Role of Electrocardiographic Manifestations in Admission Decision in Patients with Chronic Obstructive Pulmonary Disease Exacerbation.

OBJECTIVE: To determine the ECG manifestations of COPD exacerbations and their roles in the decision making process in admission. STUDY DESIGN: A descriptive cross-sectional study. PLACE AND DURATION OF STUDY: Emergency Department (ED) of Kocaeli University, Turkey, from November 2016 to December 2017. METHODOLOGY: All COPD patients who presented with exacerbation symptoms and agreed to participate in the study were enrolled, and the exacerbation characteristics were recorded in the standardised charts. Patients were excluded if they refused to participate in the study, if they presented repetitively to the ED with the same presentation, and if the ECG strip at the presentation could not be obtained. A binary logistic regression model was constructed to assess the factors predicting hospital admission, including the ECG features. RESULTS: A total of 146 patients were included in the final analysis. Upon presentation, 122 patients (83.6%) exhibited sinus rhythm, 21 exhibited atrial fibrillation (14.4%), and 3 of them were multifocal atrial tachycardia and junctional rhythm. Thirty-four admitted patients (41.0%) and 22 of the discharged patients (34.9%) exhibited ST and T wave changes in their ECGs (p=0.457). No statistically significant differences were found regarding the rhythms, axes, P wave characteristics, PR interval durations, QRS interval durations, corrected QT(QTc) durations, and bundle branch block occurrences between the admitted and discharged patients. Although the QTc dispersion was more prominent in the admitted group in the univariate analysis (p=0.035), the multivariate analysis revealed that only hypoxemia, older age, increased dyspnea scores, and sputum purulence were independent predictors of hospital admission. CONCLUSION: None of the ECG findings were determined to be successful in predicting the admission needs in COPD exacerbations.

Intravenous metoclopramide in the treatment of acute migraines: A randomized, placebo-controlled trial.

OBJECTIVES: The present study aimed to evaluate the efficacy and safety of intravenous metoclopramide for acute migraine treatment. MATERIALS AND METHODS: A double-blind, randomized, parallel-group, placebo-controlled trial was carried out in an academic emergency department. After the patients were assessed for eligibility via the International Headache Society criteria for migraines, they were randomized into 10 mg intravenous metoclopramide and normal saline groups. The headache intensity was evaluated using an 11-point numeric rating scale (NRS) score. The primary outcome measure was determined as the median between-group change in the score at the 30th minute. The secondary outcome measures were rescue medication needs, adverse events, and emergency department (ED) revisits after discharge. RESULTS: A total of 148 patients were randomized into two equal groups with similar baseline characteristics, including the baseline NRS scores (8 points). The median reduction in the NRS scores at the 30th minute was 4 [interquartile range (IQR): 2-6)] in the metoclopramide group and 3 (IQR: 1-4) in the normal saline group [median difference: -1.0, 95% confidence interval (CI): -2.1 to 0.1]. No serious adverse events were observed, and the rescue medication needs were similar in both groups. CONCLUSION: No difference was found between intravenous metoclopramide and placebo regarding efficacy and safety in patients with acute migraines.

Intranasal Lidocaine in Acute Treatment of Migraine: A Randomized Controlled Trial.

STUDY OBJECTIVE: The study aims to evaluate the efficacy and safety of intranasal lidocaine administration for migraine treatment. METHODS: This single-center, double-blind, randomized, controlled trial was conducted in a tertiary care emergency department. Included patients met the migraine criteria of the International Headache Society. Patients were randomized to intranasal lidocaine or saline solution; all participants received 10 mg of intravenous metoclopramide. Patient pain intensity was assessed with an 11-point numeric rating scale score. The primary outcome measure was the change in pain scores at 15 minutes; secondary outcomes were changes in pain intensity after pain onset and need for rescue medication. RESULTS: Patients (n=162) were randomized into 2 groups with similar baseline migraine characteristics and numeric rating scale scores. The median reduction in numeric rating scale score at 15 minutes was 3 (interquartile range [IQR] 2 to 5) for the lidocaine group and 2 (IQR 1 to 4) for the saline solution group (median difference=1.0; 95% confidence interval 0.1 to 2.1). The reduction in pain score at 30 minutes was 4 (IQR 3 to 7) for the lidocaine group and 5 (IQR 2 to 7) for the saline solution group (median difference=1.0; 95% confidence interval 0.1 to 2.1). Need for rescue medication did not differ between the groups, and local irritation was the most common adverse event in the lidocaine group. CONCLUSION: Although intranasal lidocaine was found no more efficacious than normal saline solution in our study, future studies should focus on patients who present earlier after headache onset.

Weakness in the Emergency Department: Hypokalemic Periodic Paralysis Induced By Strenuous Physical Activity.

Hypokalemic periodic paralysis is a rare but serious disorder that is typically caused by a channelopathy. Thyrotoxicosis, heavy exercise, high carbohydrate meal and some drugs can trigger channelopathy in genetically predisposed individuals. A 33-year-old male patient presented to the emergency department with weakness in the lower extremities. He stated that he had done heavy physical activity during the previous week. The patient exhibited motor weakness in the lower extremities (2/5 strength) during the physical examination. Initial laboratory tests showed a potassium level of 1.89 mEq/L. The initial electrocardiogram demonstrated T wave inversion and prominent U waves. The patient was treated in the emergency department with oral and intravenous potassium. The physical and ECG symptoms resolved within 16 hours of potassium supplementation and biochemical tests showed normal serum potassium levels. The patient was discharged shortly after the resolution of the symptoms. Weakness is an important but nonspecific symptom that may be brought on by a number of underlying physiological processes. Hypokalemic periodic paralysis is a rare disease that may be triggered by heavy physical activity and presents with recurrent admissions due to weakness.

Comparison of the therapeutic efficacy of intravenous dimenhydrinate and intravenous piracetam in patients with vertigo: a randomised clinical trial.

BACKGROUND: The present study aimed to compare the therapeutic efficacy of dimenhydrinate and piracetam in patients with vertigo. METHODS: A blinded, parallel group, superiority, randomised clinical trial was carried out on patients who presented to the emergency department (ED) with vertigo. Healthy adult patients presenting to the ED with undifferentiated vertigo were included in the study. The efficacy of intravenous dimenhydrinate (100 mg) and intravenous piracetam (2000 mg) for reducing the intensity of vertigo was compared in two randomised treatment groups using a 10-point numeric rating scale (NRS). The determination of NRS scores was performed at presentation and at the 30th minute of presentation, after the study drug was implemented, both in immobile and ambulatory positions. The primary outcome variable was reduction in vertigo intensity documented on the NRS at the 30th minute after medication administration, analysed by intention to treat. RESULTS: A total of 94 patients were included in the randomisation (n=47 in both groups). The baseline NRS scores were 7.55±2.00 in the dimenhydrinate group and 8.19±1.79 in the piracetam group. The changes from baseline for dimenhydrinate and piracetam were 2.92±3.11 and 3.75±3.40 (difference -0.83 (95% CI -2.23 to 0.57)) in the immobile position and were 2.04±3.07 and 2.72±2.91 (difference -0.68 (95% CI -2.03 to 0.67)) in the ambulatory position. Rescue medication need was similar in both treatment groups (p=0.330), and only one adverse reaction was reported. CONCLUSIONS: We found no evidence of a difference between dimenhydrinate and piracetam in relieving the symptoms of vertigo. TRIAL REGISTRATION NUMBER: Clinical Trials Registration ID: NCT01890538.