Comparison of rocuronium priming vs. standard rapid sequence intubation technique in emergency department patients requiring intubation.

OBJECTIVE: In our study, we aimed to compare the effect of standard rapid sequence intubation protocol and the application of rocuronium priming technique on the procedure time and hemodynamic profile. METHODS: Patients who applied to the emergency department and needed rapid sequence intubation were included in our study, which we conducted with a randomized controlled design. Randomization in the study was made according to the order of arrival of the cases. Rapid sequence intubation was performed in the standard group. In the priming group, 10% of the rocuronium dose was administered approximately 3 min before the induction agent. Intubation time, amount of drug used, vital signs, and end-tidal CO2 level before and after intubation used to confirm intubation were recorded. RESULTS: A total of 52 patients were included in the study, of which 26 patients were included in the standard group and 26 patients in the priming group. While intubation time was 121.2±21.9 s in the standard group, it was calculated as 68.4±11.6 s in the priming group (p<0.001). While the mean arterial pressure was 58.3±26.6 mmHg in the standard group after intubation, it was 80.6±21.1 mmHg in the priming group (p=0.002). CONCLUSION: It was observed that priming with rocuronium shortened the intubation time and preserved the hemodynamic profile better. CLINICAL TRIAL REGISTRATION NUMBER: NCT05343702.

Thiol/Disulfide Homeostasis and Ischemia-Modified Albumin Levels in 61 Patients with Hypercapnia: A Case-Control Study.

BACKGROUND Hypercapnia is abnormally high arterial partial pressure of carbon dioxide (CO2). CO2 can affect redox signaling mechanisms, leading to production of oxidative derivatives. Thiol is formed by attaching a sulfhydryl group to a carbon atom. Under oxidative stress, it forms covalent bonds called thiol disulphide bonds. Serum albumin is modified to ischemia-modified albumin (IMA) by exposure to free radicals. This case-control study aimed to evaluate thiol/disulphide homeostasis and IMA levels in 61 patients with hypercapnia. MATERIAL AND METHODS We studied 61 patients with hypercapnia and 61 normocapnic volunteers in the control group, between May 2018 and January 2019; 56 of these patients were diagnosed with chronic obstructive pulmonary disease and 5 of them were diagnosed with obstructive sleep apnea syndrome. Arterial blood samples analyzed by using the Ellman reagent for thiol/disulphide data. A colorometric assay was used for detection of IMA levels. RESULTS Native thiol and total thiol values in the hypercapnic group were significantly lower than in the control group (P=0.024, P=0.006 respectively), as IMA values were significantly higher (P<0.001). There was no statistically significant difference between the hypercapnic and control groups in terms of disulphide, disulphide/native thiol, disulphide/total thiol, and native thiol/total thiol values (P>0.05). CONCLUSIONS In hypercapnic patients, there are changes in thiol/disulphide homeostasis and IMA levels. All significant differences in this study support that changes in thiol disulphide homeostasis and IMA in hypercapnic patients are indicators of oxidative stress.

Emergency Medicine Association of Turkey Disaster Committee Summary of Field Observations of February 6th Kahramanmaras Earthquakes.

An earthquake measuring 7.7 magnitude on the Richter scale occurred at 04:17am on February 6, 2023 in the Pazarcik district of Kahramanmaras province Turkey. In the hours following the 7.7 magnitude event in Kahramanmaras, a second 7.6 magnitude earthquake struck the region and a third 6.4 magnitude earthquake struck Gaziantep, causing extensive damage and death. A total of ten provinces directly experienced the earthquake, including Kahramanmaras, Hatay, Gaziantep, Osmaniye, Malatya, Adana, Diyarbakir, Sanliurfa, Adiyaman, and Kilis. The official figures indicate 31,643 people were killed, 80,278 were injured, and 6,444 buildings were destroyed within seven days of the earthquakes (as of 12:00pm/noon on Monday, February 13th). The area affected by the earthquake has been officially declared to be 500km in diameter. This report primarily relies on observations made by pioneer Emergency Physicians (EPs) who went to the disaster areas shortly after the first earthquake (in the early stages of the disaster). According to their observations: (1) Due to winter conditions, there were transportation problems and a shortage of personnel reaching disaster areas on the first day after the disaster; (2) On the second day of the disaster, health equipment was in short supply; (3) As of the third day, health workers were unprepared in terms of knowledge and experience for the disaster; and (4) The subsequent deployment of health personnel to the disaster area was uncoordinated and unplanned on the following days, which resulted in the health personnel working there not being able to meet even their basic needs (such as food, heating, and shelter). During the first week, coordination was most frequently reported as the most significant problem.

Manual versus mechanical chest compression in in-hospital cardiac arrest: A retrospective cohort in emergency department patients.

OBJECTIVE: Mechanical chest compression (CC) devices are frequently used in in-hospital and out-of-hospital settings. In this study, mechanical and manual CC in in-hospital cardiac arrest was compared in terms of survival. METHODS: Adult patients who were admitted to the emergency department (ED) for 2 years period and had cardiac arrest in the ED were included in this retrospective, observational study. Return of spontaneous circulation (ROSC), 7-day and 30-day survival and hospital discharge data were compared between the two groups of patients who underwent manual CC and those who had mechanical CC with the Lund University Cardiac Assist System-2 device. RESULTS: Although the rate of ROSC in the mechanical CC group was lower than in the manual CC group, this difference was not statistically significant (41.7% vs. 50.4%; P = 0.133). The 7-day survival rate was found to be statistically significantly higher in the mechanical CC group (19.4% vs. 8.9%; P = 0.012). The 30-day survival rate was also found to be high in the mechanical CC group, but this difference was not statistically significant (10.6% vs. 7.3%; P = 0.339). CONCLUSION: In the light of these results, we can say that the use of piston-based mechanical CC devices in ED may be beneficial. More reliable results can be obtained with a prospective study to be performed in the ED.

Effectiveness of lidocaine spray on radial arterial puncture pain: A randomized double-blind placebo controlled trial.

OBJECTIVE: Radial arterial puncture is a painful procedure. The aim of this study was to evaluate the effect of lidocaine spray (10%) on pain associated with radial artery blood withdrawal for arterial blood gas analysis. METHODS: This randomized, controlled, double-blind study was performed between December 2018 and September 2019. Before radial arterial puncture, 10% lidocaine or placebo spray was applied to each patient by the attending physician, who was blinded with regard to random assignment. The spray was administered six times on the site from a distance of 5 cm. After waiting for 5 min, a radial arterial puncture was performed routinely. The pain levels of patients during radial arterial puncture and 5 min after puncture were evaluated with the visual analog scale (VAS). The Wilcoxon test was used to compare pain scores during puncture. RESULTS: The research was performed with 67 patients (34 patients in the lidocaine group, 33 patients in the placebo group) who were admitted to the emergency department and required ABG analysis. Forty-three patients were men, and 24 were women. The ages of the patients ranged between 19 and 86 years, and the mean (± standard deviation) age was 56.3 ± 16.6 years. Pain levels, as measured by VAS, were significantly lower in the lidocaine group (24.00 mm IQR:[14.75-33.75]) compared with the placebo group (33.00 mm IQR:[22.00-61.50]) during radial arterial puncture (p = 0.011). CONCLUSIONS: The level of pain perceived during radial arterial puncture was significantly lower in those who were administered lidocaine spray. Lidocaine spray application can be used in pain management related to radial arterial puncture.

The role of pleural fluid thiol/disulphide homoeostasis in the differentiation between transudative and exudative pleural effusions.

OBJECTIVE: In the present study, we aimed to differentiate between transudative and exudative pleural effusions using thiol sulphide homoeostasis, an oxidative stress marker. DESIGN: This was a prospective study. SETTING: Emergency Department of Ankara City Hospital, between 1 January 2020 and 15 May 2020. SUBJECTS: Patients who were diagnosed with pleural effusion and underwent thoracentesis to make a differentiation between transudative and exudative pleural effusions. The patients were divided into two groups as those who have transudative pleural effusion and those who have exudative pleural effusion. These two groups were assessed with respect to demographic features and oxidative stress parameters. MAIN OUTCOME MEASURES: Oxidative stress parameters (The native thiol (NT), total thiol (TT), and disulphide (D) levels and their ratios to one another were calculated (index 1: D/NT, index 2:D/TT, index 3: NT/TT). RESULTS: This study enrolled a total of 50 patients with pleural effusion. Twenty patients (40%) were men, and 30 patients (60%) were women. In the transudative pleural effusion group, 14 patients (56%) had decompensated heart failure, 9 patients (36%) had hepatic cirrhosis, and 2 patients (8%) had hypoalbuminemia. In the exudative pleural effusion group, 17 patients (68%) had malignancy, 7 patients (28%) had parapneumonic effusion, and 1 patient (4%) had pulmonary embolism. TT (P < .001) and NT (P = .001) values were significantly lower in the transudative pleural effusion group compared with the exudative pleural effusion group whereas there was no significant difference between the two groups with respect to D (P = .489), index 1 (P = .07), index 2 (P = .064), and index 3 (P = .063) values. CONCLUSION: We believe that a differentiation can be made between transudative and exudative pleural fluids by using thiol sulphide homoeostasis, an oxidative stress marker.

The Role of Pneumococcal Pneumonia among Community-Acquired Pneumonia in Adult Turkish Population: TurkCAP Study.

OBJECTIVE: To evaluate the rate of pneumococcal pneumonia (PP) among patients with community-acquired pneumonia (CAP) in Turkey and to investigate and compare features of PP and non-PP CAP patients. MATERIAL AND METHODS: This multicenter, non-interventional, prospective, observational study included adult CAP patients (age ≥ 18 years). Diagnosis of PP was based on the presence of at least 1 positive laboratory test result for Streptococcus pneumoniae (blood culture or sputum culture or urinary antigen test [UAT]) in patients with radiographic findings of pneumonia. RESULTS: Four hundred sixty-five patients were diagnosed with CAP, of whom 59 (12.7%) had PP. The most common comorbidity was chronic obstructive pulmonary disease (30.1%). The mean age, smoking history, presence of chronic neurological disease, and CURB-65 score were significantly higher in PP patients, when compared to non-PP patients. In PP patients, 84.8% were diagnosed based ony on the UAT. The overall rate of PP patients among CAP was calculated as 22.8% considering the UAT sensitivity ratio of 63% (95% confidence interval: 45-81). The rate of intensive care treatment was higher in PP patients (P = .007). While no PP patients were vaccinated for pneumococcus, 3.8% of the non-PP patients were vaccinated (P = .235). Antibiotic use in the preceding 48 hours was higher in the non-PP group than in the PP group (31.8% vs. 11.1%, P = .002). The CURB-65 score and the rate of patients requiring inpatient treatment according to this score were higher in the PP group. CONCLUSION: The facts that PP patients were older and required intensive care treatment more frequently as compared to non-PP patients underline the burden of PP.

Tissue adhesives to secure peripheral intravenous catheters: A randomized controlled trial in patients over 65 years.

INTRODUCTION: Peripheral venous catheterization is one of the most used medical procedures in hospitals worldwide. Recent researches state that using intravascular devices is a risk factor for both local and systemic complications. In this study, we aimed to test that addition of tissue adhesive to the insertion site of peripheral intravenous catheters (PIVC) in the emergency department (ED) would reduce the device failure rate at 6 h and 24 h following insertion. MATERIAL AND METHODS: We designed a single-site, two-arm, randomized, controlled trial. We inserted 115 PIVCs into 115 adult patients. RESULTS: PIVC device failure for the 6th hour follow up was 15.4% in the tissue adhesive group (95% CI: 4.1-26.7) vs. 25.6% with standard care group (95% CI: 11.9-39.3). There was no statistically significant difference between two groups (p = 0.33).The number of patients for 24 h follow-up was not enough and the obtained data could not be included in the study. DISCUSSION: In this study, the routine use of tissue adhesives in addition to standard care to reduce PIVC failure for patients 65 years or older in ED was not supported due to not clear benefits and cost effectivity. CONCLUSION: Even though the routine use of tissue adhesives is not recommended according to the study results, it may be reasonable to use tissue adhesives for long term hospitalization expected patients to protect from related complications due to current literature.

Verifying the Placement of Nasogastric Tubes at an Emergency Center: Comparison of Ultrasound with Chest Radiograph.

The objective of this study was to verify the nasogastric tube position with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture and auscultation and to compare the effectiveness of these methods with chest radiography. This is a single-center, prospective, single-blind study. Patients who were admitted to our emergency department and had an indication of nasogastric tube placement were included. Nasogastric tube localization was verified with neck ultrasound and subxiphoid ultrasound, by giving air-water mixture, auscultation, and direct radiography that was accepted as the 'gold standard technique'. A total of 49 patients (27 Male, 22 Female) with a mean age of 58.3±22.7 years were included. Sensitivity of neck ultrasound was 91.5%, and positive predictive value was 100%. As for the subxiphoid ultrasound sensitivity was 78.72%. When neck ultrasound + subxiphoid ultrasound and giving water-air mixture were combined sensitivity reached 95.74%. Sensitivity of neck ultrasound + subxiphoid ultrasound + air-water mixture + auscultation was 97.87% and positive predictive value was 100%. In the light of our results, neck and subxiphoid ultrasound seem to be an alternative method for verifying nasogastric tube localization. Combination of the air-water mixture and auscultation with ultrasound improves the sensitivity.

The effect of body mass index on trauma severity and prognosis in trauma patients.

BACKGROUND: As in the rest of the world, the prevalence of obesity in Turkey has been increasing in recent years and has become a major public health issue. Although many trials have been conducted to study the effects of obesity on internal diseases, there are few studies investigating the effects of obesity on prognosis of trauma patients. The present study analyzed the effects of body mass index (BMI) on trauma severity and prognosis in trauma patients. METHODS: This study was prospectively conducted with trauma patients older than 15 years of age who presented at the Dicle University Faculty of Medicine emergency medicine department trauma unit between June 1, 2013 and May 31, 2014. Patients were grouped into high-energy trauma and low-energy trauma groups based on trauma severity. In addition, 4 groups were made according to BMI value (kg/m2). Group I was defined as BMI <25 (normal weight). Group II patients had BMI of 25-29.9 (overweight). Group III had BMI of 30-34.9 (obese), and Group IV was made up of patients with BMI ≥35 (morbidly obese). RESULTS: Comparison of whole patient population for inter-group differences showed significant differences between rate of head injury, thoracic injury, extremity injury, multitrauma, clinic admission rate, and mortality rate (p<0.001). No significant difference was observed between groups in abdominal injury rate (p=0.347). CONCLUSION: Clinic admission rate, length of intensive care unit stay, mortality rate, multitrauma rate, and injury severity score increased in proportion to greater BMI.

The role of ultrasonography in the diagnosis of metacarpal fractures.

INTRODUCTION: The aim of this study was to evaluate the efficiency of ultrasonography (USG) in identifying metacarpal bone fractures in patients admitted to the emergency department (ED) with hand injury. MATERIALS AND METHODS: Patients who were admitted to a training and research hospital's ED during the study period with hand trauma and had suspected metacarpal fractures were included in the study. They were examined for metacarpal fracture by USG and x-ray. Hand radiographs reviewed by an emergency physician were considered to be the criterion standard diagnostic tool. Ultrasonography results were compared to x-ray results. RESULTS: Ninety-eight ultrasound examinations were performed on 96 adult patients who were enrolled in the study. The mean age of the patients was 30.1±11.8 years; 79.2% of the patients were male. Right hand injury was observed in 69.4% of the cases. Forty metacarpal fractures were detected in 38 patients on x-ray. We found a sensitivity of 92.5% (95% confidence interval [CI], 78.5-98), a specificity of 98.28% (95% CI, 89.5-99.9), a positive predictive value of 97.37% (95% CI, 84.5-99.8), and a negative predictive value of 95% (95% CI, 85-98) for USG to detect metacarpal fractures when compared to x-ray imaging. CONCLUSIONS: Under the light of these results, we suggest that USG may be an option for detecting metacarpal fractures and prevent unnecessary x-ray imaging examinations in patients presenting to the ED with hand trauma.

Concurrent Spontaneous Sublingual and Intramural Small Bowel Hematoma due to Warfarin Use.

Introduction. We present a case of concurrent spontaneous sublingual and intramural small bowel hematoma due to warfarin anticoagulation. Case. A 71-year-old man presented to the emergency department complaining of a swollen, painful tongue. He was on warfarin therapy. Physical examination revealed sublingual hematoma. His international normalized ratio was 11.9. The computed tomography scan of the neck demonstrated sublingual hematoma. He was admitted to emergency department observation unit, monitored closely; anticoagulation was reversed with fresh frozen plasma and vitamin K. 26 hours after his arrival to the emergency department, his abdominal pain and melena started. His abdomen tomography demonstrated intestinal submucosal hemorrhage in the ileum. He was admitted to surgical floor, monitored closely, and discharged on day 4. Conclusion. Since the patient did not have airway compromise holding anticoagulant, reversing anticoagulation, close monitoring and observation were enough for management of both sublingual and spontaneous intramural small bowel hematoma.

Subcutaneous Emphysema, Pneumomediastinum, and Pneumorrhachis after Cocaine Inhalation.

Introduction. The most prominent complications of cocaine use are adverse effects in the cardiovascular and central nervous systems. Free air in the mediastinum and subcutaneous tissue may be observed less frequently, whereas free air in the spinal canal (pneumorrhachis) is a very rare complication of cocaine abuse. In this report we present a case of pneumorrhachis that developed after cocaine use. Case. A 28-year-old male patient was admitted to the emergency department with shortness of breath, chest pain, and swelling in the neck and face which started four hours after he had sniffed cocaine. On physical examination, subcutaneous crepitations were felt with palpation of the jaw, neck, and upper chest area. Diffuse subcutaneous emphysema, pneumomediastinum, and pneumorrhachis were detected in the computed tomography imaging. The patient was treated conservatively and discharged uneventfully. Discussion. Complications such as pneumothorax, pneumomediastinum, and pneumoperitoneum that are associated with cocaine use may be seen due to increased intrathoracic pressure. The air then may flow into the spinal canal resulting in pneumorrhachis. Emergency physicians should know the possible complications of cocaine use and be prepared for rare complications such as pneumorrhachis.

Phytocontact dermatitis due to Ranunculus arvensis mimicking burn injury: report of three cases and literature review.

Ranunculus arvensis (corn buttercup) is a plant species of the genus Ranunculus that is frequently used in the Far East to treat rheumatic diseases and several dermatological disorders. In Turkey, the plant is seen in the eastern and southeastern Anatolian highlands, which are underdeveloped areas of the country. Herein, we report three patients who used Ranunculus arvensis for the treatment of arthralgia and osteoarthritis. A distinctive phytodermatitis developed on the right thumb in one patient (48-year-old male), on the anterior aspect of both knees in another patient (70-year-old female) and all around both knees in a third (59-year-old female). The patients were treated with topical antibiotics and daily wound dressing, and none of them experienced any complications. Ranunculus arvensis was confirmed as the cause of the phytodermatitis in the three cases. Poultices of plants applied to the skin demonstrate beneficial effects on many dermatological and rheumatic diseases; however, they have several adverse effects that should not be ignored. In this study, we also present a review of 25 cases reported in the literature.

The role of the heart-type fatty acid binding protein in the early diagnosis of acute coronary syndrome and its comparison with troponin I and creatine kinase-MB isoform.

OBJECTIVES: The aim of this study was to research the effectiveness of the heart-type fatty acid binding protein (H-FABP) in the early diagnosis of acute coronary syndrome (ACS) in patients admitted to emergency service (ES) within 6 hours of onset of chest pain. EQUIPMENT AND METHOD: A total of 83 patients admitted with chest pain to our ES were included in this study. The patients were divided into 2 groups: those with a diagnosed ACS and those diagnosed with non-cardiac-related chest pain. Patients were also were divided into 2 groups according to the time of admission: those admitted within 0 to 3 hours and 3 to 6 hours of onset of chest pain. Peripheral venous blood samples were obtained from all patients for H-FABP, troponin I, and creatine kinase-MB (CK-MB) serum concentration measurements. RESULTS: Of a total of 83 patients, 21.6% (n = 18) were in the control group and 78.3% (n = 65) were in the ACS group. The average H-FABP value for the patients in the control group was 0.86 ± 0.54 ng/mL. When the ACS and control groups were compared in means of cardiac markers for CK-MB (P = .000) and H-FABP (P = .000), there was a statistically significant difference, whereas no difference was observed for troponin I (P = .013). In the ACS group, H-FABP sensitivity for diagnosis was found to be 98% and specificity was 71%; CK-MB sensitivity was 86% and specificity was 52%; and troponin I sensitivity was 77% and specificity was 20%. CONCLUSIONS: For patients admitted with chest pain to ES, H-FABP was found to be more sensitive and specific than troponin I and CK-MB in the early diagnosis of ACS.

Mortality and morbidity in children caused by falling televisions: a retrospective analysis of 71 cases.

OBJECTIVES: To quantify injuries in children that result from toppled televisions. METHODS: Children presenting directly to emergency department due to injuries caused by falling televisions were identified from our digital patient database, and a retrospective chart review of 71 children was performed.Descriptive statistics were applied. RESULTS: 71(1.8%) out of 3856 admissions due to injuries sustained at home were TV-related injuries. There were 50 (70.4%) boys and 21(29.6%) girls. Mean age was 39.79 ± 20.14 SD months. Almost three quarters of the children (49/71) sustained various head and facial injuries. There was traumatic brain injury in 14 patients,extremity injuries in 30 patients, thoracic injuries in 13 patients and abdominal injuries in ten patients. 16 patients were hospitalized. 14 of them required follow-up in intensive care unit. Two patients (one with epidural hematoma and one with subdural hematoma) underwent surgical intervention. Four patients with subarachnoid bleeding died. The mean length of hospital stay was 71.25 hours (range, 48-168) in hospitalised patients. The overall mortality rate was 5.6%. CONCLUSIONS: Falling TVs may cause significant morbidity and mortality in children particularly those younger than 3 years old. Head and facial injuries are the most common body region involved and traumatic brain injury is the major cause of death.

Careless use of turban pins: a possible problem for turbaned patients.

INTRODUCTION: Foreign body ingestion is rare in adults. In recent years, however, ingestion of the pins that are used for securing turbans has frequently been observed among young Islamic women. This article reviews the patients who were admitted to our emergency unit for turban pin ingestion. METHODS: Between 2005 and 2009, 42 patients were admitted to our emergency unit with problems involving turban pins. The patients' characteristics were analyzed, including age; marital status; career; type, number, and location of pins; and history of gastrointestinal surgery. RESULTS: The patients ranged in age between 11 and 48 years. Of the patients, 22 were single, and 20 were married; 19 were students, and 23 were housewives. The patients visited the emergency unit within 1 to 12 h after they had ingested the pins. Eight of the patients had ingested two pins each, while the others had ingested one pin each. The pins ingested most frequently were those with ball heads. Spontaneous excretion took 3 to 16 days. Of the patients who did not pass the pins spontaneously with feces, the pins were extracted at endoscopy in three and at laparotomy in one. The patients were followed up for 4 to 49 months. No pathological problems were noted during follow-up. CONCLUSIONS: Turban pin ingestion is common in Islamic populations, and the treatment requires a systemic approach and careful follow-up. Pin ingestion can be prevented by increasing public awareness and avoiding holding pins in the mouth when fixing a turban or wearing a type of turban that does not require pins.