in the emergency medicine to assess intravascular volume status in critically ill patients. However, there are a limited number of studies on the interrater reliability of US examination of the inferior vena cava (IVC) by emergency residents. METHOD: One hundred eighty US examinations were performed on 90 emergency critical care unit patients by 6 emergency medicine residents. Minimum and maximum IVC diameters during normal passive inspiration were measured, and the IVC index was calculated. The interrater reliability of the measurable data was analyzed using intraclass correlation coefficients. RESULTS: The measurements of minimum and maximum IVC diameters were moderately reliable by emergency residents (κ = 0.60 [95% confidence interval {CI}, 0.45-0.72] and κ = 0.56 [95% CI, 0.41-0.69], respectively). In the patients with moderate IVC depth (8.5-12.5 cm), the interrater reliabilities of sonographers were κ = 0.51 (95% CI, 0.30-0.67) for maximum diameter and κ = 0.43 (95% CI, 0.21-0.61) for minimum diameter. In patients with superficial (≤8.5 cm) and profound located (≥12.5 cm) IVC, the interrater reliabilities of sonographers for maximum and minimum diameters were κ = 0.69 (95% CI, 0.29-0.89) and κ = 0.75 (95% CI, 0.4-0.91), and κ = 0.58 (95% CI, 0.09-0.85) and κ = 0.76 (95% CI, 0.39-0.92), respectively. CONCLUSION: The measurement of the IVC is moderately reliable by emergency residents. The interrater reliability of measurements in patients with profound and superficial located IVC is higher than that of measurements in patients with moderate-depth located IVC.

Predictive cutoff point of admission N-terminal pro-B-type natriuretic peptide testing in the ED for prognosis of patients with acute heart failure.

OBJECTIVE: The main objective of this study was to determine a cutoff level of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) that could successfully predict the short- and long-term prognosis of patients with acute heart failure at the time of admission to the emergency department. The results of our study are presented in context with previously published literature. We believe that the present study will be useful and salutary for the progress of literature. METHODS: N-terminal pro-B-type natriuretic peptide plasma levels were obtained from 100 patients with shortness of breath and left ventricular dysfunction upon admission to the emergency department. All patients underwent follow-up evaluations 30 days and 1 year after admission. The end point was defined as all-cause mortality. RESULTS: The mean age of the patients in this study was 70.8 ± 11.6 years, and 51% were female. All-cause mortality at the 30-day and 1-year follow-up evaluations was 21.2% and 53.5%, respectively. We determined that the optimal NT-proBNP cutoff point for predicting 30-day mortality at the time of admission was 9152.4 pg/mL, with a 71.4% sensitivity and an 81.3% specificity (95% confidence interval, area under the curve: 0.726; P = .002). The optimal NT-proBNP cutoff point for predicting 1-year mortality at the time of admission was 3630.5 pg/mL, with an 83.0% sensitivity and a 52.2% specificity (95% confidence interval, area under the curve: 0.644; P = .014). CONCLUSION: Elevated NT-proBNP levels at the time of admission are a strong and independent predictor of all-cause mortality in patients with acute heart failure at 30 days and 1 year after admission. Furthermore, the optimal cutoff level of NT-proBNP used to predict 30-day and 1-year mortality had high sensitivity.

Infective endocarditis complicated with cerebral and splenic infarction in a hemodialysis patient.

BACKGROUND: Infective endocarditis (IE) has a high risk of morbidity and mortality. Complications are often due to systemic embolization. We treated a 47-year-old hemodialysis man with infective endocarditis complicated with cerebral and splenic infarction. METHODS: The patient was brought to the emergency department because of altered mental status and fecal incontinence. Although he did not meet the Duke Criteria for IE diagnosis, clinical suspicions of IE warranted further diagnostic studies. Magnetic resonance imaging of the brain revealed cerebral infarction with abnormal neurological findings. An abdominal computerized tomography revealed an incidental and unexpected splenic infarction without physical findings. Echocardiography revealed a vegetative growth (-1.2×1 cm) over the mitral posterior leaflet with severe mitral valve regurgitation. Based on these results, the patient was diagnosed with IE complicated with severe cerebral and splenic infarction. RESULTS: The patient was treated with intravenous teicoplanin including gentamicin, subcutaneous low molecular weight heparin, and oral acetylsalicylic acid. Mitral valve replacement surgery was performed after the patient improved clinically. CONCLUSION: Emergency physicians should be aware of the life-threatening complications of IE, which may be presented subtly or without clinical evidence.

Etofenamate associated with Lyell syndrome: a case report.

Toxic epidermal necrolysis (Lyell syndrome) is a rare, acute, and potentially life-threatening mucocutaneous disease that is most often triggered by drugs. This is the first case of toxic epidermal necrolysis because of treatment with etofenamate of which we are aware.

Clinical course of a loxosceles spider bite in Turkey.

We report the first case from Turkey of a dermonecrotic wound associated with possible Loxosceles spider bite and offer the complete clinical course that resulted in a permanent scar. Emergency physicians in western Turkey should be aware of Loxosceles spider bites as a cause of necrotizing wounds.