Interrater reliability of emergency medicine residents in measurement of optic nerve sheath diameter with computed tomography.

OBJECTIVES: Many studies have recently been conducted on measuring optic nerve sheath diameter (ONSD) with computed tomography (CT). However, no studies focused on the interrater reliability in ONSD measurements with CT yet. Our first aim was to investigate the interrater reliability of the emergency medicine residents in the measurement of the ONSD with CT. Our secondary aim was to evaluate the interrater reliability and agreement of the emergency medicine residents and neuroradiologist measurements, which is the gold standard. METHODS: Twelve residents (six seniors and six juniors) and a neuroradiologist measured ONSD in twenty different CTs in axial and sagittal planes. The interrater reliability was calculated by the intraclass correlation coefficient (ICC), and the level of agreement in categorical variables was calculated by kappa (ĸ) analysis. RESULTS: We found that the interrater reliability level of all residents was "good" (ICC: 0.824), for seniors was "good" (ICC: 0.824), and for juniors was "moderate" (ICC: 0.748) in the measurement of ONSD. ICC was 0.812 for axial, and 0.783 for sagittal plane measurements. The interrater reliability between residents and the neuroradiologist measurements was "good" (ICC 0.891), and the agreement was found to be "good" (ĸ: 0.688; P < 0.001). The sensitivity of residents in detecting increased ONSD was 78%, and specificity was 90.8%. CONCLUSION: The ONSD measurements with CT performed by the residents are reliable in themselves, and they are compatible with the gold standard measurements.

Lactate measurements accurately predicts 1-week mortality in emergency department patients with acute kidney injury.

BACKGROUND: Studies on prognostic indicators in patients with acute kidney injury are limited. This study investigated 1-week mortality, laboratory and clinical parameters according to the lactate levels in patients with acute kidney injury. METHODS: In this cross-sectional study, we compared the lactate levels on admission and follow-up in emergency department with vital findings, laboratory parameters, and 1-week mortality. RESULTS: Data of 3375 patients examined; 2681 patients excluded and 694 patients were included. Median lactate level on admission was 1.6 (1.1-2.5) mmol/L for patients who discharged from emergency department, 2.2 (1.3-3.4) mmol/L for patients admitted to the hospital wards, 3.7 (1.7-7.2) mmol/L for patients admitted to the intensive care unit and 4.4 (2.4-8.0) mmol/L for patients with mortality within 1-week of ED presentation. Mortality was 30.4% in patients with high lactate levels and 8.1% in patients with normal lactate levels on admission. (p < 0.001, odds ratio 5.0, 95% CI 3.2-7.7) Elevated lactate level was independent risk factor for 1-week-mortality. (p < 0.001, odds ratio 1.138, 95% CI 1.067-1.214) Patients with high lactate levels have low systolic blood pressure, diastolic blood pressure, oxygen saturation, pH, base deficit, and bicarbonate, and higher heart rate and respiratory rate. The mortality of patients with normal lactate levels on admission was 8.1%, while mortality rate increased to 19% if elevated lactate levels observed during emergency department follow-up. CONCLUSIONS: Elevated lactate level predicts 1-week mortality in patients presenting with acute kidney injury in emergency department. Elevated lactate level were associated with poorer vital signs and abnormal laboratory results.

The impact of a heat wave on mortality in the emergency department.

Extreme heat wave increases the number of emergency department (ED) admissions and mortality rates. The purpose of our study is to investigate the effects of the heat wave experienced in Izmir province of Turkey on mortality.During a 9-day period between 17th and 25th June 2016 (study period), air temperature values were higher than the seasonal norms in Izmir, Turkey. In this cross-sectional study, nontraumatic admissions and in-hospital mortality rates were compared this historical interval of the extreme heat wave with the same period of the previous year and the other 21 days of June 2016.The average air temperature between 17th and 25th June 2016, was higher than the average air temperature of the previous year's same period and the average air temperature from the other 21 days of June 2016 (27.8 ±â€Š3.6 °C, (24.5 ±â€Š1.9°C, 24.1 ±â€Š2.1°C, respectively) (P <.01)During the study period, the mean number of ED visits and mortality rates were significantly higher than the previous year's same period (320 ±â€Š30/day vs 269 ±â€Š27/day, [P <.01], and 1.6% vs 0.7%, [P <.01]).Although the admission rate was similar between the study period and the other 21 days of June 2016 (320 ±â€Š30/day vs 310 ±â€Š32/ day, [P = .445]); in-hospital mortality rate was significantly higher during study period (1.6% vs 0.7%, [P <.01]).During the extreme heat waves, ED admissions and in-hospital mortality rates are increased. Precautions should be addressed for adaptation of people to extreme hot weather.

Severe allergic reaction to human insulin in the patient with diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) is an acute and major life-threatening complication of diabetes mellitus. Fluid resuscitation, insulin therapy, and electrolyte replacement are essential for DKA treatment. Rarely, life threatening allergic reactions might develop in a patient treated with insulin. If anaphylaxis develops after insulin, the DKA treatment options are restricted. A limited number of case reports have been reported in patients with severe anaphylactic reactions to human insulin who were then treated with synthetic insulin analogues. We present a case of a 45-year-old male patient with allergic reactions to human insulin. The patient was successfully treated with insulin aspart and hemodialysis.

Emergency physician accuracy using ultrasonography to diagnose lateral malleolar fracture.

OBJECTIVE: Many studies in the literature related to the investigation of the sensitivity and specificity of ultrasound examinations in lateral malleolar fractures is limited. The aim of this study is to investigate the sensitivity and specificity of ultrasound examinations performed by emergency physicians in fractures who are presented to the emergency department with blunt lateral malleolar trauma. METHOD: Patients over 18years of age who were admitted to the ED with lateral malleolar tenderness were enrolled to this study with convenience sampling. Ultrasonographic examination was performed by emergency physicians. Following the ultrasound examination, a two-sided X-ray was performed. In the case of inconsistency between the US exam and the X-ray evaluated by the emergency physician, a CT was performed on the patients. The X-ray or CT imaging evaluation of an orthopedic surgeon was accepted as the gold standard. RESULTS: A hundred-twenty patients were included in the study. Fractures in the lateral malleolus were detected in 47 patients. The sensitivity of X-ray in the diagnosis of lateral malleolar fractures was 92.8%, (95% CI, 79.4-98.1) and the specificity was 100% (95% CI, 89.5-100), while the sensitivity of US exam was 100% (95% CI, 94.1-100), and the specificity was 93% (95% CI, 85-97.6). X-ray gave false negative results in 3 patients, whereas US gave false positive results in 5 patients. CONCLUSION: In patients admitted to ED with lateral malleolus tenderness, the sensitivity of the ultrasound examination performed by emergency physicians regarding diagnosis of lateral malleolar fracture is higher than X-ray.

Comparison of the airway access skills of prehospital staff in moving and stationary ambulance simulation: A randomized crossover study.

OBJECTIVES: We aimed to compare the procedural success and intervention durations regarding various airway access skills in moving and stationary ambulance simulations. MATERIAL AND METHODS: An ambulance simulator was used to simulate the moving ambulance environment, and a standard manikin was used for airway simulation. The study included 38 paramedics and paramedic students. In stationary and moving environments, a classical endotracheal intubation with a stylet, an intubation with a gum elastic bougie (GEB), a laryngeal mask airway (LMA), and a laryngeal tube (LT) were applied randomly. The cuff inflation duration, the duration until the first ventilation, and the intubation success were assessed. RESULTS: There was no difference in terms of success and intubation durations of the four methods in moving and stationary environments. In both environments, the LT and LMA were inserted most rapidly (p < 0.001). There was no difference in the intubation duration and the success among the supraglottic methods. In moving and stationary environments, the intubation with a classic stylet was faster than the intubation with a GEB. The use of a GEB did not increase the intubation success. CONCLUSIONS: In this simulation study, the moving environment did not affect the duration or success of the endotracheal intubation. Supraglottic methods were applied more quickly in both moving and stationary environments. A GEB was used successfully by practioners with no previous experience; however, the duration of the intubation was longer.

Utility of chest CT after a chest X-ray in patients presenting to the ED with non-traumatic thoracic emergencies.

BACKGROUND: Chest radiography is the initial choice for thoracic imaging. However, the wide availability of computed tomography (CT) has led to a substantial increase in its use in the emergency department (ED). We evaluated the utility of chest CT after a chest X-ray in patients presenting to the ED with non-traumatic thoracic emergencies, and determined if the diagnosis and management decision changed after CT. METHODS: The study enrolled 500 consecutive patients with both chest X-rays and CT who presented to the ED with non-traumatic complaints. Chest X-rays and CT images obtained within 12h before any definitive treatment were randomly evaluated in consensus by two radiologists blinded to the clinical information. RESULTS: The chest X-ray and CT image findings were concordant in 49.2% of the 500 patients and this concordance was negatively correlated with patient age. Leading diagnosis and management decisions based on the chest radiograph changed after CT in 35.4% of the study group and this finding was also correlated with age. In 55% of 205 patients, pneumonic infiltrations were undiagnosed with radiography. Pulmonary edema was the most specific (93.3%) and sensitive (85.4%) radiography finding. Posteroanterior chest radiographs taken in the upright position had higher concordance with CT than anteroposterior (AP) radiographs taken in the supine position. CONCLUSIONS: Chest CT may be an appropriate imaging choice in patients presenting to the ED for non-traumatic reasons, particularly for elderly patients and when the radiograph is taken with the AP technique in a supine position.

Emergency physicians performed Point-of-Care-Ultrasonography for detecting distal forearm fracture.

OBJECTIVES: Several studies focusing diagnosis of forearm fracture using Point-of-Care-Ultrasonography (POCUS) had been carried out in children. There is a lack of evidence for the utility of sonographic (US) examination for detecting of distal forearm fracture in adults. We aim to determine the diagnostic sensitivity and specificity of POCUS examination for the fracture of the distal radius and ulna in adult patients presenting with blunt forearm trauma. MATERIAL AND METHODS: Adult patients presenting with acute distal forearm trauma and suspicion of fracture were enrolled into study. POCUS had been performed by blinded emergency physicians, than anteroposterior and lateral x-rays was obtained. If inconsistency between x-rays and POCUS has been occurred, computed tomography were ordered. Assessment of orthopedic surgeon was accepted as a gold standard diagnosis. RESULTS: Ninety three POCUS were performed in 90 patients. Fifty nine radius and 19 ulna fracture had been diagnosed. POCUS detected all radius fracture, but missed 2 ulna fracture. There were 4 false positive results for both radius and ulna with POCUS. X-ray missed 4 radius, and 1 ulna fractures. Diagnostic sensitivity and specificity of POCUS for fracture of ulna were 89.5% (CI%95, 65.5-98.1) and 94.6 (CI%95, 86-98.2), for fracture of radius were 100% (CI%95, 92.4-100), and 88.2%. (CI%95, 71.6-96.1). CONCLUSION: Emergency physician performed POCUS examination is very sensitive and specific the diagnosis of distal forearm fracture. Diagnostic sensitivity of POCUS for radius fracture is higher than x-ray.

The comparison of the efficiency of traditional lectures to video-supported lectures within the training of the Emergency Medicine residents.

OBJECTIVES: Recent developments in computer and video technology, multimedia resources enter quickest way possible into medical education and have started to gain popularity. The aim of this study is to evaluate the impact of video-supported lectures on leaning, with comparison to traditional lectures. METHODS: According to lecture techniques, two separate groups; one is the traditional lectures group (TLG) and the other is video-supported lectures group (VSLG), are formed. While the TLG is offered a traditional lecture the VSLG is offered a video-supported lecture with imbedded videos which are related to the topics in the traditional lecture. Both study groups take pretest and posttest with MCQs (multiple choice questions) and OSCEs (objective structured clinical examination). RESULTS: The study includes 30 volunteer residents in Dokuz Eylul University School of Medicine Department of Emergency Medicine. No difference is observed between TGL and VSLG in pretest and posttest scores (p = 0.949, p = 0.580). And additionally, comparing the scores of both groups, we cannot observe any difference between the pretest OSCE scores of each group (p = 0.300), however posttest OSCE scores shows a dramatic odd in-between (p = 0.010). When pretest MCQs and posttest MCQs mean scores are compared, both tests (TLG, VSLG) has not any significant difference (p=0.949, p = 0.580). Nevertheless, after comparing OSCEs pretest and posttest mean scores, we can see significant difference in mean scores of both (TLG, VSLG), (p = 0.011, p = 0.001). CONCLUSIONS: Taken into consideration, the findings of this study shows possibility of improving educational techniques to acquire clinical skills by using local resources and low-cost technology.

Retrospective evaluation of patients with elevated digoxin levels at an emergency department.

OBJECTIVES: We investigated the demographic characteristics, clinical and laboratory findings, treatment strategies and clinical outcomes of patients presenting at emergency department (ED) with digoxin levels at or above 1.2 ng/ml. MATERIALS AND METHODS: The demographic and clinical characteristics of patients with serum digoxin levels at or above 1.2 ng/ml admitted to an ED between January 2010 and July 2011 were investigated in this cross-sectional descriptive study. Patients with ECG and clinical findings consistent with digoxin toxicity and no additional explanation of their symptoms were evaluated for digoxin toxicity. RESULTS: In this study 137 patients were included, and 68.6% of patients were women with mean age 76.1 ± 12.2. There was no significant difference between gender and digoxin intoxication. The mean age of intoxicated group was significantly higher than the non-intoxicated group (P = 0.03). The most common comorbidities were congestive heart failure (n = 91) and atrial fibrillation (n = 74). The most common symptoms were nausea, vomiting and abdominal pain. The levels of hospitalization and mortality in this group were significantly higher. CONCLUSION: Digoxin intoxication must be suspected in patients present in the ED, particularly those with complaints that include nausea and vomiting, as well as new ECG changes; serum digoxin levels must be determined.

Novel biochemical marker for differential diagnosis of seizure: ischemia-modified albumin.

INTRODUCTION: Differential diagnosis of seizure is critical in patients presented to emergency department (ED) with altered mental status or loss of consciousness. Although electroencephalogram is important for the diagnosis of seizures, its use in EDs is limited. The level of ischemia-modified albumin (IMA) increases in conditions of ischemic distress such as acute coronary syndrome, pulmonary embolism, and mesenteric ischemia. No studies exist in literature regarding the increase of IMA levels parallel to increased seizure activity in adults. The aim of the study was to investigate the diagnostic value of IMA in adult patients presented to ED with seizures. METHODS: Forty patients presented to ED with seizure, and 40 control patients of similar age and sex as the study group were enrolled in this study. Initial and fourth-hour levels of IMA and albumin were measured. Groups were compared in terms of sociodemographic data and details regarding their seizures as well as initial and fourth-hour levels of IMA. RESULTS: Mean levels of IMA were 61.5 IU/mL and 18.5 IU/mL (P < .001) initially and 56.7 IU/mL and 15.4 IU/mL (P < .001) at the fourth hour; levels were higher in the study group compared with control group. Ischemia-modified albumin/albumin ratios in study and control groups were 1555.3 IU/g and 462.4 IU/g (P < .001) initially and 1431.4 IU/g and 383.6 IU/g (P < .001) at the fourth hour, respectively. CONCLUSION: Blood IMA level and IMA/albumin ratio significantly increase in adult patients who experienced seizures. Ischemia-modified albumin may be considered as a useful biomarker in the differential diagnosis of seizure.

Massive pulmonary embolism and cardiac arrest; thrombolytic therapy in a patient with recent intracranial surgery and glioblastoma multiforme.

Treatment options for pulmonary embolism are increasing, but the scale of the treatments and their availability in the emergency department (ED) are limited. Thrombolytic therapy remains the most commonly used treatment in patients who present a massive pulmonary embolism in the ED. However, systemic thrombolysis is contraindicated in certain cases, such as a known intracranial tumor or a history of cranial surgery.In this case report, we report a 63-year-old man with a history of intracranial surgery due to glioblastoma multiforme 20 days prior to being admitted to the ED. Multidetector-row computed tomography angiography revealed embolisms in both main pulmonary arteries.There was a progression of cardiac arrest while preparing for catheterization; thus, cardiopulmonary resuscitation was initiated.After administering 10 minutes of cardiopulmonary resuscitation, a50-mg alteplase bolus was given. Within minutes, a pulse has returned. No complications associated with the thrombolytic therapy were observed.Our aim was to discuss the management of massive pulmonary embolism with a contraindication to systemic thrombolytic therapy.

The comparison of heparinized insulin syringes and safety-engineered blood gas syringes used in arterial blood gas sampling in the ED setting (randomized controlled study).

INTRODUCTION: The arterial blood gas measurement process is a painful and invasive procedure, often uncomfortable for both the patient and the physician. Because the patient-related factors that determine the difficulty of the process cannot be controlled, the physician-related factors and blood gas measurement techniques are a modifiable area of improvement that ought to be considered. Many hospitals use insulin syringes or syringes washed with heparin for the purpose of blood gas measurement because they do not have blood gas-specific syringes. In this prospective cross-sectional study, we aimed to compare safety-engineered blood gas syringes and conventional heparinized syringes used during the arterial blood gas extraction process in terms of ease of operation, the physician-patient satisfaction, laboratory appropriateness, and complications. METHODS: Our study included patients whose arterial blood gas needed to be measured in the emergency department and who agreed to participate in the study. Patients were randomly divided into 2 groups. The arterial blood gas of the patients from the first group was measured by using conventional heparinized syringes, whereas safety-engineered blood gas syringes were used to measure the arterial blood gas of the patients from the second group. The groups were compared in terms of demographic data, the number of attempts, the physician and patient satisfaction, early and late-term complications, and laboratory appropriateness of the taken sample. RESULTS: A total of 550 patients were included in our study in a 2-month study period. There were no significant differences between patients in terms of sex, age, weight, height, body mass index, and wrist circumference. In addition, the number of attempts (P=.489), patients' pain level during the procedure (P=.145), and the degree of difficulty of the procedure according to the patient (P=.109) and physician (P=.554) were not significantly different between the groups. After arterial blood gas extraction procedure, 115 patients (20.9%) developed complications. In the conventional heparinized syringe group, the complication rate (n=69; 25.1%) was significantly higher compared with the group that used safety-engineered blood gas syringes (n=46; 16%; P=.0211). Localized pain, which is one of the most common early complications, was more frequent in the conventional heparinized syringe group (19.3%). Complications in women (P=.003) and local pain (P=.01) developed lesser in the second group that used safety-engineered blood gas syringes, and the patient-physician satisfaction was higher in that group, as well. In the evaluation 48 hours after the procedure, the ratios of infection and local hematoma were higher in the conventional heparinized syringe group (P=.0213 and P < .0001). CONCLUSION: In this study, we did not find any significant differences between the conventional heparinized syringes and safety-engineered blood gas syringes in terms of ease of operation, physician and patient satisfaction, and appropriateness of the taken sample. However, patients whose arterial blood gas was extracted by using safety-engineered blood gas syringes felt less pain and experienced fewer infections and hematomas at their puncture site.

Sedative-hypnotic medication exposures and poisonings in Izmir,Turkey.

The aim of this study was to analyse intoxications concerning sedative-hypnotic medication patients admitted to the Department of Emergency Medicine in Dokuz Eylul University Hospital (EMDEU) between 1993 and 2005. Demographics of the patients, characteristics of sedative-hypnotic exposures, performed treatment attempts and outcome of the poisoned patients were recorded on standard data forms that were later entered into a computerized database programme. Related to the sedative-hypnotic exposures, 686 poisoning cases were admitted to the EMDEU. Mean age was 10.8 +/- 6.5 years among the paediatric age group (<17 years old, 169, 24.6%) and 30.3 +/- 12.8 years among the adult group (>17 years old,509, 74.2%). The most common sedative-hypnotic agents were benzodiazepines (286, 35.8%), alprazolam accounted for41.6% of them (119). Most of the patients admitted to EMDEU were asymptomatic (61.7%). Observation alone was recommended in 53.9% of EMDEU cases. Although prescription of benzodiazepines is restricted, benzodiazepine was the most common cause of sedative-hypnotic medication exposures. As only a minority of patients (3%) had clinically serious signs and symptoms, most of the overdoses might be under toxic levels or the decontamination methods might be efficient. In this study, the clinical outcome of the patients is relatively better than previous results described in literature.