Contribution of goal-directed ultrasonography to clinical decision-making for emergency physicians.

OBJECTIVE: To determine the contribution of goal-directed right upper quadrant (RUQ) ultrasonography (US) on real-time decision-making of attending emergency physicians by evaluating their level of certainty for admission, surgery, medical treatment, additional laboratory and radiological investigations and discharge. METHODS: The study was conducted at an urban university tertiary care emergency department with an annual census of 60,000 adult patients. Patients with acute non-traumatic RUQ pain presenting to the emergency department during the 8-month study period were enrolled into the study. Primary outcome measures were level of certainty for admission to the hospital, emergency surgery, medical treatment, additional laboratory and radiological analyses and discharge from the emergency department. RESULTS: There was a significant difference between the pre-US and post-US certainty of the decision to perform additional diagnostic studies (56 vs 72, p = 0.01) but not in the other outcomes (treatment, admission, surgery and discharge). After categorising the physicians' decisions into low, intermediate and high, US had an effect on all primary outcomes and on all categories. This effect was most evident in the moderate category where the physicians were undecided for all primary outcomes. CONCLUSION: US performed by emergency department physicians affects the certainty of their decisions in patients presenting with RUQ pain. This effect is more evident on the decision to perform additional diagnostic studies and in patients about whom physicians are undecided.

Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma.

OBJECTIVE: To determine the accuracy of physical examination and ultrasonographic evaluation performed by emergency physicians in cases of blunt abdominal trauma for the early diagnosis of intraabdominal haemorrhage. METHODS: In this clinical prospective study, trauma patients were evaluated with four-quadrant ultrasonography by emergency physicians after initial stabilisation and physical examination. Diagnoses based on demographic data, physical examination and emergency physician's ultrasonography were compared with the subsequent clinical course. RESULTS: A total of 442 patients participated in the study. The sensitivity and specificity of emergency physician's ultrasonographic examination to detect intraabdominal haemorrhage were 86 and 99%, respectively. Pre-test sensitivity and specificity of physical examination to detect intraabdominal haemorrhage were 39 and 90%, respectively. CONCLUSIONS: Physical examination was not a reliable method to detect intraabdominal haemorrhage in cases of blunt abdominal trauma. In contrast, abdominal ultrasonography performed by emergency physicians was a reliable diagnostic tool. Emergency physicians should be familiar with abdominal ultrasonographic examination, which should be routine in cases of blunt abdominal trauma.

A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department.

The objective of this randomized, placebo-controlled, double-blind study was to determine the effectiveness of intravenous magnesium sulphate and intravenous metoclopramide in the treatment of acute migraine attacks in the Emergency Department when compared with placebo. Adult patients who presented to the Emergency Department with a headache that met International Headache Society (IHS) criteria for acute migraine were infused with either 10 mg of intravenous metoclopramide, 2 g of intravenous magnesium sulphate or normal saline over 10 min. At 0, 15, and 30 min, patients were asked to rate their pain on a standard visual analogue scale. At 30 min, patients were asked in a standard manner about the need for rescue medication. Adverse affects were also recorded. Patients were followed up by telephone within 24 h for any recurrence after discharge. The primary endpoint of the study was the difference in pain relief between the groups at 30 min. Of the 120 patients who met IHS criteria, seven were excluded from the study due to insufficient data. The number of patients, gender, age and initial visual analogue scale (VAS) scores were comparable between groups. Each group experienced more than a 25-mm improvement in VAS score at 30 min. However, there was no significant difference detected in the mean changes in VAS scores for pain. The rescue medication requirement was higher in the placebo group. The recurrence rate in 24 h was similar between the groups. Although patients receiving placebo required rescue medication more than the others, metoclopramide and magnesium have an analgesic effect similar to placebo in migraine attacks.

Intravenous single-dose tramadol versus meperidine for pain relief in renal colic.

BACKGROUND AND OBJECTIVE: Comparison of the effectiveness of tramadol with meperidine given intravenously to emergency patients with suspected renal colic. METHODS: A double-blind, randomized clinical trial was performed in the Emergency Department of a tertiary-care university hospital. Consecutive patients with suspected renal colic (n = 47) were randomized to receive intravenously an initial dose of tramadol 50 mg (n = 23) or meperidine 50 mg (n = 24). After 30 min, additional doses of meperidine 50 mg were given intravenously as a rescue medication in an open fashion. Pain relief was assessed using a 10 cm visual analogue scale, the primary outcomes being pain relief at 15 and 30 min after the analgesics. Secondary outcomes were the frequency of rescue meperidine use and the development of side-effects. RESULTS: Visual analogue scale pain scores after 15 and 30 min decreased in both tramadol and meperidine groups (P < 0.05). However, pain relief was better in the meperidine group at the 15 and 30 min evaluations (P < 0.05). Only 11 patients (48%), initially receiving meperidine, needed more meperidine compared with 16 patients (67%) initially receiving tramadol. Both drugs were well tolerated with no adverse effects occurring in either group. CONCLUSIONS: Meperidine 50 mg was superior to tramadol 50 mg for acute pain relief in patients with suspected renal colic when given intravenously. Because many patients in both groups received supplemental meperidine and the response to tramadol alone cannot be predicted, clinicians may want to choose higher doses of meperidine alone or other alternative combinations.

[Is seat belt sign a predictor for physicians in management of trauma patients in emergency settings?]. / Acil servis travma hastalarinda "emniyet kemeri izi" tedaviyi belirleyici bir klinik bulgu mudur?

Seat belt sign (SBS) is frequently seen as a clinical finding in motor vehicle accidents. The purpose of this study is to determine the diagnostic value of SBS. All adult patients presenting with an history of motor vehicle accident to a tertiary care university hospital emergency department was included in this prospective, observational study covered the time period between July 01, 1999 and February 01, 2000. 213 patients were included in this study; 135 (63.4%) were male, and 76 patients (35.7%) were seat-belted. SBS was seen on 27 (35.5%) belted patients. Fourteen of seat-belted had rib fractures nine of those patients with rib fractures were found to have SBS. There was a statistically significant difference between the patient groups with or without SBS in rib fractures (p = 0.0128) While no significant differences were detected between groups regarding the frequency of intra-cranial, intra-thoracic, intra-abdominal and extremity injuries three of four patients who had sternum and clavicular fractures took place in SBS(+) group (p = 0.090). The presence of SBS in trauma patients may create a high index of suspicion for thoracic injuries, especially for rib fractures. It is widely accepted that any delay in the diagnosis may increase morbidity and mortality following thoracic injuries. Further studies are needed to investigate the possible role of SBS in the prediction of the severity of injuries following thoracic trauma.

[The role of computed tomography for minor head injury]. / Minör kafa travmasi olan hastalarda bilgisayarli beyin tomografisinin rolü.

Head trauma is a major health problem which affects young people, especially young males and also causes serious economic losses. Although major head injuries are cause greater morbidity and mortality, minor head injuries are more common presentations to emergency departments. In this study our goal is to determine the prevalence of CT usage in minor, adult head injury patients and determine clinical variables for the use of head CT scans. In our study we retrospectively examined 230 adult head injury patients who were presented to the Dokuz Eylül University Medical School Hospital Emergency Department. We recorded age, gender, symptoms of nausea, vomiting, headache, alcohol use, physical examination findings, history of loss of consciousness prior to presentation, concurrent injuries, and Glasgow Coma Scale (GCS) scores. Head CT ordering and abnormal findings were correlated with the above clinical variables. We ascertained that all variables affected the ordering of CT scans except age, gender and alcohol use. The prevalence of abnormal head CT in all patients were 21.7%. We found that GCS is only one clinical variability of which statistically significant relationship to acquaint abnormal CT findings.

Magnesium efficacy in magnesium deficient and nondeficient patients with rapid ventricular response atrial fibrillation.

We assessed the effect of magnesium sulphate (MgSO4) on lowering the rate in ventricular atrial fibrillation (AF), and evaluated the effect of this therapy in magnesium (Mg) deficient and nondeficient patients. This experimental clinical study was performed on 34 patients with rapid AF (ventricular rate [VR] > 120/minute) presenting to the emergency department of a tertiary care university hospital. Patients with systolic blood pressure < or = 100 mmHg, Hb level < or = 11.8, saO2 of < or = 96%, BUN > or = 40 or creatine > or = 1.8 were excluded (n = 15). Nineteen patients were given an initial 2 g MgSO4 bolus i.v. and a 1 g/hour continuous infusion over 6 hours. To evaluate the presence of Mg deficiency, urine was collected from the onset of treatment and continued for the next 24 hours, and the excretion rate of administered Mg was calculated. Ventricular rates were obtained at baseline, after MgSO4 bolus, and every 15 minutes for the first hour. The decrease in the VR was statistically significant at 15, 30 and 60 minutes after Mg therapy (p = 0.0025, p < 0.001, p > 0.001). There was no difference in the response to Mg therapy between Mg deficient and nondeficient patients at 15, 30 or 60 minutes after therapy (p = 0.41, p = 0.28, p = 0.08). It is concluded that i.v. MgSO4 has a statistically significant but clinically limited effect on VR and this effect did not differ between patients with and without Mg deficiency.

[Epidemiological characteristics of trauma patients]. / Travma hastalarinin epidemiyolojik özelliklerinin arastirilmasi.

We have evaluated retrospectively adult trauma patients admitted to the Dokuz Eylul University Hospital Emergency Department (ED) between 1.1.1997-30.6.1997 by the aim of contributing epidemiological data about trauma related injuries of Turkey. Among the 1063 study patients, 626 patients were male, 437 patients were female and mean age of the patients was 40.6 +/- 18. The most common causes of injury was fall. The revised trauma score lesser than 12 was 75 patients. It has been determined that 90.8% of the patients were brought to ED by the vehicles other than the ambulance. Among all patients, 872 patients (82%) were discharged from ED, 118 patients (11.1%) were admitted, 73 patients (6.9%) were referred to another hospitals and 13 patients (1.2%) were died. We have determined the significantly increased hospital admission rate in the subgroups of the penetrating trauma patients, patients older than 65 years old (p = 0.001 and 0.003, respectively) and the significantly increased operative intervention and death in penetrating trauma patients (p = 0.000 and 0.009, respectively).

Must antidysrhythmic agents be given to all patients with new-onset atrial fibrillation?

We investigated the spontaneous conversion rate of new-onset atrial fibrillation (AF) in emergency department patients and the recurrence rate of AF during a 1 month follow-up period. Sixty-six consecutive hemodynamically stable patients presenting to a university hospital emergency department with new-onset atrial fibrillation (less than 72 hours duration) comprised the study population. Patients were initially monitored for 8 hours and observed for spontaneous conversion of AF to sinus rhythm. If conversion did not occur in the first 8 hours, an oral loading dose (600 mg) of propafenone was given, and patients were observed for an additional 8 hours. All patients were reevaluated at 24 hours and at 1 month. The spontaneous conversion rate in patients presenting within 6 hours of AF onset during the initial 8-hour observation period was 71%. The spontaneous conversion rate for all patients during the initial observation period was 53%. The conversion rates between patients presenting "early" (less than 6 hours) and "late" (7-72 hours) were significantly different (P < 0.001). Many patients with new-onset AF, especially those with atrial fibrillation duration less than 6 hours, may need observation only, rather than immediate intervention, to treat their dysrhythmia.

Predictors of success in the conversion of new-onset atrial fibrillation using oral propafenone.

We have investigated the relationship of clinical variables to successful cardioversion of atrial fibrillation (AF) to sinus rhythm using an oral loading dose of propafenone. Fifty consecutive patients with recent onset (< 72 hours) atrial fibrillation of various aetiologies were included in the study cohort. All patients were given the study medication while in the emergency department and then monitored for 8 hours. All patients converting to sinus rhythm (39 out of 50, 78%) were discharged and re-evaluated at 24 hours and 30 days. We investigated the effect of clinical factors such as age, sex, presence of hypertension (HT), chronic obstructive lung disease (COPD), diabetes mellitus (DM), mitral stenosis (MS), congestive heart failure (CHF), coronary artery disease (CAD) and the duration of atrial fibrillation on conversion to sinus rhythm. Of these factors, univariate and multivariate analysis showed that only the duration of atrial fibrillation was a significant predictor of conversion (p = 0.002). Our results suggest that most patients with new-onset AF can be converted successfully to sinus rhythm with a low incidence of adverse reactions using oral propafenone in the emergency department.